Bill Text: CA SB855 | 2019-2020 | Regular Session | Amended
Bill Title: Health coverage: mental health or substance use disorders.
Spectrum: Strong Partisan Bill (Democrat 13-1)
Status: (Passed) 2020-09-25 - Chaptered by Secretary of State. Chapter 151, Statutes of 2020. [SB855 Detail]
Download: California-2019-SB855-Amended.html
Amended
IN
Senate
May 05, 2020 |
Introduced by Senator Wiener (Principal coauthor: Senator Beall) (Principal coauthors: Assembly Members Aguiar-Curry and Chiu) (Coauthors: Senators Glazer and Hill) (Coauthors: Assembly Members Maienschein and Wicks) |
January 14, 2020 |
LEGISLATIVE COUNSEL'S DIGEST
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
SECTION 1.
The Legislature finds and declares all of the following:SEC. 2.
Section 1367.045 is added to the Health and Safety Code, to read:1367.045.
(a) If a health care service plan contract offered, issued, delivered, amended, or renewed on or after January 1, 2021,(b)For purposes of this section, “renewed” means continued in force on or after the contract’s anniversary date.
(c)
(d)
(e)
(f)The director may adopt regulations reasonably necessary to implement this section.
(g)This section is self-executing. If a health care service plan contract contains a provision rendered void and unenforceable by this section, the parties to the contract and the courts shall treat that provision as void and unenforceable.
SEC. 3.
Section 1374.72 of the Health and Safety Code is repealed.SEC. 4.
Section 1374.72 is added to the Health and Safety Code, to read:1374.72.
(a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021,(A)Recommended by the patient’s treatment provider.
(B)Furnished in the manner and setting that can most effectively and comprehensively address the patient’s conditions, including, but not limited to, functional impairments, lack of coping skills, symptoms, and the underlying biopsychosocial determinants of mental health, substance use, and medical disorders, and any combination thereof.
(C)Provided in sufficient amount, duration, and scope to
do any of the following:
(i)Prevent, diagnose, or treat a disorder.
(ii)Minimize the progression of a disorder or its symptoms.
(iii)Achieve age-appropriate growth and development.
(iv)Minimize the progression of disability.
(v)Attain, maintain, regain, or maximize full functional capacity.
(D)Consistent with generally accepted standards of practice, which shall be based on either of the following:
(i)Scientific evidence published in peer-reviewed medical literature generally recognized by the relevant clinical community.
(ii)Clinical specialty society recommendations, professional standards, and consensus statements.
(5)(A)Consistent with paragraph (3), for all medical necessity determinations concerning level of care placement, continued stay, and transfer or discharge, a health care service plan shall exclusively rely on the most recent editions of the following:
(i)The American Society of Addiction Medicine (ASAM) criteria developed by the American Society of Addiction Medicine for substance use disorders for patients of any age.
(ii)The Level of Care Utilization System (LOCUS) criteria developed by the American Association of Community Psychiatrists for mental health disorders for patients 18 years of age and over.
(iii)The Child and Adolescent Level of Care Utilization System (CALOCUS) developed by the American Association of Community Psychiatrists or the Child and Adolescent Service Intensity Instrument (CASII) developed by the American Academy of Child and Adolescent Psychiatry for mental health disorders for patients 6 to 17 years of age, inclusive.
(iv)The Early Childhood Service Intensity Instrument (ECSII) developed by the American Academy of Child and Adolescent Psychiatry for mental health disorders for patients zero to five years of age, inclusive.
(v)The American
Psychiatric Association criteria for eating disorders for a primary diagnosis of an eating disorder for patients any of age.
(vi)“Clarifications Regarding Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers” or subsequent guidelines developed by the Behavior Analyst Certification Board or the Association of Professional Behavior Analysts for individuals with autistic spectrum disorders undergoing behavior therapy.
(B)As specified in clauses (i) to (vi), inclusive, of subparagraph (A), reviewers shall err on the side of caution and safety in making medical necessity determinations by placing patients in higher levels of care when there is ambiguity as to the appropriate level of care.
(6)To ensure the proper use of the criteria described in
paragraph (5), every health care service plan shall do all of the following:
(A)Sponsor a formal education program by nonprofit clinical specialty associations to educate plan staff, including any third parties contracted with the health plan to review claims, conduct utilization reviews, or make medical necessity determinations, and other stakeholders, including the plan’s participating providers and covered lives, about the guidelines, and provide the guidelines and any training material or resources to providers and insured patients.
(B)Track, identify, and analyze how the clinical guidelines are used to certify care, deny care, and support the appeals process.
(C)Run inter-rater reliability reports about how the clinical guidelines are used in conjunction with the utilization management process and parity
compliance activities.
(D)Achieve inter-rater reliability pass rates of at least 90 percent and, if this threshold is not met, immediately provide for the remediation of poor inter-rater reliability and inter-rater relatability testing for all new staff before they can conduct utilization review without supervision.
