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| 1 | + | Amended IN Assembly September 05, 2019 Amended IN Assembly September 03, 2019 Amended IN Assembly June 27, 2019 Amended IN Assembly June 11, 2019 Amended IN Senate May 17, 2019 Amended IN Senate April 09, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Senate Bill No. 163Introduced by Senator Portantino(Coauthor: Assembly Member Nazarian)January 24, 2019 An act to amend Section 1374.73 of the Health and Safety Code, and to amend Section 10144.51 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTSB 163, as amended, Portantino. Health care coverage: pervasive developmental disorder or autism.Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service provider to refer to a person who is certified or licensed and a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider. Existing law also requires a qualified autism service provider to design, in connection with the treatment plan, an intervention plan that describes, among other information, the parent participation needed to achieve the plans goals and objectives, as specified. Under existing law, these coverage requirements provide an exception for specialized health care service plans or health insurance policies that do not cover mental health or behavioral health services, accident only, specified disease, hospital indemnity, or Medicare supplement health insurance policies, and health care service plans and health insurance policies in the Medi-Cal program.Existing federal law, the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), requires group health plans and health insurance issuers that provide both medical and surgical benefits and mental health or substance use disorder benefits to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. Existing state law subjects nongrandfathered individual and small group health care service plan contracts and health insurance policies that provide coverage for essential health benefits to those provisions of the MHPAEA.This bill would revise the definition of behavioral health treatment to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models. The bill would remove the exception for health care service plans and health insurance policies in the Medi-Cal program, consistent with the MHPAEA. This bill also would expand the definition of a qualified autism service professional to include behavioral service providers who meet specified educational and professional or work experience qualifications. The bill would revise the definition of a qualified autism service paraprofessional by deleting the reference to an unlicensed and uncertified individual and by requiring the individual to comply with revised educational and training, or professional, requirements. The bill would also revise the definitions of both a qualified autism service professional and a qualified autism service paraprofessional to include the requirement that these individuals complete a background check.This bill would require the intervention plan designed by the qualified autism service provider to include parent or caregiver participation, when clinically appropriate, that is individualized to the patient and takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities, as specified. The bill would specify that the lack of parent or caregiver participation shall not be used to deny or reduce medically necessary services and that the setting, location, or time of treatment not be used as the only reason to deny medically necessary services. Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. This act shall be known, and may be cited, as Lucas Law.SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 2 | 2 | ||
| 3 | - | ||
| 3 | + | Amended IN Assembly September 05, 2019 Amended IN Assembly September 03, 2019 Amended IN Assembly June 27, 2019 Amended IN Assembly June 11, 2019 Amended IN Senate May 17, 2019 Amended IN Senate April 09, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Senate Bill No. 163Introduced by Senator Portantino(Coauthor: Assembly Member Nazarian)January 24, 2019 An act to amend Section 1374.73 of the Health and Safety Code, and to amend Section 10144.51 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTSB 163, as amended, Portantino. Health care coverage: pervasive developmental disorder or autism.Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service provider to refer to a person who is certified or licensed and a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider. Existing law also requires a qualified autism service provider to design, in connection with the treatment plan, an intervention plan that describes, among other information, the parent participation needed to achieve the plans goals and objectives, as specified. Under existing law, these coverage requirements provide an exception for specialized health care service plans or health insurance policies that do not cover mental health or behavioral health services, accident only, specified disease, hospital indemnity, or Medicare supplement health insurance policies, and health care service plans and health insurance policies in the Medi-Cal program.Existing federal law, the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), requires group health plans and health insurance issuers that provide both medical and surgical benefits and mental health or substance use disorder benefits to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. Existing state law subjects nongrandfathered individual and small group health care service plan contracts and health insurance policies that provide coverage for essential health benefits to those provisions of the MHPAEA.This bill would revise the definition of behavioral health treatment to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models. The bill would remove the exception for health care service plans and health insurance policies in the Medi-Cal program, consistent with the MHPAEA. This bill also would expand the definition of a qualified