AB 796
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Date of Hearing: January 12, 2016
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
AB 796 (Nazarian) – As Amended January 4, 2016
NOTE: This bill is double referred, and if passed by this Committee, it will be referred to the
Assembly Committee on Health.
SUBJECT: Health care coverage: autism and pervasive developmental disorders.
SUMMARY: Extends the sunset date for health care service plans to contract, and health
insurance policies to provide coverage for behavioral health treatment for pervasive
developmental disorders, from January 1, 2017 to January 1, 2022, and requires the Board of
Psychology to create a list of evidence-based treatment modalities for autism or pervasive
developmental disorders by December 31, 2017.
EXISTING LAW:
1) Establishes the Board of Psychology, within the Department of Consumer Affairs (DCA), to
license and regulate the practice of psychology. (BPC § 2900 et seq.)
2) Establishes the Board of Behavioral Sciences, within the DCA, to license and regulate
clinical social workers, professional clinical counselors, marriage and family therapists and
educational psychologists. (BPC § 4990 et seq.)
3) Establishes the Medical Board, within the DCA, to license physicians and surgeons and
regulate the practice of medicine. (BPC § 2000 et seq.)
4) Establishes the Physical Therapy Board, within the DCA, to license physical therapists, and
regulate the practice of physical therapy. (BPC § 2600 et seq.)
5) Establishes the Occupational Therapy Board, within DCA, to license occupational therapists,
and regulate the practice of occupational therapy. (BPC § 2570 et seq.)
6) Establishes the Speech-Language Pathologists and Audiologists and Hearing Aid Dispensers
Board, within DCA, to license and regulate the practice or speech-language pathology,
audiology and hearing aid dispensing. (BPC § 2530 et seq.)
7) Establishes an entitlement to services for individuals with developmental disabilities under
the Lanterman Developmental Disabilities Services Act (Lanterman Act). (Welfare and
Institutions Code (WIC) § 4500 et seq.)
8) Grants all individuals with developmental disabilities, among all other rights and
responsibilities established for any individual by the United States Constitution and laws and
the California Constitution and laws, the right to treatment and habilitation services and
supports in the least restrictive environment. (WIC § 4502)
9) Defines “behavioral health treatment,” for purposes of payment under a health care service
plan contract or a health insurance policy, as professional services and treatment programs,
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including applied behavior analysis and evidence-based behavior intervention programs,
which develop or restore, to the maximum extent practicable, the functioning of an individual
with pervasive developmental disorder or autism, and sets forth criteria that must be met
related to the treatment plan, prescription of the treatment, and the providers authorized to
provide such treatment, which includes qualified autism service professionals, as specified.
(Health and Safety Code (HSC) § 1374.73(c)(1), Insurance Code (INS) 10144.51(c)(1))
10) Defines as “qualified autism service provider” as:
a. A person, entity or group that is certified by a national entity, such as the Behavior
Analyst Certification Board, that is accredited by the National Commission for Certifying
Agencies, and who designs, supervises, or provides treatment for pervasive developmental
disorders or autism, as specified; or,
b. A person licensed as a physician and surgeon, physical therapist, occupational therapist,
educational psychologist, clinical social worker, professional clinical counselor, speechlanguage pathologists, or audiologist, who designs, supervises or provides treatment for
pervasive developmental disorders or autism, as specified. (HSC § 1374.73(c)(3) et seq.)
