BILL NUMBER: AB 171	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MAY 3, 2011
	AMENDED IN ASSEMBLY  APRIL 6, 2011

INTRODUCED BY   Assembly Member Beall
   (Coauthors: Assembly Members Ammiano, Blumenfield, Brownley,
Carter, Chesbro, Eng, Huffman, Mitchell, Swanson,  Wieckowski,
 Williams, and Yamada)

                        JANUARY 20, 2011

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



	LEGISLATIVE COUNSEL'S DIGEST


   AB 171, as amended, Beall. Autism spectrum disorder.
   (1) Existing law provides for licensing and regulation of health
care service plans by the Department of Managed Health Care. A
willful violation of these provisions is a crime. Existing law
provides for licensing and regulation of health insurers by the
Insurance Commissioner. Existing law requires health care service
plan contracts and health insurance policies to provide benefits for
specified conditions, including certain mental health conditions.
   This bill would require health care service plan contracts and
health insurance policies to provide coverage for the screening,
diagnosis, and treatment of autism spectrum disorders. The bill
would, however, provide that no benefits are required to be provided
by a health benefit plan offered through the California Health
Benefit Exchange that exceed the essential health benefits required
under federal law. The bill would prohibit coverage from being denied
for specified reasons. Because the bill would change the definition
of a crime with respect to health care service plans, it would
thereby impose a state-mandated local program.
   (2) The California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1374.73 is added to the Health and Safety Code,
to read:
   1374.73.  (a) Every health care service plan contract issued,
amended, or renewed on or after January 1, 2012, that provides
hospital, medical, or surgical coverage shall provide coverage for
the screening, diagnosis, and treatment of autism spectrum disorders.

