The California Department of Insurance will conduct a prenotice public discussion regarding contemplated revisions to California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Article 15.2 (commencing with section 2562.1). The purpose of the contemplated revisions is to adopt regulations implementing Senate Bill 855 (Wiener, Stats. 2020, ch. 151), which repealed and replaced section 10144.5 and added section 10144.52 to the Insurance Code.

The anticipated benefits of the contemplated regulations include the following:
• Clarifying the scope of the statutory coverage mandate for mental health and substance use disorder (MHSUD) benefits, including basic health care services, intermediate services, behavioral health crisis services, and if covered, outpatient prescription drugs, to facilitate health insurer compliance
• Clarifying the current, generally acceptable standards of MHSUD care that are statutorily applicable to utilization management of MHSUD benefits, including “level of care” coverage determinations placing patients in the continuum of MHSUD care, to facilitate health insurer compliance
• Ensuring that the most recent, generally accepted standards of MHSUD care are used in utilization review of MHSUD benefits by minimizing lag time, variation, or insurer error in implementing and incorporating evidence-based nonprofit professional association clinical criteria in utilization review
• Clarifying the obligation of health insurers to arrange and pay for out-of-network MHSUD care when clinically appropriate care is unavailable from a network provider or facility within applicable geographic or timely access standards
• Clarifying requirements for insurer-sponsored formal education programs on utilization review criteria, as well as the provision of education program materials and utilization review criteria • Clarifying the treatment of urgent care, as well as content and language assistance requirements applicable to notices of adverse utilization review coverage determinations, under Insurance Code section 10123.135 and Senate Bill 855
• Ensuring that coverage for behavioral health crisis services pursuant to Assembly Bill 988 (Bauer-Kahan, Stats. 2022, ch. 747), including mobile crisis teams and crisis receiving and stabilization services, is integrated with coverage requirements under Senate Bill 855 • Clarifying how Insurance Code section 10144.4, through which the federal Mental Health Parity and Addiction Equity Act (MHPAEA) is incorporated in the Insurance Code, regulates health insurer utilization review practices, and interacts with Senate Bill 855 and Insurance Code section 10144.51 on behavioral health treatment • Easing and enhancing consumer access to medically necessary and clinically appropriate MHSUD care by incentivizing health insurers to proactively comply with benefits coverage, provider and facility network, utilization review, transparency, and parity and nondiscrimination requirements.

This is all very hopeful, and the result of a strong coalition effort – of which CSAP has been an active participant – to influence the development of these regulations at not just the Department of Insurance but the Department of Managed Care as well.

You can participate in the scheduled prenotice public discussion. The purpose of this discussion is to provide interested and affected persons an opportunity to present statements or comments regarding the contemplated regulations. The prenotice public discussion will be held on November 8 at 10:00 a.m. The virtual workshop shall continue until all in attendance wishing to provide comments have commented, or 1:00 p.m., whichever is earlier. As always, don’t worry if you can’t make it – SYASL will be there for CSAP and you and will produce notes for the newsletter immediately following.

You may view more details and registration here. Additionally, you may view the text of the regulation here

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