autism service professional to include behavioral service providers who meet specified educational and professional or work experience qualifications. The bill would revise the definition of a qualified autism service paraprofessional by deleting the reference to an unlicensed and uncertified individual and by requiring the individual to comply with revised educational and training, or professional, requirements. The bill would also revise the definitions of both a qualified autism service professional and a qualified autism service paraprofessional to include the requirement that these individuals complete a background check.This bill would require the intervention plan designed by the qualified autism service provider to include parent or caregiver participation, when clinically appropriate, that is individualized to the patient and takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities, as specified. The bill would specify that the lack of parent or caregiver participation shall not be used to deny or reduce medically necessary services and that the setting, location, or time of treatment not be used as the only reason to deny medically necessary services. Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES | |
| 4 | 4 | ||
| 5 | - | ||
| 5 | + | Amended IN Assembly September 05, 2019 Amended IN Assembly September 03, 2019 Amended IN Assembly June 27, 2019 Amended IN Assembly June 11, 2019 Amended IN Senate May 17, 2019 Amended IN Senate April 09, 2019 | |
| 6 | 6 | ||
| 7 | - | Enrolled September 13, 2019 | |
| 8 | - | Passed IN Senate September 11, 2019 | |
| 9 | - | Passed IN Assembly September 09, 2019 | |
| 10 | 7 | Amended IN Assembly September 05, 2019 | |
| 11 | 8 | Amended IN Assembly September 03, 2019 | |
| 12 | 9 | Amended IN Assembly June 27, 2019 | |
| 13 | 10 | Amended IN Assembly June 11, 2019 | |
| 14 | 11 | Amended IN Senate May 17, 2019 | |
| 15 | 12 | Amended IN Senate April 09, 2019 | |
| 16 | 13 | ||
| 17 | 14 | CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION | |
| 18 | 15 | ||
| 19 | 16 | Senate Bill | |
| 20 | 17 | ||
| 21 | 18 | No. 163 | |
| 22 | 19 | ||
| 23 | 20 | Introduced by Senator Portantino(Coauthor: Assembly Member Nazarian)January 24, 2019 | |
| 24 | 21 | ||
| 25 | 22 | Introduced by Senator Portantino(Coauthor: Assembly Member Nazarian) | |
| 26 | 23 | January 24, 2019 | |
| 27 | 24 | ||
| 28 | 25 | An act to amend Section 1374.73 of the Health and Safety Code, and to amend Section 10144.51 of the Insurance Code, relating to health care coverage. | |
| 29 | 26 | ||
| 30 | 27 | LEGISLATIVE COUNSEL'S DIGEST | |
| 31 | 28 | ||
| 32 | 29 | ## LEGISLATIVE COUNSEL'S DIGEST | |
| 33 | 30 | ||
| 34 | - | SB 163, Portantino. Health care coverage: pervasive developmental disorder or autism. | |
| 31 | + | SB 163, as amended, Portantino. Health care coverage: pervasive developmental disorder or autism. | |
| 35 | 32 | ||
| 36 | 33 | Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service provider to refer to a person who is certified or licensed and a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider. Existing law also requires a qualified autism service provider to design, in connection with the treatment plan, an intervention plan that describes, among other information, the parent participation needed to achieve the plans goals and objectives, as specified. Under existing law, these coverage requirements provide an exception for specialized health care service plans or health insurance policies that do not cover mental health or behavioral health services, accident only, specified disease, hospital indemnity, or Medicare supplement health insurance policies, and health care service plans and health insurance policies in the Medi-Cal program.Existing federal law, the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), requires group health plans and health insurance issuers that provide both medical and surgical benefits and mental health or substance use disorder benefits to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. Existing state law subjects nongrandfathered individual and small group health care service plan contracts and health insurance policies that provide coverage for essential health benefits to those provisions of the MHPAEA.This bill would revise the definition of behavioral health treatment to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models. The bill would remove the exception for health care service plans and health insurance policies in the Medi-Cal program, consistent with the MHPAEA. This bill also would expand the definition of a qualified autism service professional to include behavioral service providers who meet specified educational and professional or work experience qualifications. The bill would revise the definition of a qualified autism service paraprofessional by deleting the reference to an unlicensed and uncertified individual and by requiring the individual to comply with revised educational and training, or professional, requirements. The bill would also revise the definitions of both a qualified autism service professional and a qualified autism service paraprofessional to include the requirement that these individuals complete a background check.This bill would require the intervention plan designed by the qualified autism service provider to include parent or caregiver participation, when clinically appropriate, that is individualized to the patient and takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities, as specified. The bill would specify that the lack of parent or caregiver participation shall not be used to deny or reduce medically necessary services and that the setting, location, or time of treatment not be used as the only reason to deny medically necessary services. Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.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. | |
| 37 | 34 | ||
| 38 | 35 | Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism. | |
| 39 | 36 | ||