   (b) A health care service plan shall not terminate coverage, or
refuse to deliver, execute, issue, amend, adjust, or renew coverage,
to an enrollee solely because the individual is diagnosed with, or
has received treatment for, an autism spectrum disorder.
   (c) Coverage required to be provided under this section shall
extend to all medically necessary services and shall not be subject
to any limits regarding age, number of visits, or dollar amounts.
Coverage required to be provided under this section shall not be
subject to provisions relating to lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that are
less favorable to an enrollee than lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that apply
to physical illness generally under the plan contract.
   (d) Coverage required to be provided under this section is a
health care service and a covered health care benefit for purposes of
this chapter. Coverage shall not be denied on the basis that the
treatment is habilitative, nonrestorative, educational, academic, or
custodial in nature.
   (e) A health care service plan may request, no more than once
annually, a review of treatment provided to an enrollee for autism
spectrum disorders. The cost of obtaining the review shall be borne
by the plan. This subdivision does not apply to inpatient services.
   (f) A health care service plan shall establish and maintain an
adequate network of qualified autism service providers with
appropriate training and experience in autism spectrum disorders to
ensure that enrollees have a choice of providers, and have timely
access, continuity of care, and ready referral to all services
required to be provided by this section consistent with Sections 1367
and 1367.03 and the regulations adopted pursuant thereto.
   (g) (1) This section shall not be construed as reducing any
obligation to provide services to an enrollee under an individualized
family service plan, an individualized program plan, a prevention
program plan, an individualized education program, or an
individualized service plan.
   (2) This section shall not be construed as limiting benefits that
are otherwise available to an enrollee under a health care service
plan.
   (3) This section shall not be construed as affecting litigation
that is pending on January 1, 2012.
   (h) On and after January 1, 2014, to the extent that this section
requires health benefits to be provided that exceed the essential
health benefits required to be provided under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) by qualified health
plans offering those benefits in the California Health Benefit
Exchange pursuant to Title 22 (commencing with Section 100500) of the
Government Code, the specific benefits that exceed the federally
required essential health benefits are not required to be provided
when offered by a health care service plan contract through the
Exchange. However, those specific benefits are required to be
provided if offered by a health care service plan contract outside of
the Exchange.
   (i) As used in this section, the following terms shall have the
following meanings:
   (1) "Autism spectrum disorder" means a neurobiological condition
that includes autistic disorder, Asperger's disorder, Rett's
disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified.
   (2) "Behavioral health treatment" means professional services and
treatment programs, including behavioral intervention therapy,
applied behavioral analysis, and other intensive behavioral programs,
that have demonstrated efficacy to develop, maintain, or restore, to
the maximum extent practicable, the functioning or quality of life
of an individual and that have been demonstrated to treat the core
symptoms associated with autism spectrum disorder.
   (3) "Behavioral intervention therapy" means the design,
implementation, and evaluation of environmental modifications, using
behavioral stimuli and consequences, to produce socially significant
improvement in behaviors, including the use of direct observation,
measurement, and functional analyses of the relationship between
environment and behavior.
   (4) "Diagnosis of autism spectrum disorders" means medically
necessary assessment, evaluations, or tests to diagnose whether an
individual has one of the autism spectrum disorders.
   (5) "Evidence-based research" means research that applies
rigorous, systematic, and objective procedures to obtain valid
knowledge relevant to autism spectrum disorders.
   (6) "Pharmacy care" means medications prescribed by a licensed
physician and surgeon or other appropriately licensed or certified
provider and any health-related services deemed medically necessary
to determine the need or effectiveness of the medications.
   (7) "Psychiatric care" means direct or consultative psychiatric
services provided by a psychiatrist or any other appropriately
licensed or certified provider.
   (8) "Psychological care" means direct or consultative
psychological services provided by a psychologist or any other
appropriately licensed or certified provider. 
   (9) "Qualified autism service provider" shall include any
nationally or state licensed or certified person, entity, or group
that designs, supervises, or provides treatment of autism spectrum
disorders and the unlicensed personnel supervised by the licensed or
certified person, entity, or group, provided the services are within
the experience and scope of practice of the licensed or certified
person, entity, or group. "Qualified autism service provider" shall
also include any service provider that is vendorized by a regional
center to provide those same services for autism spectrum disorders
under Division 4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000) of the
Government Code and the unlicensed personnel supervised by that
provider, or a State Department of Education nonpublic, nonsectarian
agency as defined in Section 56035 of the Education Code approved to
provide those same services for autism spectrum disorders and the
unlicensed personnel supervised by that agency. A qualified autism
service provider shall ensure criminal background screening and
fingerprinting, and adequate training and supervision of all
personnel utilized to implement services. Any national license or
certification recognized by this section shall be accredited by the
National Commission for Certifying Agencies (NCCA).  
   (9) 
    (10)  "Therapeutic care" means services provided by
licensed or certified speech therapists, occupational therapists, or
physical therapists or any other appropriately licensed or certified
provider. 
   (10) 
    (11)  "Treatment for autism spectrum disorders" means
all of the following care, including necessary equipment, prescribed
or ordered for an individual diagnosed with one of the autism
spectrum disorders by a licensed physician and surgeon or a licensed
psychologist or any other appropriately licensed or certified
provider who determines the care to be medically necessary:
   (A) Behavioral health treatment.
   (B) Pharmacy care.
   (C) Psychiatric care.
   (D) Psychological care.
   (E) Therapeutic care.
   (F) Any care for individuals with autism spectrum disorders that
is demonstrated, based upon best practices or evidence-based
research, to be medically necessary.
   (j) This section, with the exception of subdivision (b), shall not
apply to dental-only or vision-only health care service plan
contracts.
  SEC. 2.  Section 10144.51 is added to the Insurance Code, to read:
   10144.51.  (a) Every health insurance policy issued, amended, or
