Section 1300.74.72.01 - Scope of Required Benefits for Mental Health and Substance Use Disorders(a) A health plan shall provide coverage of health care benefits for preventing, diagnosing, and treating mental health conditions and substance use disorders as medically necessary for an enrollee, in accordance with current generally accepted standards of mental health and substance use disorder care, including but not limited to, the following: (1) Basic health care services, including the following: (A) Emergency health care services as defined by Health and Safety Code section 1317.1 rendered both inside and outside the service area of the applicable network consistent with the Knox-Keene Act.(B) Urgent care services rendered inside and outside the service area of the of the applicable network consistent with the Knox-Keene Act.(C) Physician services, including but not limited to consultation and referral to other health care providers and prescription drugs when furnished or administered by a health care provider or facility.(D) Hospital inpatient services, including services of licensed general acute care, acute psychiatric, and chemical dependency recovery hospitals.(E) Ambulatory care services, including but not limited to physical therapy, occupational therapy, speech therapy, and infusion therapy.(F) Diagnostic laboratory services, diagnostic and therapeutic radiologic services, and other diagnostic and therapeutic services.(G) Home health care service.(H) Preventive health care services, regardless of whether an enrollee has been diagnosed with a mental health condition or substance use disorder.(I) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.), (December 2022), and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations (December 2022), except Subparts A, B, G, and H.(2) Behavioral health treatment for pervasive developmental disorder or autism spectrum disorder pursuant to Health and Safety Code section 1374.73.(3) Coordinated specialty care for the treatment of first episode psychosis.(5) Drug testing, both presumptive and definitive, including for initial and ongoing patient assessment during substance use disorder treatment.(6) Electroconvulsive therapy.(7) For gender dysphoria, all health care benefits identified in the most recent edition of the Standards of Care developed by the World Professional Association for Transgender Health.(8) Inpatient services, including but not limited to all the following: (A) American Society of Addiction Medication (ASAM) inpatient levels of care (3rd edition) for substance use disorder rehabilitation and withdrawal management, or as described in the most recent version of the ASAM Criteria. (i) 3.7, medically monitored intensive (adults) or high-intensity (adolescents) inpatient services.(ii) 4, medically managed intensive inpatient services.(B) High intensity acute medically managed residential programs Level of Care Utilization System and Child and Adolescent Level of Care/Service Intensity Utilization System (LOCUS and CALOCUS-CASII level 6A (version 2020), or as described in the most recent versions of LOCUS and CALOCUS-CASII).(C) Medically managed extended care residential programs (LOCUS and CALOCUS-CASII level 6B (version 2020), or as described in the most recent versions of LOCUS and CALOCUS-CASII).(9) Intensive community-based treatment, including assertive community treatment and intensive case management.(10) Intensive home-based treatment.(11) Intensive outpatient treatment.(12) Medication management.(13) Narcotic (opioid) treatment programs.(14) Outpatient prescription drugs, if coverage for outpatient prescription drugs is provided. Outpatient prescription drugs prescribed for mental health and substance use disorder pharmacotherapy, including office-based opioid treatment.(15) Outpatient professional services, including but not limited to individual, group, and family substance use and mental health counseling.(16) Partial hospitalization.(18) Psychiatric health facility services, including structured outpatient services as described in Health and Safety Code section 1250.2.(19) Psychological and neuropsychological testing.(20) Reconstructive surgery pursuant to Health and Safety Code section 1374.72. For gender dysphoria, reconstructive surgery of primary and secondary sex characteristics to improve function, or create a normal appearance to the extent possible, for the gender with which the enrollee identifies, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery who are competent to evaluate the specific clinical issues involved in the care requested.(21) Residential treatment facility services, including all the following: (A) Intensive short-term residential services (LOCUS and CALOCUS-CASII level 5A (version 2020), or as described in the most recent versions of LOCUS and CALOCUS-CASII).(B) Moderate intensity intermediate stay residential treatment programs (LOCUS and CALOCUS-CASII level 5B (version 2020), or as described in the most recent versions of LOCUS and CALOCUS-CASII).(C) Moderate intensity long-term residential treatment programs (LOCUS and CALOCUS-CASII level 5C (version 2020), or as described in the most recent versions of LOCUS and CALOCUS-CASII).(D)ASAM residential levels of care (3rd edition), or as described in the most recent version of The ASAM Criteria:(i) 3.1, clinically managed low intensity residential services.(ii) 3.3, clinically managed population-specific high intensity residential services.(iii) 3.5, clinically managed high intensity (adults) or medium intensity (adolescents) residential services.(22) Schoolsite services for a mental health condition or substance use disorder that are delivered to an enrollee at a schoolsite pursuant to Health and Safety Code section 1374.722.(23) Transcranial magnetic stimulation.(24) Withdrawal management services, including all the following ASAM levels (3rd edition), or as described in the most recent version of The ASAM Criteria: (A) 1-WM, ambulatory withdrawal management without extended on-site monitoring.(B) 2-WM, ambulatory withdrawal management with extended on-site monitoring.(C) 3.2-WM, clinically managed residential withdrawal management.(D) 3.7-WM, medically monitored inpatient withdrawal management.