Cal. INS § 10144.57 — California Code / Code ins / Division 2 / Part 2 / Chapter 1 / Article 2.5 / Section 10144.57
Section 10144.57
Status: in_force

(a) Coverage of mental health and substance use disorder treatment pursuant to Section 10144.5 includes behavioral health crisis services that are provided to an insured by a 988 center, mobile crisis team, or other provider of behavioral health crisis services, as set forth in Chapter 1 (commencing with Section 53123.1) of Part 1 of Division 2 of Title 5 of the Government Code, regardless of whether the service is provided by an in-network or out-of-network provider or facility. With respect to behavioral health crisis services that are provided to an insured by a 988 center or mobile crisis team, a health insurance policy shall cover, at a minimum, all items and services that are eligible for coverage under the Medi-Cal program.

(b) (1) An insurer shall not require prior authorization for behavioral health crisis stabilization services and care provided by a 988 center, mobile crisis team, or other provider of behavioral health crisis services.

(2) Notwithstanding any other law, payment for behavioral health crisis stabilization services and care pursuant to this section shall not be denied unless a health insurer reasonably determines that care was not rendered.

(3) If its prior authorization requirements comply with Section 10144.4, a health insurer may require prior authorization for poststabilization care. If there is a disagreement between a health insurer and behavioral health crisis services provider or facility regarding the need for poststabilization care, an insurer shall assume responsibility for care of the insured by promptly arranging for care pursuant to Section 10144.5 at a level of care determined in accordance with utilization review criteria under Section 10144.52.

(4) An insurer shall not require, under any circumstances, a behavioral health crisis services provider or facility to discharge or transfer an insured before stabilization has occurred or before it has conducted utilization review in accordance with Sections 10144.5 and 10144.52.

(c) (1) If prior authorization is required for poststabilization care, a health insurer that is contacted by a 988 center, mobile crisis team, or other provider of behavioral health crisis services shall, within 30 minutes of the time the provider makes the initial contact, either authorize poststabilization care or inform the provider that it will arrange for the prompt transfer of the insured’s care to another provider.

(2) A health insurer that is contacted by a 988 center, mobile crisis team, or other provider of behavioral health crisis services shall reimburse the provider or facility for poststabilization care rendered to the insured if any of the following occur:

(A) The health insurer authorized the 988 center, mobile crisis team, or other provider of behavioral health crisis services to provide poststabilization care.

(B) The health insurer did not respond to the provider’s initial contact or did not make a decision regarding whether to authorize poststabilization care or to promptly transfer the insured’s care within the timeframe set forth in paragraph (1).

(C) There is an unreasonable delay in the transfer of the insured’s care to another provider, and the provider determines that the insured requires poststabilization care.

(3) A health insurer shall prominently display on its internet website the specific telephone number for noncontracting providers to obtain prompt authorization for the transfer of a stabilized insured’s care to another provider or authorization to provide poststabilization care. The health insurer shall ensure the telephone number published on its internet website is the correct telephone number for purposes of this paragraph. The health insurer shall update the telephone number on its internet website within one business day if the telephone number changes. A health insurer shall provide the telephone number to the department.

(4) A health insurer shall not require a 988 center, mobile crisis team, or other provider of behavioral health crisis services to make more than one telephone call to the number provided in advance by the health insurer. The representative of the 988 center, mobile crisis team, or other provider of behavioral health crisis services that makes the telephone call may be, but is not required to be, a physician or surgeon.

(5) A 988 center, mobile crisis team, or other provider of behavioral health crisis services shall not bill a patient who is an insured of a health insurer for poststabilization care, except for the in-network cost-sharing amount as defined in paragraph (2) of subdivision (d). An insured who is billed in violation of this section may report receipt of the bill to the health insurer and the department. The department shall forward that report to the State Department of Public Health.

(d) (1) An insurer shall reimburse a 988 center, mobile crisis team, or other provider of behavioral health crisis services for emergency or nonemergency behavioral health crisis services and care pursuant to this section, consistent with the requirements of Sections 10123.13, 10123.147, and any other applicable requirement of this part.

(2) If an insured receives behavioral health crisis services and care pursuant to this section from a 988 center, mobile crisis team, or other provider of behavioral health crisis services that is an out-of-network provider, the insured shall pay no more than the same cost sharing that the insured would pay for the same items or services received from an in-network provider. This amount shall be referred to as the “in-network cost-sharing amount.” An out-of-network 988 center, mobile crisis team, or other provider of behavioral health crisis services shall not bill or collect an amount from the insured for services subject to this section except for the in-network cost-sharing amount.

(e) For purposes of this section:

(1) “Behavioral health crisis services” has the same meaning as set forth in Section 53123.1.5 of the Government Code.

(2) “Behavioral health crisis stabilization services” means health care items and services that are necessary to determine if a behavioral health crisis exists and, if a behavioral health crisis does exist, the care and treatment that is necessary to stabilize the behavioral health crisis, within the capability of the 988 center, mobile crisis team, or other provider of behavioral health crisis services.

(3) “Poststabilization care” means medically necessary care provided after a behavioral health crisis has been stabilized.

(4) An insured is “stabilized” or “stabilization” has occurred when, in the opinion of the treating provider or facility, the insured’s condition is such that, within reasonable medical probability, both of the following criteria are satisfied:

(A) Material deterioration of the insured’s condition is unlikely to result from, or occur during, the discharge or transfer of the insured to the care of another provider or facility.

(B) The insured is able to travel safely from the site of care using nonmedical transportation or nonemergency medical transportation. The health insurer shall continue to cover all services and care as behavioral health crisis stabilization services until the insured is discharged or transferred.

(f) This section does not excuse a disability insurer from complying with Section 10144.5 or any other requirement of this part.

(g) This section does not apply to Medicare supplement, dental-only, or vision-only health insurance policies.

(h) The commissioner may promulgate regulations subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) to implement this section, and Section 10144.4, 10144.5, 10144.51, or 10144.52 of this code. This subdivision shall not be construed to impair or restrict the commissioner’s rulemaking authority pursuant to another provision of this code or the Administrative Procedure Act.