renewed on or after January 1, 2012, that provides hospital, medical,
or surgical coverage shall provide coverage for the screening,
diagnosis, and treatment of autism spectrum disorders.
   (b) A health insurer shall not terminate coverage, or refuse to
deliver, execute, issue, amend, adjust, or renew coverage, to an
insured solely because the individual is diagnosed with, or has
received treatment for, an autism spectrum disorder.
   (c) Coverage required to be provided under this section shall
extend to all medically necessary services and shall not be subject
to any limits regarding age, number of visits, or dollar amounts.
Coverage required to be provided under this section shall not be
subject to provisions relating to lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that are
less favorable to an insured than lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that apply
to physical illness generally under the policy.
   (d) Coverage required to be provided under this section is a
health care service and a covered health care benefit for purposes of
this part. Coverage shall not be denied on the basis that the
treatment is habilitative, nonrestorative, educational, academic, or
custodial in nature.
   (e) A health insurer may request, no more than once annually, a
review of treatment provided to an insured for autism spectrum
disorders. The cost of obtaining the review shall be borne by the
insurer. This subdivision does not apply to inpatient services.
   (f) A health insurer shall establish and maintain an adequate
network of qualified autism service providers with appropriate
training and experience in autism spectrum disorders to ensure that
insureds have a choice of providers, and have timely access,
continuity of care, and ready referral to all services required to be
provided by this section consistent with Sections 10133.5 and
10133.55 and the regulations adopted pursuant thereto.
   (g) (1) This section shall not be construed as reducing any
obligation to provide services to an insured under an individualized
family service plan, an individualized program plan, a prevention
program plan, an individualized education program, or an
individualized service plan.
   (2) This section shall not be construed as limiting benefits that
are otherwise available to an enrollee under a health insurance
policy.
   (3) This section shall not be construed as affecting litigation
that is pending on January 1, 2012.
   (h) On and after January 1, 2014, to the extent that this section
requires health benefits to be provided that exceed the essential
health benefits required to be provided under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) by qualified health
plans offering those benefits in the California Health Benefit
Exchange pursuant to Title 22 (commencing with Section 100500) of the
Government Code, the specific benefits that exceed the federally
required essential health benefits are not required to be provided
when offered by a health insurance policy through the Exchange.
However, those specific benefits are required to be provided if
offered by a health insurance policy outside of the Exchange.
   (i) As used in this section, the following terms shall have the
following meanings:
   (1) "Autism spectrum disorder" means a neurobiological condition
that includes autistic disorder, Asperger's disorder, Rett's
disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified.
   (2) "Behavioral health treatment" means professional services and
treatment programs, including behavioral intervention therapy,
applied behavioral analysis, and other intensive behavioral programs,
that have demonstrated efficacy to develop, maintain, or restore, to
the maximum extent practicable, the functioning or quality of life
of an individual and that have been demonstrated to treat the core
symptoms associated with autism spectrum disorder.
   (3) "Behavioral intervention therapy" means the design,
implementation, and evaluation of environmental modifications, using
behavioral stimuli and consequences, to produce socially significant
improvement in behaviors, including the use of direct observation,
measurement, and functional analyses of the relationship between
environment and behavior.
   (4) "Diagnosis of autism spectrum disorders" means medically
necessary assessment, evaluations, or tests to diagnose whether an
individual has one of the autism spectrum disorders.
   (5) "Evidence-based research" means research that applies
rigorous, systematic, and objective procedures to obtain valid
knowledge relevant to autism spectrum disorders.
   (6) "Pharmacy care" means medications prescribed by a licensed
physician and surgeon or other appropriately licensed or certified
provider and any health-related services deemed medically necessary
to determine the need or effectiveness of the medications.
   (7) "Psychiatric care" means direct or consultative psychiatric
services provided by a psychiatrist or any other appropriately
licensed or certified provider.
   (8) "Psychological care" means direct or consultative
psychological services provided by a psychologist or any other
appropriately licensed or certified provider. 
   (9) "Qualified autism service provider" shall include any
nationally or state licensed or certified person, entity, or group
that designs, supervises, or provides treatment of autism spectrum
disorders and the unlicensed personnel supervised by the licensed or
certified person, entity, or group, provided the services are within
the experience and scope of practice of the licensed or certified
person, entity, or group. "Qualified autism service provider" shall
also include any service provider that is vendorized by a regional
center to provide those same services for autism spectrum disorders
under Division 4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000) of the
Government Code and the unlicensed personnel supervised by that
provider, or a State Department of Education nonpublic, nonsectarian
agency as defined in Section 56035 of the Education Code approved to
provide those same services for autism spectrum disorders and the
unlicensed personnel supervised by that agency. A qualified autism
service provider shall ensure criminal background screening and
fingerprinting, and adequate training and supervision of all
personnel utilized to implement services. Any national license or
certification recognized by this section shall be accredited by the
National Commission for Certifying Agencies (NCCA).  
   (9) 
    (10)  "Therapeutic care" means services provided by
licensed or certified speech therapists, occupational therapists, or
physical therapists or any other appropriately licensed or certified
provider. 
   (10) 
    (11)  "Treatment for autism spectrum disorders" means
all of the following care, including necessary equipment, prescribed
or ordered for an individual diagnosed with one of the autism
spectrum disorders by a licensed physician and surgeon or a licensed
psychologist or any other appropriately licensed or certified
provider who determines the care to be medically necessary:
   (A) Behavioral health treatment.
   (B) Pharmacy care.
   (C) Psychiatric care.
   (D) Psychological care.
   (E) Therapeutic care.
   (F) Any care for individuals with autism spectrum disorders that
is demonstrated, based upon best practices or evidence-based
research, to be medically necessary.
   (j) This section, with the exception of subdivision (b), shall not
apply to dental-only or vision-only health insurance policies.
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.