Newsfeed > California Expands Access to Mental Health Care
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Dear Colleagues,
I am very pleased to share that, this morning, Governor Gavin Newsom signed SB855, a bill that I helped draft and in support of which I testified at the California legislature, into law. SB855 ushers in an era of accountability for commercial health insurers in California and sets the stage for national reform.
First, the law expands parity protections to all conditions described in the DSM, rather than to just nine previously identified mental health disorders. Second, by establishing a state-wide definition of “medical necessity” for coverage of mental health and substance disorder treatment, the law requires insurers to make benefit determinations that are consistent with “generally accepted standards of care,” and codifies the generally accepted standards of care articulated in the landmark Wit decision. Notably, with respect to mental health and substance use disorders, the law requires insurers to exclusively apply medical necessity criteria developed by non-profit clinical specialty associations (such as AACP and ASAM), to receive trainings from non-profit clinical specialty associations in the application of such criteria, and to achieve inter-rater reliability scores of at least 90% when applying these criteria. The law expressly forbids insurers from limiting benefits or coverage for mental health and substance use disorders to short-term or acute treatment and from conditioning coverage for medically necessary services on the basis that those 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.
Additionally, the law requires insurers to cover out-of-network treatment so that patients are not subject to anything beyond in-network cost-sharing if medically necessary mental health or substance use services are not available in-network within geographical and timeliness standards set by law or regulation. The practical effect is that insurers will be incentivized to expand their network capacity by recruiting suitable providers based on competitive market (rather than artificially devalued) reimbursement rates.
Finally, the law prohibits discretionary clauses in insurance contracts that give rise to a deferential standard of judicial review. This provision will require courts to review legal claims against health insurers de novo and will serve as another deterrent against insurer misconduct.
SB855 will be in full effect as of January 1, 2021.
Best regards,
Meiram Bendat, JD, PhD
To read the text of the law, click HERE.
