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SB-1397 Behavioral health services coverage.(2023-2024)



Current Version: 04/15/24 - Amended Senate

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SB1397:v97#DOCUMENT

Amended  IN  Senate  April 15, 2024
Amended  IN  Senate  March 20, 2024

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Senate Bill
No. 1397

Introduced by Senator Eggman

February 16, 2024

An act to add Section 1374.198 to the Health and Safety Code, and to add Section 10144.58 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


SB 1397, as amended, Eggman. Behavioral health services coverage.
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 and disability insurers by the Department of Insurance. Existing law requires a health care service plan contract or disability insurance policy to provide coverage for medically necessary treatment of mental health and substance use disorders.
This bill would require a health care service plan contract or health insurance policy issued, amended, renewed, or delivered on or after July 1, 2025, that covers medically necessary mental health and substance use disorder services to comply with rate and timely reimbursement requirements for services delivered by a county behavioral health agency, as specified. The bill would require in-network cost sharing, capped at the in-network deductible and in-network out-of-pocket maximum, to apply to these services. Unless an enrollee or insured is referred or authorized by the plan or insurer, the bill would require a county behavioral health agency to contact a plan or insurer before initiating services. The bill would authorize a plan or insurer to conduct a postclaim review to determine appropriate payment of a claim, and would authorize the use of prior authorization as permitted by the regulating department. The bill would require the departments to issue guidance to plans and insurers regarding compliance with these provisions no later than April 1, 2025. Because a willful violation of these provisions by a health care service plan would be a crime, and the bill would impose a higher level of service on a county behavioral health agency, this bill 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, with regard to certain mandates, no reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that, if the Commission on State Mandates determines that the bill contains costs so mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1374.198 is added to the Health and Safety Code, immediately following Section 1374.197, to read:

1374.198.
 (a) This section governs medically necessary mental health and substance use disorder services covered under the Full Service Partnership Service Category regulated pursuant to Section 3620 of Title 9 of the California Code of Regulations and provided to an enrollee.
(b) (1) A health care service plan contract issued, amended, renewed, or delivered on or after July 1, 2025, that covers medically necessary mental health and substance use disorder services under Section 1374.72 shall comply with this section for services provided to an enrollee referred or agreed to by the plan or a plan provider with approval from the plan, when delivered by a county behavioral health agency that complies with subdivision (g).
(2) A health care service plan may conduct a postclaim review to determine appropriate payment of a claim. Payment for services subject to this section may be denied only if the health care service plan reasonably determines the enrollee was not enrolled with the plan at the time the services were rendered, the services were never performed, or the services were not provided by a health care provider appropriately licensed or authorized to provide the services pursuant to subdivision (a).
(3) Notwithstanding paragraph (1), a health care service plan may require prior authorization for services as permitted by the department pursuant to subdivision (d).
(4) Referral or authorization by a health care service plan for services provided by a behavioral health agency under this section shall constitute authorization for coverage of any services provided under the Full Service Partnership Service Category identified in the Individual Services and Supports Plan pursuant to Section 3620 of Title 9 of the California Code of Regulations.
(c) (1) A health care service plan shall provide for reimbursement of services provided to an enrollee reimburse a county behavioral health agency for services pursuant to this section, other than prescription drugs, at the greater of either of the following amounts:
(A) The health plan’s contracted rate with the provider. county behavioral health agency.
(B) The fee-for-service or case reimbursement rate paid in the Medi-Cal specialty behavioral health program for the same or similar services as identified by the State Department of Health Care Services.
(2) A health care service plan shall provide for reimbursement of reimburse a county behavioral health agency for prescription drugs provided to an enrollee pursuant to this section at the health care service plan’s contracted in-network rate.
(3) A health care service plan shall provide reimbursement reimburse a county behavioral health agency for services provided pursuant to this section in compliance with the requirements for timely payment of claims, as required by this chapter.
(d) No later than April 1, 2025, the department may issue guidance to health care service plans regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision shall be effective only until the department adopts regulations pursuant to the Administrative Procedure Act.
(e) This section does not exempt a health care service plan from complying with Section 1374.72. 1374.72 or 1374.721.
(f) This section does not apply to Medi-Cal managed care contracts entered into pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.
(g) (1) Unless the enrollee is referred or authorized by the plan, a county behavioral health agency shall contact the plan before initiating services to determine whether the enrollee needs an urgent or nonurgent appointment and to facilitate a referral to the plan’s network providers, as appropriate and consistent with professionally recognized standards of practice.
(2) After contacting the plan, if the plan is able to offer the enrollee an appointment within 48 hours for an urgent care appointment or within 10 business days for a nonurgent appointment, the plan’s designated behavioral health professional shall facilitate referral to the plan’s network providers.
(3) If the plan is unable to offer the enrollee an appointment within 48 hours for an urgent care appointment or within 10 business days for a nonurgent appointment, except as provided in paragraph (4), the designated behavioral health professional may continue health care service plan shall authorize the services and the county behavioral health agency may initiate and complete the treatment.
(4) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed behavioral health provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the individual’s practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.
(5) The county behavioral health services agency shall not bill the enrollee more than the in-network cost sharing, if any.
(h) If the plan disputes the services provided or the amount, billed charges, the plan may submit a dispute to the department, but the plan shall comply with requirements for timely payment, including for services or amounts in dispute. The department shall have trained staff available to address any disputes arising from this section.
(i) In-network cost sharing for mental health and substance use disorder services and prescription drugs shall apply to services subject to this section. Cost sharing shall accrue to a plan’s in-network deductible, if any, and in-network out-of-pocket maximum.