(E)Report the activities in this paragraph to the plan’s quality assurance committee.
(1)Outpatient services.
(2)Inpatient services.
(3)
(4)
(2)Copayments.
SEC. 5.
Section 1374.75 is added to the Health and Safety Code, to read:1374.75.
(a) A health care service plan shall base any medical necessity determination or the utilization review criteria that the plan, and any entity acting on the plan’s behalf, applies to determine the medical necessity of health care services and benefits for the diagnosis, prevention, and treatment of mental health and substance use disorders on current generally accepted standards of medical and behavioral health care practice. Current generally accepted standards of medical and behavioral health care practice are evidence-based sources of standards of care and clinical practice that are generally accepted by health care providers practicing in relevant clinical specialties, including peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of health care provider professional associations, and specialty societies and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.SEC. 5.SEC. 6.
Section 10144.5 of the Insurance Code is repealed.SEC. 6.SEC. 7.
Section 10144.5 is added to the Insurance Code, to read:10144.5.
(a) (1) Every(2)Mental health and substance use disorders shall mean a mental health condition or substance use disorder that falls under any of the diagnostic
categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders.
(3)Medically necessary treatment of a mental health or substance use disorder shall be a covered service that is all of the following:
(A)Recommended by the patient’s treatment provider.
(B)Furnished in the manner and setting that can most effectively and comprehensively address the patient’s conditions, including, but not limited to, functional impairments, lack of coping skills, symptoms, and the underlying biopsychosocial determinants of mental health, substance use,
and medical disorders, and any combination thereof.
(C)Provided in sufficient amount, duration, and scope to do any of the following:
(i)Prevent, diagnose, or treat a disorder.
(ii)Minimize the progression of a disorder or its symptoms.
(iii)Achieve age-appropriate growth and development.
(iv)Minimize the progression of disability.
(v)Attain, maintain, regain, or maximize full functional capacity.
(D)Consistent with generally accepted standards of practice, which shall be
based on either of the following:
(i)Scientific evidence published in peer-reviewed medical literature generally recognized by the relevant clinical community.
(ii)Clinical specialty society recommendations, professional standards, and consensus statements.
(5)(A)Consistent with paragraph (3), for all medical necessity determinations concerning level of care placement, continued stay, and transfer or discharge, a health insurer shall exclusively rely on the most recent editions of the
following:
(i)The American Society of Addiction Medicine (ASAM) criteria developed by the American Society of Addiction Medicine for substance use disorders for patients of any age.
(ii)The Level of Care Utilization System (LOCUS) criteria developed by the American Association of Community Psychiatrists for mental health disorders for patients 18 years of age and over.
(iii)The Child and Adolescent Level of Care Utilization System (CALOCUS) developed by the American Association of Community Psychiatrists or the Child and Adolescent Service Intensity Instrument (CASII) developed by the American Academy of Child and Adolescent Psychiatry for mental health disorders for patients 6 to 17 years of age, inclusive.
(iv)The Early Childhood Service Intensity Instrument (ECSII) developed by the American Academy of Child and Adolescent Psychiatry for mental health disorders for patients zero to five years of age, inclusive.
(v)The American Psychiatric Association criteria for eating
disorders for a primary diagnosis of an eating disorder for patients any of age.
(vi)“Clarifications Regarding Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers” or subsequent guidelines developed by the Behavior Analyst Certification Board or the Association of Professional Behavior Analysts for individuals with autistic spectrum disorders undergoing behavior therapy.
(B)As specified in clauses (i) to (vi), inclusive, of subparagraph (A), reviewers shall err on the side of caution and safety in making medical necessity determinations by placing patients in higher levels of care when there is ambiguity as to the appropriate level of care.
(6)To ensure the proper use of the criteria described in paragraph (5), every health insurer shall do all of the following:
(A)Sponsor a formal education program by nonprofit clinical specialty associations to educate the health insurer’s staff, including any third parties contracted with the health insurer to review claims, conduct utilization reviews, or make medical necessity determinations, and other stakeholders, including the insurer’s participating providers and covered lives, about the guidelines, and provide the guidelines and any training material or resources to providers and insured patients.
(B)Track, identify, and analyze how the clinical guidelines are used to certify care, deny care, and support the appeals process.
(C)Run inter-rater reliability reports about how the clinical guidelines are used in conjunction with the utilization management process and parity compliance activities.
(D)Achieve inter-rater reliability pass rates of at least 90 percent and, if this threshold is not met, immediately provide for the remediation of poor inter-rater reliability and inter-rater relatability testing for all new staff before they can conduct utilization review without supervision.
(E)Report the activities in this paragraph to the plan’s quality assurance committee.
(1)Outpatient
services.
(2)Inpatient services.
(3)
(4)
(2)Copayments.