California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.72 - Mental Health and Substance Use Disorder Coverage Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  health care service plan (health plan) shall provide coverage for mental health
				  and substance use disorder (MH/SUD) medically necessary services (MH/SUD
				  services) pursuant to Health and Safety Code section
				  1374.72(a)
				  and this Rule.
(b) A health plan
				  shall provide coverage for MH/SUD services delivered by a "health care
				  provider" as that term is defined under Health and Safety Code sections
				  1374.72(a)(4)(A)-(H).
(c) A health plan shall maintain a provider
				  network sufficient to provide all medically necessary services, including
				  MH/SUD services, within geographic and timely access standards, pursuant to the
				  Knox-Keene Act and its implementing regulations. If such MH/SUD services are
				  not available to an enrollee in accordance with geographic and timely access
				  standards such as those required by Rule 1300.67.2.2 and Rule 1300.67.2.1, the
				  health plan shall provide and arrange coverage for medically necessary MH/SUD
				  services from an out-of-network provider or providers. In such cases:
(1) The health plan shall issue a written
				  notice to the enrollee, the enrollee's authorized representative (if any), and
				  the requesting provider (if any), within five (5) calendar days following the
				  initial request for in-network MH/SUD services, which shall include the
				  following statement in a paragraph separate from other content and in no less
				  than 12-point font on page one or two of the notice:
(Insert health plan name) must arrange and pay for the
					 services requested by (provider's name) from a health care provider outside our
					 network because (plan name) does not have an in-network (Mental Health or
					 Substance Use Disorder (MH/SUD)) provider available within the required
					 timeframe or geographic area. Your provider requested coverage for the
					 following services: (describe services). You will only be responsible for
					 paying your usual in-network cost sharing amount for these services. You may
					 obtain additional information about obtaining out-of-network MH/SUD services
					 from (insert plan name) at (insert plan's toll-free customer service number).
					 If you are having trouble with (insert health plan name) arranging the approved
					 out-of-network services and have been unable to resolve the issue with (insert
					 health plan name), please contact the Department of Managed Health Care's Help
					 Center at 1-888-466-2219 or go to the Department's website at
www.healthhelp.ca.gov
to
					 receive additional help.
(2) The health plan shall select and contact
				  an out-of-network provider or providers who are qualified and available to
				  provide the MH/SUD services the enrollee needs. Such provider(s) shall be
				  located consistent with the geographic access standards in Rule 1300.67.2.1, if
				  possible. Within three (3) business days of when the health plan contacts the
				  selected provider, the health plan shall furnish a written authorization to the
				  provider specifying, at a minimum, the following:
(a) provider name;
(b) service authorization number;
(c) services authorized;
(d) negotiated reimbursement
				  rate(s);
(e) date range for the
				  authorization;
(f) the health plan's
				  contact and claims submission information; and
(g) the health plan's provider dispute
				  resolution information. The health plan shall document and retain a record of
				  this communication.
(3)
				  The health plan shall schedule the appointment for the enrollee or arrange for
				  the admission of the enrollee if the MH/SUD services will be in an inpatient
				  (including residential) setting, when accepted by the enrollee. The offered
				  appointment or admission shall be scheduled as follows, unless Health and
				  Safety Code section
				  1367.03
				  subdivisions (a)(5)(H) or (a)(5)(I) apply:
(A) No more than ten (10) business days after
				  the initial request for non-urgent MH/SUD services;
(B) Within 15 business days of a request for
				  specialist physician MH/SUD services;
(C) Within 48 hours of the initial request
				  for urgent MH/SUD services (as defined by Health and Safety Code section
				  1367.01(h)(2))
				  when the health plan does not require prior authorization; or
(D) Within 96 hours of the initial request
				  for urgent MH/SUD services (as defined by Health and Safety Code section
				  1367.01(h)(2))
				  if the health plan requires prior authorization.
If the enrollee is unable to attend the appointment offered
					 by the health plan, the health plan shall continue to arrange and schedule a
					 new appointment with the same out-of-network provider or a different
					 out-of-network provider to ensure the delivery of medically necessary MH/SUD
					 services.
(4)
				  Within 24 hours of scheduling the appointment or admission, the health plan
				  shall communicate the following information in the most expeditious manner
				  possible to the enrollee, the enrollee's authorized representative, or the
				  enrollee's provider:
(A) that the health plan
				  has scheduled the appointment or admission;
(B) the name of the provider;
(C) the date and time of the appointment or
				  admission; and,
(D) the location
				  and contact information for the provider.
(5) The health plan shall document and retain
				  a record of all communications with the enrollee pursuant to subdivision (c),
				  including a description of the requested MH/SUD services, the name and location
				  of the provider(s) contacted, the date(s) the plan contacted the provider(s),
				  the type of provider(s), the MH/SUD service(s) authorized, and the selected
				  provider(s), location(s), and duration of the MH/SUD service(s)
				  provided.
(6) The limit on the
				  enrollee's financial obligation for out-of-network MH/SUD services pursuant to
				  Health and Safety Code section
				  1374.72(d)
				  shall be set forth in the written agreement between the health plan and the
				  out-of-network provider(s). The health plan shall contact the enrollee in
				  writing to explain the enrollee's financial obligation to the out-of-network
				  provider(s).