11) Defines a "qualified autism service professional" as a behavioral service provider approved
as a vendor by a California regional center to provide services as an associate behavior
analyst, behavior analyst, behavior management assistant, behavior management consultant,
or behavior management program as defined in Title 17 CCR § 54342. (HSC § 1374.73
(c)(4)(D), INS § 10144.51(c)(4)(D))
12) Defines “qualified autism service paraprofessional” as an unlicensed and uncertified
individuals who is employed and supervised by a qualified autism service provider; and,
provides treatment and implements services pursuant to a treatment plan developed and
approved by the qualified autism service provider, as specified. (HSC § 1374.73 (c)(4))
13) Defines a “qualified autism service professional” as an individual who provides behavioral
health treatment and is employed and supervised by a qualified autism service provider, as
specified. (WIC § 1374.73 (c)(4))
14) Defines a “qualified autism service paraprofessional” as an unlicensed and uncertified
individual who is employed and supervised by a qualified autism service provider; and,
provides treatment and implements services pursuant to a treatment plan developed and
approved by the qualified autism service provider. (WIC § 1374.73 (c)(5))
15) Defines a “qualified autism service professional” as an individual who provides behavioral
health treatment; is employed and supervised by a qualified autism service provider; provides
treatment pursuant to a treatment plan developed and approved by the provider; and, is a
behavioral service provider, as specified. (INS § 10144.51 (c)(4))
16) Defines a “qualified autism service paraprofessional” as an unlicensed and uncertified
individual who is employed and supervised by a qualified autism service provider; provides
treatment and implements services pursuant to a treatment plan developed and approved by
the qualified autism service provider; has adequate education, training and experience as
certified by a qualified autism service provider, as specified. (INS § 10144.51 (c)(5))
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THIS BILL:
1) Extends the sunset date for health care service plans to contract, and health insurance policies
to provide coverage for behavioral health treatment for pervasive developmental disorders,
and extends the definition of “behavioral health treatment” and “qualified autism service
professional” from January 1, 2017 to January 1, 2022.
2) Requires the Board of Psychology to convene a committee to create a list of evidence-based
treatment modalities for pervasive developmental disorders or autism by December 31, 2017.
FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.
COMMENTS:
Purpose. This bill is sponsored by the DIR Floor Time Coalition. According to the author, “AB
796 recognizes that there is no one size fits all behavior health treatment for an individual
diagnosed with autism. Every child on the autism spectrum presents differently, as such
treatment options must reflect that spectrum. This bill ensures children diagnosed with autism
will receive insurance coverage for the type of evidence-based behavior health treatment that is
right and selected for them by the medical professional that knows the child best.”
Background. The Lanterman Act guides the provision of services and supports for Californians
with developmental disabilities. Each individual under the Lanterman Act, is legally entitled to
treatment and habilitation services and supports in the least restrictive environment. Lanterman
Act services are designed to enable all consumers to live more independent and productive lives
in the community.
The term "developmental disability" means a disability that originates before an individual
attains 18 years of age, is expected to continue indefinitely, and constitutes a substantial
disability for that individual. It includes intellectual disabilities, cerebral palsy, epilepsy, and
pervasive developmental disorder/autism spectrum disorder (PDD/ASD). Other developmental
disabilities are those disabling conditions similar to an intellectual disability that require
treatment (e.g., care and management) similar to that required by individuals with an intellectual
disability.
Autism Spectrum Disorders. Defined as a group of neurodevelopmental disorders linked to
atypical biology and chemistry in the brain that generally appears within the first three years of
life, autism is a growing epidemic among children. The diagnosis is often characterized by
delayed, impaired, or otherwise atypical verbal and social communication skills, sensitivity to
sensory stimulation, atypical behaviors and body movements, and sensitivity to changes in
routines. Although symptoms and severity differ among individuals with an autism diagnosis,
all individuals affected by the disorder have impaired communication skills, difficulties initiating
and sustaining social interactions, and restricted, repetitive patterns of behavior and/or interests.
According to the American Psychiatric Association, people with ASD tend to have
communication deficits, such as responding inappropriately in conversations, misreading
nonverbal interactions, or having difficulty building friendships appropriate to their age. In
addition, people with ASD may be overly dependent on routines, highly sensitive to changes in
their environment, or intensely focused on inappropriate items. The symptoms of people with
ASD will fall on a continuum, with some individuals showing mild symptoms and others having
much more severe symptoms.