SEC. 2.Section 1044.58 is added to the Insurance Code, to read:
1044.58.

SEC. 2.

 Section 10144.58 is added to the Insurance Code, to read:

10144.58.
 (a) This section governs medically necessary mental health and substance use disorder services covered under the Full Service Partnership Service Category regulated pursuant to Section 3620 of Title 9 of the California Code of Regulations and provided to an insured.
(b) (1) A health insurance policy issued, amended, renewed, or delivered on or after July 1, 2025, that covers medically necessary mental health and substance use disorder services under Section 10144.5 shall comply with this section for services provided to an insured referred or agreed to by the insurer or an insurer provider with approval from the insurer, when delivered by a county behavioral health agency that complies with subdivision (f).
(2) An insurer may conduct a postclaim review to determine appropriate payment of a claim. Payment for services subject to this section may be denied only if the insurer reasonably determines the insured was not insured at the time the services were rendered, the services were never performed, or the services were not provided by a health care provider appropriately licensed or authorized to provide the services pursuant to subdivision (a).
(3) Notwithstanding paragraph (1), an insurer may require prior authorization for services as permitted by the department pursuant to subdivision (d).
(4) Referral or authorization by an insurer for services provided by a behavioral health agency under this section shall constitute authorization for coverage of any services provided under the Full Service Partnership Service Category identified in the Individual Services and Supports Plan pursuant to Section 3620 of Title 9 of the California Code of Regulations.
(c) (1) An insurer shall provide for reimbursement of services provided to an insured reimburse a county behavioral health agency for services pursuant to this section, other than prescription drugs, at the greater of either of the following amounts:
(A) The insurer’s contracted rate with the provider. county behavioral health agency.
(B) The fee-for-service or case reimbursement rate paid in the Medi-Cal specialty behavioral health program for the same or similar services as identified by the State Department of Health Care Services.
(2) An insurer shall provide for reimbursement of reimburse a county behavioral health agency for services for prescription drugs provided to an insured pursuant to this section at the insurer’s contracted in-network rate.
(3) An insurer shall provide reimbursement reimburse a county behavioral health agency for services provided pursuant to this section in compliance with the requirements for timely payment of claims, as required by this chapter. part.
(d) No later than April 1, 2025, the department may issue guidance to insurers regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision shall be effective only until the department adopts regulations pursuant to the Administrative Procedure Act.
(e) This section does not exempt an insurer from complying with Section 10144.5. 10144.5 or 10144.52.
(f) (1) Unless the insured is referred or authorized by the insurer, a county behavioral health agency shall contact the insurer before initiating services to determine whether the insured needs an urgent or nonurgent appointment and to facilitate a referral to the insurer’s network providers, as appropriate and consistent with professionally recognized standards of practice.
(2) After contacting the insurer, if the insurer is able to offer the insured an appointment within 48 hours for an urgent care appointment or within 10 business days for a nonurgent appointment, the insurer’s designated behavioral health professional shall facilitate referral to the insurer’s network providers.
(3) If the insurer is unable to offer the insured an appointment within 48 hours for an urgent care appointment or within 10 business days for a nonurgent appointment, except as provided in paragraph (4), the designated behavioral health professional may continue insurer shall authorize the services and the county behavioral health agency may initiate and complete the treatment.
(4) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed behavioral health provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the individual’s practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the insured.
(5) The county behavioral health services agency shall not bill the insured more than the in-network cost sharing, if any.
(g) If the insurer disputes the services provided or the amount, billed charges, the insurer may submit a dispute to the department, but the insurer shall comply with requirements for timely payment, including for services or amounts in dispute. The department shall have trained staff available to address any disputes arising from this section.
(h) In-network cost sharing for mental health and substance use disorder services and prescription drugs shall apply to services subject to this section. Cost sharing shall accrue to a insurer’s in-network deductible, if any, and in-network out-of-pocket maximum.

SEC. 3.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution for certain costs that may be incurred by a local agency or school district because, in that regard, 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.
However, if the Commission on State Mandates determines that this act contains other costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.