| 40 | 37 | Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service provider to refer to a person who is certified or licensed and a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider. Existing law also requires a qualified autism service provider to design, in connection with the treatment plan, an intervention plan that describes, among other information, the parent participation needed to achieve the plans goals and objectives, as specified. Under existing law, these coverage requirements provide an exception for specialized health care service plans or health insurance policies that do not cover mental health or behavioral health services, accident only, specified disease, hospital indemnity, or Medicare supplement health insurance policies, and health care service plans and health insurance policies in the Medi-Cal program. | |
| 41 | 38 | ||
| 42 | 39 | Existing federal law, the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), requires group health plans and health insurance issuers that provide both medical and surgical benefits and mental health or substance use disorder benefits to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. Existing state law subjects nongrandfathered individual and small group health care service plan contracts and health insurance policies that provide coverage for essential health benefits to those provisions of the MHPAEA. | |
| 43 | 40 | ||
| 44 | 41 | This bill would revise the definition of behavioral health treatment to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models. The bill would remove the exception for health care service plans and health insurance policies in the Medi-Cal program, consistent with the MHPAEA. | |
| 45 | 42 | ||
| 46 | 43 | This bill also would expand the definition of a qualified autism service professional to include behavioral service providers who meet specified educational and professional or work experience qualifications. The bill would revise the definition of a qualified autism service paraprofessional by deleting the reference to an unlicensed and uncertified individual and by requiring the individual to comply with revised educational and training, or professional, requirements. The bill would also revise the definitions of both a qualified autism service professional and a qualified autism service paraprofessional to include the requirement that these individuals complete a background check. | |
| 47 | 44 | ||
| 48 | 45 | This bill would require the intervention plan designed by the qualified autism service provider to include parent or caregiver participation, when clinically appropriate, that is individualized to the patient and takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities, as specified. The bill would specify that the lack of parent or caregiver participation shall not be used to deny or reduce medically necessary services and that the setting, location, or time of treatment not be used as the only reason to deny medically necessary services. Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program. | |
| 49 | 46 | ||
| 50 | 47 | 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. | |
| 51 | 48 | ||
| 52 | 49 | This bill would provide that no reimbursement is required by this act for a specified reason. | |
| 53 | 50 | ||
| 54 | 51 | ## Digest Key | |
| 55 | 52 | ||
| 56 | 53 | ## Bill Text | |
| 57 | 54 | ||
| 58 | - | The people of the State of California do enact as follows:SECTION 1. This act shall be known, and may be cited, as Lucas Law.SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 55 | + | The people of the State of California do enact as follows:SECTION 1. This act shall be known, and may be cited, as Lucas Law.SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 59 | 56 | ||
| 60 | 57 | The people of the State of California do enact as follows: | |
| 61 | 58 | ||
| 62 | 59 | ## The people of the State of California do enact as follows: | |
| 63 | 60 | ||
| 64 | 61 | SECTION 1. This act shall be known, and may be cited, as Lucas Law. | |
| 65 | 62 | ||
| 66 | 63 | SECTION 1. This act shall be known, and may be cited, as Lucas Law. | |
| 67 | 64 | ||
| 68 | 65 | SECTION 1. This act shall be known, and may be cited, as Lucas Law. | |
| 69 | 66 | ||
| 70 | 67 | ### SECTION 1. | |
| 71 | 68 | ||
| 72 | - | SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 69 | + | SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 73 | 70 | ||
| 74 | 71 | SEC. 2. Section 1374.73 of the Health and Safety Code, as amended by Section 1 of Chapter 385 of the Statutes of 2017, is amended to read: | |
| 75 | 72 | ||
| 76 | 73 | ### SEC. 2. | |
| 77 | 74 | ||
| 78 | - | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 75 | + | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 79 | 76 | ||
| 80 | - | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 77 | + | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 81 | 78 | ||
| 82 | - | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 79 | + | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 83 | 80 | ||
| 84 | 81 | ||
| 85 | 82 | ||
| 86 | 83 | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 1374.72. | |
| 87 | 84 | ||
| 88 | 85 | (2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide 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). | |
| 89 | 86 | ||
| 90 | 87 | (3) This section shall not affect services for which an individual is eligible 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. | |
| 91 | 88 | ||
| 92 | 89 | (4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations. | |
| 93 | 90 | ||
| 94 | 91 | (b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements. | |
| 95 | 92 | ||
| 96 | 93 | (c) For the purposes of this section, the following definitions shall apply: | |
| 97 | 94 | ||
| 98 | 95 | (1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria: | |
| 99 | 96 | ||
| 100 | 97 | (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code. | |
| 101 | 98 | ||
| 102 | 99 | (B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following: | |
