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.