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Information released in March 2014 by the Centers for Disease Control (CDC) Autism and
Developmental Disabilities Monitoring (ADDM) Network estimates prevalence of ASD for
children born in 2002 and surveyed in 2010 to be 14.7 per 1,000 children, which translates to one
in 68 children. This is a drastic increase from CDC data for children born in 2000 and surveyed
in 2008, which estimated the prevalence of children with ASD to be one in 88. Average
prevalence for children surveyed in 2006 was one in 110 children. ASD continues to be five
times more prevalent for boys than for girls.
Early Intervention Services. Research shows that a child's development can be greatly
impacted by early intervention treatment services, especially when provided during a child's first
three years. During that time, a child is developing motor skills and language, and begins to
socialize with others. Early intervention services for babies and toddlers that have been
diagnosed with, or seem to be at risk for, a developmental delay or disability often include
physical, cognitive, communication, social/emotional and self-help skill building. While there is
no proven cure for ASD, early intervention can dramatically change the trajectory of a child's life
over time, including his or her ability to learn new skills throughout childhood and an increased
ability to integrate into, and have a positive relationship with, his or her community.
Treatments for ASD. According to information retrieved from the National Institute of Mental
Health, there are various modalities for treating ASD including a combination of medication,
occupational therapy, speech therapy, physical therapy, and behavioral interventions. With
regard to behavioral interventions, there are several different types that have been scientifically
studied and found to be effective. There are also a number of behavioral treatments in practice
that have not yet met the criteria to be considered “evidence-based.” In California, many
practitioners report that the most widely reimbursed evidence-based behavioral treatment for
ASD is Applied Behavioral Analysis. Providers also report that they utilize other forms of
behavioral health treatment, e.g. Developmental, Individual Difference, Relationship-based
(DIR) Floortime, but they list the treatment modalities under different billing codes to ensure
they receive reimbursement.
Applied Behavior Analysis (ABA). A widely accepted evidence-based treatment for ASD is ABA.
There are many research articles demonstrating the efficacy of ABA as an intervention for
individuals with autism. These studies range from group design outcome studies to single subject
studies supporting the use of one specific intervention or technique.
The goals of ABA are to shape and reinforce new behaviors, such as learning to speak and play,
and reduce undesirable ones. This is done by systematically applying interventions, based upon
the principles of learning theory, to improve socially significant behaviors to a meaningful
degree. Further, the contingent use of reinforcement and other important principles to increase
behaviors, generalize learned behaviors or reduce undesirable behaviors is fundamental to ABA.
For example, ABA techniques use rewards—goldfish crackers, playing with toys, praise—to
teach children all kinds of behaviors, lessons and life skills, step by tiny step, in intensive, oneon-one drills.
Developmental, Individual Difference, Relationship-based (DIR)/Floortime Model—aims to
build healthy and meaningful relationships and abilities by following the natural emotions and
interests of the child. One particular example is the Early Start Denver Model, which fosters
improvements in communication, thinking, language, and other social skills and seeks to reduce
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atypical behaviors. Using developmental and relationship-based approaches, this therapy can be
delivered in natural settings such as the home or pre-school.
SB 946. SB 946 (Steinberg), Chapter 650, Statutes of 2011, defined “behavioral health
treatment” (BHT) as professional services and treatment programs, including ABA and
evidence-based behavior intervention programs, that develop or restore, to the maximum extent
practicable, the functioning of an individual with PDD or ASD. The bill mandated coverage of
all evidence-based BHTs prescribed by a physician and surgeon, or developed by a psychologist,
provided under a treatment plan prescribed by a qualified autism service provider, and
administered by a qualified autism service provider, a qualified autism service professional, or
qualified autism service paraprofessional. When defining the minimum requirements for
providers, the bill referred to a section of Title 17 which references only one type of evidencebased BHTs, ABA. The sponsor believes that this was a mistake. The sponsor also believes that
the spirit of the legislation was to allow for various modalities of treatment. The sponsor
indicates that this discrepancy in existing law makes it difficult for parents to obtain coverage for
prescribed treatments that their children need.
