AB 796
Page 1
Date of Hearing: May 5, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
AB 796 (Nazarian) – As Introduced February 26, 2015
NOTE: This bill is double referred, and if passed by this Committee, it will be referred to the
Assembly Health Committee.
SUBJECT: Health care coverage: autism and pervasive developmental disorders.
SUMMARY: Expands the eligibility for a person to be a qualified autism service professional
to include a person who possesses a bachelor of arts or science degree and meets other
requirements as specified, or is a registered psychological assistant, a registered psychologist or
an associate clinical social worker. Expands the eligibility for a person to be a qualified autism
service paraprofessional to include a person with a high school diploma or equivalent, and six
months experience working with persons with developmental disabilities.
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)
AB 796
Page 2
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,
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" 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
AB 796
Page 3
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))
THIS BILL:
1) Adds additional criteria to the definition of “qualified autism service professional” within the
HSC as follows:
a) Is 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 Section 54342 of
Title 17 of the California Code of Regulations.
b) Possesses a bachelor of arts or science degree and has either of the following:
i) Twelve semester units from an accredited institute of higher learning in either applied
behavioral analysis or clinical coursework in behavioral health and one year of
experience in designing or implementing behavioral health treatment; or,
ii) Two years of experience in designing or implementing behavioral health treatment.
c) The person is a registered psychological assistant or registered psychologist.
d) The person is an associate clinical social worker registered with the Board of Behavioral
Sciences.
2) Adds additional criteria to the definition of a “qualified autism service paraprofessional”
within the HSC as follows:
a) Meets the criteria set forth in the regulations adopted pursuant to Section 4686.3 of the
WIC or meets all of the following:
i) Possesses a high school diploma or equivalent;
ii) Has six months experience working with persons with a developmental disability;
iii) Has 30 hours of training in the specific form of evidence-based behavioral health
treatment administered by a qualified autism provider or qualified autism service
professional; and,
iv) Has successfully passed a background check conducted by a state-approved agency.
3) Adds additional criteria to the definition of a “qualified autism service professional” within
the INS as follows:
a) Is a behavioral service provider who meets one of the following criteria:
i) Is 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
Section 54342 of Title 17 of the California Code of Regulations; or,
AB 796
Page 4
ii) Possesses a bachelor of arts or science degree and has either of the following:
(1) Twelve semester units from an accredited institute of higher learning in either
applied behavioral analysis or clinical coursework in behavioral health and one
year of experience in designing or implementing behavioral health treatment; or,
(2) Two years of experience in designing or implementing behavioral health
treatment.
b) The person is a registered psychological assistant or registered psychologist.
c) The person is an associate clinical social worker registered with the Board of Behavioral
Sciences.
4) Adds additional criteria to the definition of a “qualified autism service paraprofessional”
within the INS as follows:
a) Meets the criteria set forth in the regulations adopted pursuant to Section 4686.3 of the
WIC or meets all of the following:
i) Possesses a high school diploma or equivalent;
ii) Has six months experience working with persons with a developmental disability;
iii) Has 30 hours of training in the specific form of evidence-based behavioral health
treatment administered by a qualified autism provider or qualified autism service
professional; and,
iv) Has successfully passed a background check conducted by a state-approved agency.
FISCAL EFFECT: None. This bill has been keyed non-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
AB 796
Page 5
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. While there are many "autisms," 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. ASD, is one of the commonly-used
terms to describe the various "autisms" and other PDD, and it more appropriately captures the
array of symptoms and varying levels in the severity of symptoms experienced by individuals
with a diagnosis within ASD.
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. Specifically, there are a several different
types of behavioral health treatment 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.”
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
AB 796
Page 6
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
atypical behaviors. Using developmental and relationship-based approaches, this therapy can be
delivered in natural settings such as the home or pre-school.
TEACCH (Treatment and Education of Autistic and related Communication Handicapped
Children)—emphasizes adapting the child's physical environment and using visual cues (for
example, having classroom materials clearly marked and located so that students can access them
independently). Using individualized plans for each student, TEACCH builds on the child's
strengths and emerging skills.
Interpersonal Synchrony—targets social development and imitation skills, and focuses on
teaching children how to establish and maintain engagement with others.
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 evidence
based 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.
AB 796
Page 7
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;
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 lease 60-75 percent of the supervision should be direct
fact-to-face supervision and include significant co-therapy with the top or mid-level
supervisor; and,
d) The supervision shall cover the functions of ongoing treatment planning and case
supervision.
