In 2021 most health insurance plans must expand coverage to all mental health conditions and substance use disorders and adhere to the same level of standards of care that are followed by addiction and mental health care providers. Health insurance must cover all medically necessary care for mental health and substance use disorders and can no longer limit coverage for treatment in ways that conflict with prevailing standards of care.
California Insurance Commissioner Lara issued a press release on December 10th alerting health insurance companies of their obligation to comply with Senate Bill 855, the California Mental Health Parity Act. Commissioner Lara informed the health plans they must submit their updated medical policies by December 31, 2020, as the new mental health care requirements go into effect January 1, 2021.
SAN FRANCISCO, Calif. — Today Insurance Commissioner Ricardo Lara issued a Notice to all health insurance companies in California informing them of their obligation to comply with landmark changes to the California Mental Health Parity Act following the recent enactment of Senate Bill 855, authored by Senator Scott Wiener. Under the new law, health insurance must cover health care services that are medically necessary to diagnose, prevent, and treat all mental health conditions, as well as substance use disorders, equal to coverage provided for other medical conditions.http://www.insurance.ca.gov/0400-news/0100-press-releases/2020/release135-2020.cfm
The specific changes that must be enacted to health insurance plans is somewhat murky in the notice. There is broad language stating that mental health conditions and substance use disorders must be treated like any other medically necessary health condition. In other words, some health plans had not elevated mental health and substance abuse to the level of other health conditions such as diabetes, a broken leg, or cancer in terms of the authorization of treatment and coverage. Senate Bill 855 is meant to force the insurers to treat mental health and substance use disorders like any other accident or illness that might befall an individual.
What is not included in the notice are specific health care services that must be covered as medically necessary for the treatment of mental health and substance use disorders. This is understandable as the list of services is long and maybe situation specific. While the lack of specificity as it may apply to any one individual’s condition is lacking, the authors of Senate Bill 855 and the health plans do know what is being addressed.
For example, a test, image, or diagnostic evaluation, may have been denied by a health plan as not being directly related to addressing a mental health or substance use disorder. Presumably, such diagnostic tests, as identified by mental health professionals, will now be covered by the health plan. Such tests help to either identify or eliminate possible treatment options for the patient.
Some of the requirements health plans must adhere to as outlined in the Commission’s notice:
• Requiring health insurance policies to cover medically necessary prevention, diagnosis, and treatment of all mental health conditions, as well as substance use disorders, that are listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the mental and behavioral disorders chapter of the most recent edition of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10).
• Defining medical necessity for purposes of the coverage mandate.
• Prohibiting limiting coverage to short-term or acute treatment.
• Providing that if medically necessary mental health or substance use disorder services are not available in-network within the geographic and timely access standards set by network adequacy law or regulation, an insurer must arrange for the provision of out-of-network services that, to the maximum extent possible, meet the network adequacy standards, and cover the out-of-network services subject to in-network cost sharing.
• Prohibiting coverage limitations and exclusions for medically necessary services because the services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance.
• Providing that medical necessity determinations, including on service intensity, level of care placement, continued stay, and transfer or discharge, must be made using the most recent versions of clinical practice guidelines developed by nonprofit professional associations for the relevant clinical specialty.
However, as we all know, just because specific language has been codified in law, that doesn’t necessarily translate into tangible benefits for the health plan member. The implementation of the Mental Health Parity Act requirements will most likely be contested by health plan members who have not received what they believe to be adequate health care coverage. With the updated requirements, we can hope that the road to recovery is made a little easier for some of our neighbors and family members.
Notice to California insurers regarding the new coverage requirements for mental health and substance use disorders for health insurance plan in California for 2021.