| Last Version Text |
<?xml version="1.0" ?>
<ns0:MeasureDoc xmlns:html="http://www.w3.org/1999/xhtml" xmlns:ns0="http://lc.ca.gov/legalservices/schemas/caml.1#" xmlns:ns3="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" version="1.0" xsi:schemaLocation="http://lc.ca.gov/legalservices/schemas/caml.1# xca.1.xsd">
<ns0:Description>
<ns0:Id>20250AB__095196CHP</ns0:Id>
<ns0:VersionNum>96</ns0:VersionNum>
<ns0:History>
<ns0:Action>
<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2025-02-20</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_SENATE</ns0:ActionText>
<ns0:ActionDate>2025-06-23</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>PASSED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-07-14</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>PASSED_SENATE</ns0:ActionText>
<ns0:ActionDate>2025-07-10</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>ENROLLED</ns0:ActionText>
<ns0:ActionDate>2025-07-16</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>CHAPTERED</ns0:ActionText>
<ns0:ActionDate>2025-07-30</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>APPROVED</ns0:ActionText>
<ns0:ActionDate>2025-07-30</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>FILED</ns0:ActionText>
<ns0:ActionDate>2025-07-30</ns0:ActionDate>
</ns0:Action>
</ns0:History>
<ns0:LegislativeInfo>
<ns0:SessionYear>2025</ns0:SessionYear>
<ns0:SessionNum>0</ns0:SessionNum>
<ns0:MeasureType>AB</ns0:MeasureType>
<ns0:MeasureNum>951</ns0:MeasureNum>
<ns0:MeasureState>CHP</ns0:MeasureState>
<ns0:ChapterYear>2025</ns0:ChapterYear>
<ns0:ChapterType>CHP</ns0:ChapterType>
<ns0:ChapterSessionNum>0</ns0:ChapterSessionNum>
<ns0:ChapterNum>84</ns0:ChapterNum>
</ns0:LegislativeInfo>
<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Ta</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthors: Assembly Members Alanis, DeMaio, and Nguyen)</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_OPPOSITE">(Coauthor: Senator Menjivar)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Ta</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Alanis</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>DeMaio</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Nguyen</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Menjivar</ns0:Name>
</ns0:Legislator>
</ns0:Authors>
<ns0:Title> 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. </ns0:Title>
<ns0:RelatingClause>health care coverage</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Health care coverage: behavioral diagnoses. </ns0:Subject>
</ns0:GeneralSubject>
<ns0:DigestText>
<html:p>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 provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism.</html:p>
<html:p>This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2026, from requiring an enrollee or insured previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage for behavioral health treatment for their
condition. The bill would require a treatment plan to be made available to the plan or insurer upon request. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program.</html:p>
<html:p>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.</html:p>
<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
</ns0:DigestText>
<ns0:DigestKey>
<ns0:VoteRequired>MAJORITY</ns0:VoteRequired>
<ns0:Appropriation>NO</ns0:Appropriation>
<ns0:FiscalCommittee>YES</ns0:FiscalCommittee>
<ns0:LocalProgram>YES</ns0:LocalProgram>
</ns0:DigestKey>
<ns0:MeasureIndicators>
<ns0:ImmediateEffect>NO</ns0:ImmediateEffect>
<ns0:ImmediateEffectFlags>
<ns0:Urgency>NO</ns0:Urgency>
<ns0:TaxLevy>NO</ns0:TaxLevy>
<ns0:Election>NO</ns0:Election>
<ns0:UsualCurrentExpenses>NO</ns0:UsualCurrentExpenses>
<ns0:BudgetBill>NO</ns0:BudgetBill>
<ns0:Prop25TrailerBill>NO</ns0:Prop25TrailerBill>
</ns0:ImmediateEffectFlags>
</ns0:MeasureIndicators>
</ns0:Description>
<ns0:Bill id="bill">
<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_F08298A3-DACF-46B4-A7D3-97469F183A7D">
<ns0:Num>SECTION 1.</ns0:Num>
<ns0:ActionLine action="IS_AMENDED" ns3:href="urn:caml:codes:HSC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'2.2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'ARTICLE'%20and%20caml%3ANum%3D'5.6.'%5D%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'1374.73.'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 1374.73 of the
<ns0:DocName>Health and Safety Code</ns0:DocName>
is amended to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_E3FB1FC7-5133-4DD7-8C07-F2CA838429CB">
<ns0:Num>1374.73.</ns0:Num>
<ns0:LawSectionVersion id="id_D8B6F149-0994-4123-9655-9BB461406A36">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding paragraph (1), as of the date that the 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).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health care service plan contract issued, amended, or renewed on or after January 1, 2026, shall not require an enrollee previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage for behavioral health treatment for pervasive developmental disorder or
autism.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
This subdivision does not prohibit or restrict a treating provider from reevaluating an enrollee for purposes of determining the appropriate treatment. The treatment plan shall be made available to the health care service plan upon request.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
This subdivision does not prohibit a treating provider from prescribing a rediagnosis at the discretion of the physician licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code or a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
A health care service plan shall not discontinue or delay existing treatment while waiting for a
rediagnosis to be completed.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
This subdivision does not prohibit a health care service plan from requiring utilization review. For the purpose of this section, utilization review is distinct from a rediagnosis.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
For the purposes of this section, the following definitions shall apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Behavioral health treatment” means professional services and treatment programs, including applied behavior analysis and 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:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
A qualified autism service provider.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
A qualified autism service professional supervised by the qualified autism service provider.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism
service professional.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
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:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Describes the patient’s behavioral health impairments or developmental challenges that are to be treated.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Designs an intervention plan that includes the service type, number of hours, and parent
participation needed to achieve the plan’s goal and objectives, and the frequency at which the patient’s progress is evaluated and reported.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.
