Lara expands mental health access

Continuing the transformation in expanding access to mental health and substance use disorder treatment, California Insurance Commissioner Ricardo Lara enacted landmark regulations enforcing California's Mental Health Parity Act.

These regulations follow the passage of Senate Bill 855 , authored by Senator Scott Wiener, and commit to end decades of unfair and unequal treatment by health insurance companies that has disadvantaged many vulnerable Californians.

The regulations also implement Assembly Bill 988, authored by Assembly Member Rebecca Bauer-Kahan, and ensure that coverage for behavioral health crisis services under the AB 988 system are integrated into the requirements of SB 855.

The newly enacted regulations spell out rules that insurance companies must follow, requiring that health insurance 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. These regulations also establish a formal process for patients to file complaints so the California Department of Insurance can investigate claims denials and other unequal service by insurance companies.

"Mental health is human health, and we are making clear that treating mental health and substance use disorders should not be an afterthought," said Lara, who strongly supported SB 855. "At a time when access to this lifesaving care is being threatened at the federal level, California will not turn its back on the vulnerable who are under threat of losing the help they urgently need."

The purpose of SB 855 was to modernize California's mental health parity law to require health insurance companies cover treatment for all mental health and substance use disorders that are recognized by the national and international authorities, and to require health insurance companies to cover such treatment consistent with clinical standards that constitute generally accepted standards of mental health and substance use disorder treatment and care. Requiring health insurance companies to cover behavioral health crisis services under the AB 988 system in a manner consistent with these regulations is particularly important with the on-going opioid addiction crisis, because it ensures that all protections conferred by SB 855 apply equally to services mandated under AB 988.

At a time when the federal administration is eliminating specialized suicide prevention support for LGBTQ+ youth callers through the AB 988 system, gutting access to medically necessary gender affirming care to treat gender dysphoria, and forbidding states from covering treatment as an essential health benefit, these regulations reaffirm California's values by protecting access to gender affirming care.

The department's new regulations require health insurance companies to align with the World Professional Association of Transgender Health guidelines for treatment of gender dysphoria for people of all ages, defined by the American Psychological Association as "discomfort or distress related to incongruence between a person's gender identity, sex assigned at birth, gender identity, and/or primary and secondary sex characteristics." In managing benefits, under these regulations, insurance companies must now use clinical practice guidelines from nonprofit specialty associations like the APA and follow accepted standards of care. The regulation further details the process that health insurance companies must use to arrange for care for an out-of-network health care provider or facility, if no in-network provider/facility is available.

Consumers may also contact the department with any questions or concerns relating to their coverage for mental health and substance use disorders, including network adequacy and timely access. Under the regulations, consumers who believe that they were denied care in violation of the regulations can file a complaint with the Department by calling our hotline at (800) 927-4357, or online at insurance.ca.gov. These regulations now outline a process of administrative law to hold insurance companies accountable who are not following the law.

The rulemaking had the support of a coalition of advocates, including The Kennedy Forum and the Steinberg Institute, co-sponsors of SB 855 and AB 988, known as the Miles Hall Lifeline and Suicide Prevention Act.

"SB 855 was a landmark step forward in requiring insurers to treat mental health and substance use disorders on par with physical health conditions. But without strong enforcement, even the best laws can fall short," said Tara Gamboa-Eastman, Director of Government Affairs of the Steinberg Institute. "These new regulations are essential to realizing the promise of parity. The Steinberg Institute is grateful for Commissioner Lara's leadership in bringing together advocates, experts, and stakeholders to develop regulations that put Californians' mental health needs front and center."

"Californians deserve what that law has already promised: coverage for mental health care without delays, denials, and frustrating hurdles," said Lauren Finke, Senior Director of Policy at The Kennedy Forum, a nonprofit that advances mental health parity in California and nationwide. "Alongside numerous partners and advocates, the California Department of Insurance has played a critical role in closing the gap between promise and practice, connecting more consumers to the care they need — and deserve. We're gratified to see these nation leading enforcements, which we consider gold standards."

Notes

The regulations can be accessed here.

Major benefits of these regulations include

Clarifying the scope of the statutory coverage mandate for mental health and substance use disorder benefits, including basic health care services, intermediate services, behavioral health crisis services, and if covered, outpatient prescription drugs, to facilitate health insurer compliance.

Ensuring that the most recent, generally accepted standards of mental health and substance use disorder care are used in utilization review of benefits by minimizing lag time, variation, or insurance company error in implementing and incorporating evidence-based nonprofit professional association clinical criteria in utilization review.

Clarifying the obligation of insurance companies to arrange and pay for out-of-network mental health and substance use disorder care when medically necessary care is unavailable from a network provider or facility within applicable geographic or timely access standards for network adequacy.

For substance use disorder benefits, a health care provider who is competent to evaluate the specific clinical issues involved in the benefits under review and make an adverse benefit determination means an actively practicing board-certified addiction specialist physician.

Ensuring that coverage for behavioral health crisis services pursuant to AB 988, including mobile crisis teams and crisis receiving and stabilization services, is integrated with coverage requirements under SB 855.

Easing and enhancing consumer access to medically necessary and clinically appropriate mental health and substance use disorder care by incentivizing insurance companies to proactively comply with benefits coverage, provider and facility network, utilization review, transparency, and parity and nondiscrimination requirements.

Clarifying administrative enforcement mechanisms and considerations for assessing penalty amounts, deterring noncompliance and facilitating effective enforcement of mental health and substance use disorder benefits coverage requirements under SB 855 and AB 988.