| 103 | 100 | ||
| 104 | 101 | (i) A qualified autism service provider. | |
| 105 | 102 | ||
| 106 | 103 | (ii) A qualified autism service professional supervised by the qualified autism service provider. | |
| 107 | 104 | ||
| 108 | 105 | (iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional. | |
| 109 | 106 | ||
| 110 | 107 | (C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: | |
| 111 | 108 | ||
| 112 | 109 | (i) Describes the patients behavioral health impairments or developmental challenges that are to be treated. | |
| 113 | 110 | ||
| 114 | 111 | (ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy. | |
| 115 | 112 | ||
| 116 | 113 | (iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism. | |
| 117 | 114 | ||
| 118 | 115 | (iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate. | |
| 119 | 116 | ||
| 120 | 117 | (D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request. | |
| 121 | 118 | ||
| 122 | 119 | (2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72. | |
| 123 | 120 | ||
| 124 | 121 | (3) Qualified autism service provider means either of the following: | |
| 125 | 122 | ||
| 126 | 123 | (A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified. | |
| 127 | 124 | ||
| 128 | 125 | (B) A 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 licensee. | |
| 129 | 126 | ||
| 130 | 127 | (4) Qualified autism service professional means an individual who meets all of the following criteria: | |
| 131 | 128 | ||
| 132 | 129 | (A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional. | |
| 133 | 130 | ||
| 134 | 131 | (B) Is supervised by a qualified autism service provider. | |
| 135 | 132 | ||
| 136 | 133 | (C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. | |
| 137 | 134 | ||
| 138 | 135 | (D) Is a behavioral service provider who meets one of the following criteria: | |
| 139 | 136 | ||
| 140 | 137 | (i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program. | |
| 141 | 138 | ||
| 142 | 139 | (ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications: | |
| 143 | 140 | ||
| 144 | 141 | (I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health. | |
| 145 | 142 | ||
| 146 | 143 | (II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider. | |
| 147 | 144 | ||
| 148 | 145 | (III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration. | |
| 149 | 146 | ||
| 150 | 147 | (IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration. | |
| 151 | 148 | ||
| 152 | 149 | (V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration. | |
| 153 | 150 | ||
| 154 | 151 | (VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration. | |
| 155 | 152 | ||
| 156 | 153 | (VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider. | |
| 157 | 154 | ||
| 158 | 155 | (E) Has training and experience in providing services for pervasive developmental disorder or autism. | |
| 159 | 156 | ||
| 160 | 157 | (F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. | |
| 161 | 158 | ||
| 162 | - | (G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 159 | + | (G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 163 | 160 | ||
| 164 | 161 | (5) Qualified autism service paraprofessional means an individual who meets all of the following criteria: | |
| 165 | 162 | ||
| 166 | 163 | (A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice. | |
| 167 | 164 | ||
| 168 | 165 | (B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider. | |
| 169 | 166 | ||
| 170 | 167 | (C) Meets one of the following: | |
| 171 | 168 | ||
| 172 | 169 | (i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations. | |
| 173 | 170 | ||
| 174 | 171 | (ii) For other evidence-based behavioral health treatments, all of the following qualifications: | |
| 175 | 172 | ||
| 176 | 173 | (I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study. | |
| 177 | 174 | ||
| 178 | 175 | (II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional. | |
| 179 | 176 | ||
| 180 | 177 | (III) Has adequate education, training, and experience, as certified by a qualified autism service provider. | |
| 181 | 178 | ||
| 182 | 179 | (iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute. | |
| 183 | 180 | ||
| 184 | 181 | However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential. | |
| 185 | 182 | ||
| 186 | 183 | (D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers. | |
| 187 | 184 | ||
| 188 | 185 | (E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. | |
| 189 | 186 | ||
| 190 | - | (F) Has completed a background check performed by an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 187 | + | (F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 191 | 188 | ||
| 192 | 189 | (d) This section shall not apply to a specialized health care service plan that does not deliver mental health or behavioral health services to enrollees. | |
| 193 | 190 | ||
| 194 | 191 | (e) This section does not limit the obligation to provide services under Section 1374.72. | |
| 195 | 192 | ||
| 196 | 193 | (f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. | |
| 197 | 194 | ||
| 198 | 195 | (g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health care service plan to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health care service plan to cover services rendered outside of the plans service area unless the services are urgently needed services, as described in subdivision (h) of Section 1345, or emergency services, as defined in Section 1317.1, or unless the benefit plan expressly covers out-of-area services. | |
| 199 | 196 | ||
| 200 | 197 | (2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 201 | 198 | ||
| 202 | - | SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 199 | + | SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 203 | 200 | ||
| 204 | 201 | SEC. 3. Section 10144.51 of the Insurance Code, as amended by Section 2 of Chapter 385 of the Statutes of 2017, is amended to read: | |
| 205 | 202 | ||
| 206 | 203 | ### SEC. 3. | |
| 207 | 204 | ||
