SB 855 (Wiener) is a senate bill that revised provisions in the California Mental Health Parity Act. SB 855 requires commercial insurers to provide coverage for medically necessary treatment for all mental health and substance use disorders (MH/SUD) in the same manner as applied to other medical conditions. The law became effective on January 1, 2021 and applies to all commercial plans and policies in the group and individual market regulated by the Department of Managed Health Care and Department of Insurance, respectively.
SB 855 creates substantive changes affecting commercial plans and policies. Following are just a few changes, of which all commercial plans affected by SB 855 should take note:
- Medical Necessity is defined as health care services or products addressing the specific needs of a patient (a) for the purpose of preventing, diagnosing or treating a condition or its symptoms, consistent with accepted standards of mental health and substance use disorder care, or (b) that is clinically appropriate, and not primarily for the economic benefit of the plan or policy, or for the convenience of the patient, treating physician or other health care providers. Please note that members are not precluded from exercising their rights to appeal, submit a grievance, or request an independent medical review, among others.
- If the mental health or substance use disorder treatment services are not available in-network in accordance with the geographic and timely access standards, the plan or policy must arrange and provide its members out-of-network services and follow up services that satisfy the geographic and timely access standards. Please note that plans and policies are prohibited from charging members additional cost-sharing fees on any out-of-network services.
- For purposes of SB 855, health care providers include the following: marriage and family therapist or trainees, autism service provider, associate clinical social worker, associate professional clinical counselor or trainee, registered psychologist, registered psychological assistant, psychology trainee, as well as healing arts professionals licensed under Division 2 of the Business & Professions Code.
Health care plans and policies must ensure that their contracts are not in conflict with the requirements imposed under SB 855. If you need assistance with updating your plan contracts, policies or provider agreements, health plan licensing or other compliance matters, please do not hesitate to contact us at (916) 441-2430.
Magaly Zagal (left) is an Associate at Wilke Fleury.
Heather Claus (center) is Of Counsel at Wilke Fleury.
Aaron Claxton (right) is an Associate at Wilke Fleury.
Arielle E. Brown is our new associate at Wilke Fleury!
Prior to joining Wilke Fleury, Arielle practiced Torts and Product Liability, focusing on commercial and consumer breach of warranty law. She also gained extensive courtroom and trial experience as a criminal defense attorney. While at the San Francisco Public Defender’s Office, Arielle personally advocated for clients and tried many jury trials to verdict.
During law school, Arielle tutored Contracts and Torts. She serves on several governing boards, including as Parliamentarian for the Western Regional Black Law Students Association and Executive Lt. Governor for the American Bar Association – Law School Division. She interned at Open Door Legal, where she participated in administrative hearings regarding foster care licensing cases. She also interned at several public defender offices, where she fought for humanity and justice in defense of the damned.
The recently passed $1.9 trillion COVID-19 relief bill provides Americans with $1,400 stimulus payments and $7.5 billion for the Department of Health and Human Services and Centers for Disease Control and Prevention. Funds are earmarked for vaccine education, and clinic and mobile unit operation. The bill also includes a significant change strengthening the Affordable Care Act (ACA). This ACA provision expands ACA marketplace subsidies temporarily, lowering marketplace premiums by providing health insurance premiums for qualified individuals.
Through this package, there will be a significant expansion of subsidies for health insurance to middle-class and low-income individuals for the next two years. Numerous families struggle to pay their monthly healthcare premiums. With this in mind, the new legislation will fully cover premiums for those making within 150% of the federal poverty level (FPL), which is approximately $19,320 annually. Individuals earning more than 400% of the FPL – approximately $51,000 per year – will be able to purchase healthcare plans on the marketplace, with premiums capped at 8.5% of their income. For example, the monthly premium will drop from $1,075 to $412.50 for an individual making approximately $58,000 a year.
The legislation provides relief for those who purchase health insurance through the exchange, particularly those who have plans with high deductibles and low premiums. An individual with a high deductible may be incentivized not to seek health services due to high initial out-of-pocket costs. With this legislation, approximately 14 million enrollees from the marketplace may pay less by purchasing an entirely different plan from those savings. This change is in response to criticisms of unaffordability, causing individuals to opt to not purchase any health insurance. But with this change, the Congressional Budget Office estimates that approximately 1.7 million Americans would enroll within the marketplace, 1.3 million of which are previously uninsured.
Additionally, under the relief package, those who receive unemployment benefits may be eligible to enroll in the exchange this year. Prior, these individuals were not eligible for subsidies on the exchange. This new bill will cover cost of premiums for those who receive health benefits through COBRA.
In addition to the relief package, President Biden opened a special enrollment period due to the pandemic. Open enrollment typically comes only once a year, in which individuals can purchase a health plan through the marketplace. With this special enrollment period, Americans can now enroll until May 15. Though these changes are temporary for now, lawmakers are expecting these subsidies to become permanent. Others note that improvements may continuously be made, following the original goals of the ACA under the Obama administration. The current legislation proposes narrow improvements but additional provisions regarding premium affordability and subsidies may be explored in the future.
Annie Lee was a Law Clerk at Wilke Fleury in the Spring of 2021.
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-  The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families who have lost health benefits due to loss of job continued coverage at a higher cost. https://dol.gov/general/topic/health‐plans/cobra
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