</html:p>
<html:p>
(iv)
<html:span class="EnSpace"/>
Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Pervasive developmental disorder or autism” shall have the same meaning and interpretation as used in Section 1374.72.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
“Qualified autism service provider” means either of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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, 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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
“Qualified autism service professional” means an individual who meets all of the following criteria:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Provides behavioral health treatment, which may include clinical
case management and case supervision under the direction and supervision of a qualified autism service provider.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Is supervised by a qualified autism service provider.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Is either of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
A behavioral service provider who 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.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
(i)
<html:span class="EnSpace"/>
Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section
4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
“Qualified autism service paraprofessional” means an unlicensed and uncertified individual who meets all of the following criteria:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Provides treatment and implements services pursuant to a treatment plan
developed and approved by the qualified autism service provider.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
“Rediagnosis” means a subsequent undertaking by any method, device, or procedure, whether gratuitous or not, to ascertain
or establish if a person is suffering from a physical or mental health disorder, pursuant to Section 2038 of the Business and Professions Code. “Rediagnosis” also means prescription of a subsequent diagnosis of pervasive developmental disorders or autism to ascertain or establish if a person is suffering from a pervasive developmental disorder or autism.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
“Utilization review” means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code before, after, or concurrent with the provision of medical treatment services. “Utilization review”
refers to an evaluation of existing treatment to ensure an enrollee receives the proper care at the proper time.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
This section shall not apply to either of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
This section does not limit the obligation to provide services under Section 1374.72.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
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.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_9FDD51A0-8146-4668-9ADE-55AB7622001A">
<ns0:Num>SEC. 2.</ns0:Num>
<ns0:ActionLine action="IS_AMENDED" ns3:href="urn:caml:codes:INS:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'PART'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'1.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'ARTICLE'%20and%20caml%3ANum%3D'2.5.'%5D%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'10144.51.'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 10144.51 of the
<ns0:DocName>Insurance Code</ns0:DocName>
is amended to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_6FA68106-52C1-4148-BB8C-0516B1DF7C8E">
<ns0:Num>10144.51.</ns0:Num>
<ns0:LawSectionVersion id="id_9ECDBBE4-90F5-46E0-B24C-E136138AA331">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding paragraph (1), as of the date that the 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).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health insurance policy issued, amended, or renewed on or after January 1, 2026, shall not require an insured previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage for behavioral health treatment
for pervasive developmental disorder or autism.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
This subdivision does not prohibit or restrict a treating provider from reevaluating an insured for purposes of determining the appropriate treatment. The treatment plan shall be made available to the insurer upon request.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
This subdivision does not prohibit a treating provider from prescribing a rediagnosis at the discretion of the physician licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code or a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
A health insurer shall not discontinue or delay existing treatment while waiting
for a rediagnosis to be completed.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
This subdivision does not prohibit a health insurer from requiring utilization review. For the purpose of this section, utilization review is distinct from a rediagnosis.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
For the purposes of this section, the following definitions shall apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Behavioral health treatment” means professional services and treatment programs, including applied behavior analysis and 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:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
A qualified autism service provider.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
A qualified autism service professional supervised by the qualified autism service provider.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified
autism service professional.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
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:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Describes the patient’s behavioral health impairments or developmental challenges that are to be treated.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Designs an intervention plan that includes the service type, number of hours, and
parent participation needed to achieve the plan’s goal and objectives, and the frequency at which the patient’s progress is evaluated and reported.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.
</html:p>
<html:p>
(iv)
<html:span class="EnSpace"/>
Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Pervasive developmental disorder or autism” shall have the same meaning and interpretation as used in Section 10144.5.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
“Qualified autism service provider” means either of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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, 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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
“Qualified autism service professional” means an individual who meets all of the following criteria:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Is supervised by a qualified autism service provider.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Is either of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
A behavioral service provider who 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.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
A psychological associate, an associate marriage and family therapist, an
associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
(i)
<html:span class="EnSpace"/>
Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
“Qualified autism service paraprofessional” means an unlicensed and uncertified individual who meets all of the following criteria:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Meets the education
and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
“Rediagnosis” means a subsequent undertaking by any method, device, or procedure, whether gratuitous or not, to ascertain or establish if a person is suffering from a physical or mental health disorder, pursuant to Section 2038 of the Business and Professions Code.
“Rediagnosis” also means prescription of a subsequent diagnosis of pervasive developmental disorders or autism to ascertain or establish if a person is suffering from a pervasive developmental disorder or autism.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
“Utilization review” means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code before, after, or concurrent with the provision of medical treatment services. “Utilization review” refers to an evaluation of existing treatment to ensure
the insured receives the proper care at the proper time.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
This section shall not apply to either of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
This section does not limit the obligation to provide
services under Section 10144.5.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
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.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_3776DCD2-303A-45F8-9C75-E59F73B7E751">
<ns0:Num>SEC. 3.</ns0:Num>
<ns0:Content>
<html:p>
No reimbursement is required by this act pursuant to Section 6 of Article XIII
<html:span class="ThinSpace"/>
B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII
<html:span class="ThinSpace"/>
B of the California Constitution.
</html:p>
</ns0:Content>
</ns0:BillSection>
</ns0:Bill>
</ns0:MeasureDoc>
|