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SB-770 Health care coverage: mental illness: developmental disorder and autism.(2011-2012)

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Amended  IN  Assembly  August 31, 2011
Amended  IN  Assembly  August 16, 2011
Amended  IN  Assembly  June 30, 2011
Amended  IN  Senate  May 31, 2011
Amended  IN  Senate  April 25, 2011
Amended  IN  Senate  March 24, 2011
Amended  IN  Senate  March 21, 2011

CALIFORNIA LEGISLATURE— 2011–2012 REGULAR SESSION

Senate Bill
No. 770

Introduced  by  Senator Steinberg, Evans
 (Principal Coauthor(s): Assembly Member Beall)
Fuentes

February 18, 2011

An act to add Section 1374.73 to the Health and Safety Code, and to add Sections 10144.51 and 10144.52 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


SB 770, as amended, Steinberg. Health care coverage: mental illness: developmental disorder and autism.
(1) Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of these provisions is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide benefits for specified conditions, including certain mental health conditions.
This bill would require those health care service plan contracts and health insurance policies to also provide coverage for behavioral health treatment, as defined, for pervasive developmental disorder or autism. The bill would provide, however, that no benefits are required to be provided that exceed the essential health benefits required under specified federal law. Because a violation of these provisions with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.
(2) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 The Legislature finds and declares all of the following:
(a) Scientific research has established that behavioral health treatment can significantly improve the cognitive function and emotional capabilities, and reduce self-injurious behavior, for a significant number of individuals with pervasive developmental disorder or autism.
(b) Existing law requires health care service plan contracts and health insurance policies to provide coverage for all medically necessary treatment for individuals with pervasive developmental disorder or autism pursuant to Section 1374.72 of the Health and Safety Code and Section 10144.5 of the Insurance Code.
(c) Scientists, physicians, and other autism experts consider behavioral health treatment an important and medically necessary treatment for a significant number of individuals with pervasive developmental disorder or autism.
(d) Despite Section 1374.72 of the Health and Safety Code, Section 10144.5 of the Insurance Code, and the scientific literature findings that behavioral health treatment is efficacious in the treatment of pervasive developmental disorder and autism, some health care service plans and health insurers continue to refuse to cover medically necessary behavioral health treatment for individuals with these disorders.
(e) Of the grievances and appeals that have been filed with the Department of Managed Health Care and the Department of Insurance, an increasing number of independent medical review decisions have determined that behavioral health treatment is medically necessary for the treatment of pervasive developmental disorder or autism.
(f) Therefore, it is the intent of the Legislature to ensure that behavioral health treatment is considered a covered benefit, when it is medically necessary, for the treatment of pervasive developmental disorder or autism.

SEC. 2.

 Section 1374.73 is added to the Health and Safety Code, to read:

1374.73.
 (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2012, that provides hospital, medical, or surgical coverage pursuant to Section 1374.72 shall provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 1374.72.
(2) Notwithstanding paragraph (1), this section does not require any benefits to be provided that exceed the essential health benefits required to be provided under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).
(3) This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan as described in Section 95020 of the Government Code, an individualized program plan as described in Section 4646 of the Welfare and Institutions Code, a prevention program plan as described in Section 4435 of the Welfare and Institutions Code, an individualized education program as defined in Section 56032 of the Education Code, or an individualized service plan as described in Section 5600.4 of the Welfare and Institutions Code.
(b) Every health care service plan subject to this section shall maintain an adequate network of qualified autism service providers, and the plan shall comply with all applicable provisions of this act or regulations adopted thereunder.
(c) (1) Notwithstanding any other provision of law, unlicensed or uncertified staff may implement services if the qualified autism service provider ensures that each staff person implementing services pursuant to this section has adequate training and the qualified autism service provider supervises these staff persons.
(2) Prior to implementing services, all unlicensed or uncertified staff shall be subject to criminal background screening and fingerprinting meeting requirements established by the department.
(d) For the purposes of this section, the following definitions shall apply:
(1) “Behavioral health treatment” means professional services and treatment programs, including, but not limited to, applied behavior analysis and other intervention programs, such as Pivotal Response Therapy and Early Start Denver Model, that meet all of the following criteria:
(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.
(B) The treatment shall be derived from peer-reviewed literature or scientific evidence-based research that has demonstrated clinical efficacy in treating the symptoms or manifestations associated with pervasive developmental disorder or autism.
(C) The treatment is provided or supervised by a qualified autism service provider.
(2) “Pervasive developmental disorder or autism” shall have the same meaning and interpretation as used in Section 1374.72.
(3) “Qualified autism service provider” shall include any person, entity, or group that is nationally certified by an entity, such as, but not limited to, the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, or any person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person, entity, or group that is nationally certified or the licensee. A “qualified autism service provider” shall also include both of the following:
(A) Any service provider that is approved as a vendor of a regional center to provide those same services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
(B) A State Department of Education nonpublic, nonsectarian agency, as defined in Section 56035 of the Education Code, that is approved to provide those same services for pervasive developmental disorder or autism.