| 208 | - | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 205 | + | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
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| 210 | - | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 207 | + | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 211 | 208 | ||
| 212 | - | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 209 | + | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. 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), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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 affect services for which an individual is eligible 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.(4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and 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, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3) Qualified autism service provider means either of the following:(A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B) A 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 licensee.(4) Qualified autism service professional means an individual who meets all of the following criteria:(A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional.(B) Is supervised by a qualified autism service provider.(C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D) Is a behavioral service provider who meets one of the following criteria:(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.(ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications:(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration.(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration.(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration.(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration.(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.(E) Has training and experience in providing services for pervasive developmental disorder or autism.(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(5) Qualified autism service paraprofessional means an individual who meets all of the following criteria:(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C) Meets one of the following:(i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(ii) For other evidence-based behavioral health treatments, all of the following qualifications:(I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study.(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.(III) Has adequate education, training, and experience, as certified by a qualified autism service provider.(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute.However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.(D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code.(d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.(g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 213 | 210 | ||
| 214 | 211 | ||
| 215 | 212 | ||
| 216 | 213 | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 10144.5. | |
| 217 | 214 | ||
| 218 | 215 | (2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide 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). | |
| 219 | 216 | ||
| 220 | 217 | (3) This section shall not affect services for which an individual is eligible 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. | |
| 221 | 218 | ||
| 222 | 219 | (4) This section shall not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations. | |
| 223 | 220 | ||
| 224 | 221 | (b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements. | |
| 225 | 222 | ||
| 226 | 223 | (c) For the purposes of this section, the following definitions shall apply: | |
| 227 | 224 | ||
| 228 | 225 | (1) Behavioral health treatment means professional services and treatment programs based on behavioral, developmental, relationship-based, or other evidence-based models, including applied behavior analysis and other evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria: | |
| 229 | 226 | ||
| 230 | 227 | (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code. | |
| 231 | 228 | ||
| 232 | 229 | (B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following: | |
| 233 | 230 | ||
| 234 | 231 | (i) A qualified autism service provider. | |
| 235 | 232 | ||
| 236 | 233 | (ii) A qualified autism service professional supervised by the qualified autism service provider. | |
| 237 | 234 | ||
| 238 | 235 | (iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional. | |
| 239 | 236 | ||
| 240 | 237 | (C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: | |
| 241 | 238 | ||
| 242 | 239 | (i) Describes the patients behavioral health impairments or developmental challenges that are to be treated. | |
| 243 | 240 | ||
| 244 | 241 | (ii) Designs an intervention plan that includes the service type, number of hours, and parent participation, when clinically appropriate, needed to achieve the plans goals and objectives, and the frequency at which the patients progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other recommended activities. This clause does not limit the right of a parent or caregiver to participate in the patients therapy. | |
| 245 | 242 | ||
| 246 | 243 | (iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism. | |
| 247 | 244 | ||
| 248 | 245 | (iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate. | |
| 249 | 246 | ||
| 250 | 247 | (D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request. | |
| 251 | 248 | ||
| 252 | 249 | (2) Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5. | |
| 253 | 250 | ||
| 254 | 251 | (3) Qualified autism service provider means either of the following: | |
| 255 | 252 | ||
| 256 | 253 | (A) A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified. | |
| 257 | 254 | ||
| 258 | 255 | (B) A 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 licensee. | |
| 259 | 256 | ||
| 260 | 257 | (4) Qualified autism service professional means an individual who meets all of the following criteria: | |
| 261 | 258 | ||