Department of Managed Healthcare (DMHC) Task Force. SB 946 called for the DMHC to
convene a task force to report to the Governor and Legislature with recommendations for
implementing SB 946. The 18 member task force met for one year. An excerpt from the report
summarizes the Task Force’s recommendations regarding BHT:
A guiding principle of the Task Force was that every individual with autism or PDD is unique.
Therefore, behavioral health interventions need to be highly individualized. Since treatment
selection should be made by a team of individuals, who can consider the unique needs and
history of the individual with autism or PDD, the Task Force determined that it would not be
informative to state policy makers to merely develop a list of BHTs that are determined to be
effective, based solely on current scientific literature. Since scientific research and findings
naturally advance, the Task Force determined that the choice of BHTs should be grounded in
scientific evidence, clinical practice guidelines, and/or evidence based practice.
In regards to the individuals who are most appropriate to administer BHT, the Task Force
concluded:
The Task Force concluded that all top level providers [physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family therapist, educational
psychologist, clinical social worker, professional clinical counselor, or speech language
pathologist or audiologists] should be licensed by the state.
The Task Force also included requirements for individuals who are unlicensed and who are not
certified as follows:
a) Have adequate training and specific competence in implementing BHT for autism,
including competence in the scope of treatments outlined in the treatment plan and a
minimum of 30 hours of interactive, competency-based autism-specific training, as
verified by the treatment plan developer or treatment provider;
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b) Be enrolled in a bachelor’s program or possess a bachelor’s degree; be enrolled in an
associate’s degree program or possess an associate’s degree; or, at minimum, possess a
high school diploma;
c) Receive adequate supervision. At least 60 to 75 percent of the supervision should be
direct fact-to-face supervision and include significant co-therapy with the top or midlevel supervisor; and,
d) The supervision shall cover the functions of ongoing treatment planning and case
supervision.
Prior Related Legislation. SB 479 (Bates) of 2015, would have established the Behavior
Analyst Act which would have required a person to apply for and obtain a license from the
Board of Psychology prior to engaging in the practice of behavior analysis, as defined, either as a
behavior analyst or an assistant behavior analyst, and meet certain educational and training
requirements. NOTE: This bill was held on the Senate Appropriations Committee suspense file.
SB 946 (Steinberg), Chapter 650, Statutes of 2011, required health plan and health insurance
policies to cover behavioral health therapy for pervasive developmental disorders or autism. The
bill also requires plans and insurers to maintain adequate networks of autism service providers.
AB 2041 (Jones) of 2014, would have required that a regional center classify a vendor as a
behavior management consultant or behavior management assistant if the vendor designs or
implements evidence-based behavioral health treatment, has a specified amount of experience in
designing or implementing that treatment, and meets other licensure and education requirements.
The bill would have required the Department of Developmental Services to amend its regulations
as necessary to implement the provisions of the bill. NOTE: The bill died in the Senate
Appropriations Committee.
POLICY ISSUES:
1) The author has proposed that a subcommittee of the Board of Psychology develop a list of
evidence-based treatments for behavioral health treatment. This would require the Board to
consistently review treatments that emerge and add them to the list. An alternative would be
to task the Board’s subcommittee with defining evidence based practices. This may help to
clarify the standards that guide the classification of behavioral health treatments as evidencebased.
2) The author should consider the following technical and clarifying amendments:
On page 16, line 19, and on page 20, line 22, consider amending the bill as follows:
(g) No later than December 31, 2017, and thereafter as necessary, the Board of Psychology, upon
appropriation of the Legislature, shall convene a committee to create a list of evidence-based
treatment modalities for purposes of developing mandated behavioral health treatment modalities
for pervasive developmental disorder or autism. The Board of Psychology shall post the list of
evidence-based treatment modalities on their webpage no later than January 1, 2019.
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REGISTERED SUPPORT:
None on file.
REGISTERED OPPOSITION:
None on file.
Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. / (916) 319-3301