Signed by Governor Gavin Newsom

Vote Smart's Synopsis:

Vote to concur with House amendments and pass a bill that expands health insurance coverage for mental health treatment and services.

Highlights:

• Requires every health care service plan contract or disability insurance policy issued, amended, or renewed on or after January 1, 2021 that provides hospital, medical, or surgical coverage to provide coverage for medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions (Sec. 4, 7).

• Prohibits a health care service plan or disability insurer from limiting benefits or coverage for mental health and substance use disorders to short-term or acute treatment (Sec. 4, 7).

• Amends the covered benefits to include basic health services, intermediate services, and prescription drugs (Sec. 4, 7). 

• Requires medical necessity determinations and utilization review criteria applied to determine the medical necessity of health care services and benefits for the diagnosis, prevention, and treatment of mental health and substance use disorders to be based on current generally accepted standards of mental health and substance use disorder care (Sec. 5, 8).

• Prohibits a health care service plan or disability insurer from applying different, additional, conflicting, or more restrictive utilization review criteria than the most recent criteria developed by the nonprofit professional association for the relevant clinical specialty unless such criteria meets either of the following criteria (Sec. 5, 8):

• The criteria are outside of the association’s criteria’s scope and follow current generally accepted standards of care; or

• The criteria relate to advancements in technology or types of care that are not covered in the most recent criteria, and follow current generally accepted standards of care.

• Requires every health care service plan and disability insurer to do the following, including, but not limited to (Sec. 5, 8):

• Sponsor a formal education program to educate staff about the clinical review criteria; 

• Make the education program available to other stakeholders;

• Provide the criteria and any training material or resources to providers and plan enrollees; and

• Track, identify, and analyze how the criteria are used to certify care, deny care, and support the appeals process.

• Requires health care service plans and disability insurers to arrange coverage to ensure the delivery of medically necessary out-of-network services and any followup services that meet geographic and timely access standards if services for the treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards (Sec. 4, 7).

• Authorizes the Director of the Department of Managed Health Care to assess administrative penalties for violations of the utilization review criteria requirements (Sec. 5).

• Authorizes the Insurance Commissioner to assess civil penalties for disability insurer violations of the utilization review criteria requirements that do not exceed $5,000 for each violation, or $10,000 for each wilful violation (Sec. 8).

• Repeals any provisions of health care service plans offered, issued, delivered, amended, or renewed on or after January 1, 2021 that reserve discretionary authority to the plan, or agent of the plan, to determine eligibility for benefits or coverage, to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of this state (Sec. 2).

• Specifies that the provisions of this act are severable (Sec. 9).

Full Bill Text