(E) 4-WM, medically managed intensive inpatient withdrawal management.(b) Home health care services. (1) A health plan shall cover home health care services if all the following conditions are satisfied: (A) An enrollee is confined to the home except for infrequent or relatively short duration absences, or when absences are attributable to the need to receive medical treatment, due to a mental health condition or substance use disorder.(B) Skilled nursing care on an intermittent basis, physical therapy, occupational therapy, or speech-language pathology services are medically necessary for the evaluation or treatment of an enrollee's mental health condition or substance use disorder or its symptoms. For purposes of this subdivision (b)(1)(B), skilled care shall be reasonable and necessary to improve an enrollee's current condition, maintain an enrollee's current condition, or prevent or slow further deterioration of an enrollee's condition.(C) An enrollee's physician, physician assistant, nurse practitioner, or clinical nurse specialist attests that the conditions in subdivisions (b)(1)(A) and (b)(1)(B) of this Rule are met, and establishes, and periodically reviews no less frequently than once every 60 days, a plan of care that includes the services specified in subdivision (b)(2) and the frequency and duration of visits.(2) A health plan shall cover all the following home health care services as specified in the plan of care prepared by the enrollee's physician, physician assistant, nurse practitioner, or clinical nurse specialist: (A) Part-time skilled nursing care, including by a registered nurse, licensed practical nurse under the supervision of a registered nurse, or psychiatrically trained nurse.(B) Part-time home health aide services for personal care.(D) Speech-language pathology.(E) Occupational therapy.(F) Medical social services.(G) Medical supplies provided by a home health agency while an enrollee is under a home health plan of care.(H) Durable medical equipment while an enrollee is under a home health plan of care to the extent the enrollee's health plan contract includes coverage for durable medical equipment.(3) For purposes of subdivision (b)(2) of this Rule, part-time means both skilled nursing services and home health aide services furnished any number of days per week, provided that the skilled nursing services and home health aide services, combined, are furnished less than eight hours per day and 35 hours per week. If a health plan covers more than the foregoing number of hours for conditions other than mental health conditions or substance use disorders, it shall cover an equivalent or greater number of hours for a mental health condition or substance use disorder.(4) Any quantitative or nonquantitative treatment limitations or limitations on eligibility for coverage of home health care services shall be consistent with those limitations permitted under this article and Medicare, shall not be more restrictive than such limitations permitted under this article, and shall be subject to prior review by the Department.(c) Preventive health care services, including the following:(1) Screening, brief intervention and referral to treatment, primary care-based interventions, and specialty services for persons with hazardous, at-risk, or harmful substance use who do not meet the diagnostic criteria for a substance use disorder, or persons for whom there is not yet sufficient information to document a substance use or addictive disorder, as described in ASAM level of care 0.5 (3rd edition), or the most recent version of The ASAM Criteria.(2) Basic services for prevention and health maintenance, including: screening for mental health and developmental disorders and adverse childhood experiences; multidisciplinary assessments; expert evaluations; referrals; consultations and counseling by mental health clinicians; emergency evaluation, brief intervention and disposition; crisis intervention and stabilization; community outreach prevention and intervention programs; mental health first aid for victims of trauma or disaster; and health maintenance and violence prevention education, as described in LOCUS and CALOCUS-CASII level of care zero (version 2020), or the most recent versions of LOCUS and CALOCUS-CASII.(3) Preventive health care services for a mental health condition or substance use disorder that are required under Health and Safety Code section 1367.002. Any permissible scope of coverage limitations on health care benefits required under Health and Safety Code section 1367.002 shall not provide a basis to limit coverage for medically necessary treatment of a mental health or substance use disorder in a manner inconsistent with Health and Safety Code sections 1367.005, 1374.72, 1374.721, 1374.73, and 1374.76 or this Rule.(d) A health plan shall cover the following for a mental health condition or substance use disorder:(1) A health care benefit that is medically necessary under the requirements of this Rule, and Rules 1300.74.72, and 1300.74.721, and is furnished or delivered by, or under the direction of, a health care provider or facility acting within the scope of practice of the provider's or facility's license or certification under applicable state law.(2) Emergency health care services that are furnished or delivered by, or under the direction of, a health care provider or facility acting within the scope of practice of the provider's or facility's license or certification under applicable state law, including by or at a licensed or certified health care provider or facility owned or operated by, employed by, or contracted with, a political subdivision to provide emergency health care services or behavioral health crisis services, regardless of whether the health plan is contracted with the health care provider, facility, or political subdivision to furnish emergency health care services or behavioral health crisis services to its enrollees.Cal. Code Regs. Tit. 28, § 1300.74.72.01
Note: Authority cited: Section 1344, Health and Safety Code. Reference: Sections 1367, 1367.005, 1374.72, 1374.721 and 1374.722 and 1374.73, Health and Safety Code.
1. New section filed 1-12-2024; operative 4/1/2024 (Register 2024, No. 2).