Current Related Legislation. SB 479 (Bates), of the current legislative session, establishes the
Behavior Analyst Act which would require 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. STATUS: This bill passed the Senate Committee on Business, Professions and
Economic Development with an 8-0 vote and is now in the Senate Appropriations Committee.
Prior Related Legislation. 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.
AB 796
Page 8
ARGUMENTS IN SUPPORT:
Hundreds of individuals wrote letters of support. They write, “When the members of the
Legislature passed SB 946, the definition for “behavioral health treatments” was broadly defined
to include all physician or psychologist prescribed evidence-based forms of therapy. Despite the
best intentions of the Legislature, the law limited this in practice. Many children are being
denied specific forms of prescribed therapy they need. AB 796 is right for children with autism,
for parents of those children and for the state. By passing this bill, children in California will be
able to receive the treatment they need and deserve and state costs will be reduced as health
insurance will cover all forms of prescribed, evidence-based treatment for autism.”
ARGUMENTS IN OPPOSITION:
The Autism Research Group opposes the bill and writes, “…we are especially concerned about
the potential effects of a bill that would allow paraprofessionals untrained in applied behavior
analysis to replace ABA professionals. The developmental window during which children with
ASD can optimally benefit from treatment is narrow, and AB 796 could potentially allow
precious time to be squandered “treating” children with ASD with experimental treatment, rather
than treating children using ABA.”
The California Association of Behavior Analysts also write in opposition, “Our concern is less
about the particular discipline being employed by the service providers, and more about diluting
the training and education requirements of anyone providing services for this population. SB
946 established standards applicable to the principle treatment for autism, which is behavior
analysis. Since its enactment, the health insurance industry has accepted this as the appropriate
treatment for autism, based both on the science and on the qualifications of those providing the
services. AB 796 proposes to elevate into the realm of accepted providers for the delivery of
behavior analysis individuals that lack the requisite training and education to provide those
services at the level of ‘qualified autism professional.’”
The Center for Autism & Related Disorders shares their opposition to the bill, “AB 796 would
jeopardize Californians who seek medically necessary treatment for autism spectrum disorder by
diluting California’s professional standards and allowing children with ASD to be treated by
unqualified personnel.”
POLICY ISSUES FOR CONSIDERATION:
This bill would amend the definitions of a qualified autism service professional and qualified
autism service paraprofessional. The author contends that there is a need to expand these
definitions to allow more individuals the ability to offer, and be reimbursed for, a variety of
behavioral health treatment modalities, other than evidence-based treatment and ABA, for
individuals who have ASD and PDD. The Committee may wish to consider if this bill takes the
right approach to achieving this goal. Currently, providers can only be reimbursed for ABA and
evidence-based interventions.
In the DMHC’s Task Force report, it outlines the qualifications for unlicensed and uncertified
front line treatment providers and many of the recommended qualifications have been codified.
The author has included some of these qualifications in this bill and aims to allow these
unlicensed providers to be recognized as qualified autism services paraprofessionals. For
example, the author wishes to expand the definition of a qualified paraprofessional to include an
AB 796
Page 9
individual who has a high school diploma and six months of working with individuals who have
a developmental disability.
The author also wishes to expand the definition of a qualified professional to include an
individual who has a bachelors degree, coursework in behavioral health and experience in
designing or implementing BHT, while current law requires that the individual be recognized as
a vendor approved by a Regional Center. The vendors that are approved have to be able to show
evidence of being able to provide ABA or evidence-based treatment. By adding these additional
qualifications to the definition of a qualified professional, additional modalities of treatment
would be permitted to be utilized, such as DIR Floortime.
It is clear that the author’s intent is to allow for other methodologies to be recognized as
reimbursable treatment for developmental disabilities such as ASD and PDD. The way the
author seeks to do this is by curtailing the existing definitions of autism professionals and
paraprofessionals which will allow them to utilize other forms of treatment that are not evidencebased or currently recognized in the code of regulations. Rather than curtail the criteria for the
providers of evidence-based treatments for ASD and PDD, that the DMHC has already
thoroughly reviewed and established in law and in the regulations, perhaps a better approach
would be to propose legislation that would amend the Insurance Code and the Health and Safety
Code to recognize non-evidence-based treatments as acceptable and reimbursable forms of
treatment for developmental disabilities such as ASD and PDD.
REGISTERED SUPPORT:
Hundreds of individuals
REGISTERED OPPOSITION:
Autism Research Group
California Association of Behavior Analysts
Center for Autism & Related Disorders
Southern California Consortium for Behavior Analysis
Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. / (916) 319-3301