SEC. 3.

 Section 10144.51 is added to the Insurance Code, to read:

10144.51.
 (a) (1) Every health insurance policy issued, amended, or renewed on or after January 1, 2012, that provides hospital, medical, or surgical coverage pursuant to Section 10144.5 shall provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 10144.5.
(2) Notwithstanding paragraph (1), this section does not require any benefits to be provided that exceed the essential health benefits required to be provided under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).
(3) This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan as described in Section 95020 of the Government Code, an individualized program plan as described in Section 4646 of the Welfare and Institutions Code, a prevention program plan as described in Section 4435 of the Welfare and Institutions Code, an individualized education program as defined in Section 56032 of the Education Code, or an individualized service plan as described in Section 5600.4 of the Welfare and Institutions Code.
(b) Pursuant to Article 6 (commencing with Section 2240.1) of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network of qualified autism service providers to ensure that all insureds have timely access to qualified autism service providers, continuity of care, and ready referral to in-network qualified autism service providers.
(c) (1) Notwithstanding any other provision of law, unlicensed or uncertified staff may implement services if the qualified autism service provider ensures that each staff person implementing services pursuant to this section has adequate training and the qualified autism service provider supervises these staff persons.
(2) All unlicensed or uncertified staff implementing services pursuant to this section shall be subject to criminal background screening and fingerprinting meeting requirements established by the department.
(d) For the purposes of this section, the following definitions shall apply:
(1) “Behavioral health treatment” means professional services and treatment programs, including, but not limited to, applied behavior analysis and other intervention programs, such as Pivotal Response Therapy and Early Start Denver Model, that meet all of the following criteria:
(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.
(B) The treatment shall be derived from peer-reviewed literature or scientific evidence-based research that has demonstrated clinical efficacy in treating the symptoms or manifestations associated with pervasive developmental disorder or autism.
(C) The treatment is provided or supervised by a qualified autism service provider.
(2) “Pervasive developmental disorder or autism” shall have the same meaning and interpretation as used in Section 10144.5.
(3) “Qualified autism service provider” shall include any person, entity, or group that is nationally certified by an entity, such as, but not limited to, the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, or any person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person, entity, or group that is nationally certified or the licensee. A “qualified autism service provider” shall also include both of the following:
(A) Any service provider that is approved as a vendor of a regional center to provide those same services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
(B) A State Department of Education nonpublic, nonsectarian agency as defined in Section 56035 of the Education Code, approved to provide those same services for pervasive developmental disorder or autism.

SEC. 4.

 Section 10144.52 is added to the Insurance Code, to read:

10144.52.
 For purposes of this part, the terms “provider,” “professional provider,” “network provider,” “mental health provider,” and “mental health professional” shall include the term “qualified autism service provider” provider,” as defined in subdivision (d) of Section 10144.51.

SEC. 5.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.