| 262 | 259 | (A) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The services shall be consistent with the experience, training, or education of the professional. | |
| 263 | 260 | ||
| 264 | 261 | (B) Is supervised by a qualified autism service provider. | |
| 265 | 262 | ||
| 266 | 263 | (C) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. | |
| 267 | 264 | ||
| 268 | 265 | (D) Is a behavioral service provider who meets one of the following criteria: | |
| 269 | 266 | ||
| 270 | 267 | (i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program. | |
| 271 | 268 | ||
| 272 | 269 | (ii) Possesses a bachelor of arts or science degree and meets one of the following qualifications: | |
| 273 | 270 | ||
| 274 | 271 | (I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health. | |
| 275 | 272 | ||
| 276 | 273 | (II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider. | |
| 277 | 274 | ||
| 278 | 275 | (III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered psychologist may not supervise a qualified autism service paraprofessional until the registered psychological assistant or registered psychologist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered psychological assistant or registered psychologist in complying with this section shall conform to all of the requirements for their registration. | |
| 279 | 276 | ||
| 280 | 277 | (IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until the associate clinical social worker has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. An associate clinical social worker in complying with this section shall conform to all of the requirements for their registration. | |
| 281 | 278 | ||
| 282 | 279 | (V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate marriage and family therapist may not supervise a qualified autism service paraprofessional until the registered associate marriage and family therapist has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate marriage and family therapist in complying with this section shall conform to all of the requirements for their registration. | |
| 283 | 280 | ||
| 284 | 281 | (VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until the registered associate professional clinical counselor has obtained at least 500 hours of experience in designing or implementing behavioral health treatment. A registered associate professional clinical counselor in complying with this section shall conform to all of the requirements for their registration. | |
| 285 | 282 | ||
| 286 | 283 | (VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board, which is accredited by the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider. | |
| 287 | 284 | ||
| 288 | 285 | (E) Has training and experience in providing services for pervasive developmental disorder or autism. | |
| 289 | 286 | ||
| 290 | 287 | (F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. | |
| 291 | 288 | ||
| 292 | - | (G) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 289 | + | (G) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 293 | 290 | ||
| 294 | 291 | (5) Qualified autism service paraprofessional means an individual who meets all of the following criteria: | |
| 295 | 292 | ||
| 296 | 293 | (A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice. | |
| 297 | 294 | ||
| 298 | 295 | (B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider. | |
| 299 | 296 | ||
| 300 | 297 | (C) Meets one of the following: | |
| 301 | 298 | ||
| 302 | 299 | (i) For applied behavioral analysis, the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations. | |
| 303 | 300 | ||
| 304 | 301 | (ii) For other evidence-based behavioral health treatments, all of the following qualifications: | |
| 305 | 302 | ||
| 306 | 303 | (I) Possesses an associates degree or has completed two years of study from an accredited college or university with coursework in a related field of study. | |
| 307 | 304 | ||
| 308 | 305 | (II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional. | |
| 309 | 306 | ||
| 310 | 307 | (III) Has adequate education, training, and experience, as certified by a qualified autism service provider. | |
| 311 | 308 | ||
| 312 | 309 | (iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute. | |
| 313 | 310 | ||
| 314 | 311 | However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential. | |
| 315 | 312 | ||
| 316 | 313 | (D) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers. | |
| 317 | 314 | ||
| 318 | 315 | (E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. | |
| 319 | 316 | ||
| 320 | - | (F) Has completed a background check performed by an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 317 | + | (F) Has completed a background check performed by a Department of Justice approved agency, an agency approved by the Department of Justice, with subsequent notification to the persons employer pursuant to Section 11105.2 of the Penal Code. | |
| 321 | 318 | ||
| 322 | 319 | (d) This section shall not apply to a specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy. | |
| 323 | 320 | ||
| 324 | 321 | (e) This section does not limit the obligation to provide services under Section 10144.5. | |
| 325 | 322 | ||
| 326 | 323 | (f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. | |
| 327 | 324 | ||
| 328 | 325 | (g) (1) The setting, location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollees individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurers service area unless the services are urgently needed services to prevent serious deterioration of a covered persons health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurers service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services. | |
| 329 | 326 | ||
| 330 | 327 | (2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services. | |
| 331 | 328 | ||
| 332 | 329 | SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 333 | 330 | ||
| 334 | 331 | SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 335 | 332 | ||
| 336 | 333 | SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 337 | 334 | ||
| 338 | 335 | ### SEC. 4. |