Bill Text: CA SB855 | 2019-2020 | Regular Session | Amended
Bill Title: Health coverage: mental health or substance use disorders.
Spectrum: Strong Partisan Bill (Democrat 13-1)
Status: (Passed) 2020-09-25 - Chaptered by Secretary of State. Chapter 151, Statutes of 2020. [SB855 Detail]
Download: California-2019-SB855-Amended.html
Amended
IN
Senate
May 19, 2020 |
Amended
IN
Senate
May 05, 2020 |
Introduced by Senator Wiener (Principal coauthor: Senator Beall) (Principal coauthors: Assembly Members Aguiar-Curry and Chiu) (Coauthors: Senators (Coauthors: Assembly Members Maienschein and Wicks) |
January 14, 2020 |
LEGISLATIVE COUNSEL'S DIGEST
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
SECTION 1.
The Legislature finds and declares all of the following:(f)If the California Mental Health Parity Act is so expanded, coverage of medically necessary treatment would increase for the fewer than one-half of
adults with a mental health disorder who now receive treatment and the fewer than 1 in 10 individuals 12 years of age or older with a substance use disorder who now receive treatment.
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
SEC. 2.
Section 1367.045 is added to the Health and Safety Code, to read:1367.045.
(a) If a health care service plan contract offered, issued, delivered, amended, or renewed on or after January 1, 2021, contains a provision that reserves discretionary authority to the plan, or an agent of the plan, to determine eligibility for benefits or coverage, to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of this state, that provision is void and unenforceable.SEC. 3.
Section 1374.72 of the Health and Safety Code is repealed.SEC. 4.
Section 1374.72 is added to the Health and Safety Code, to read:1374.72.
(a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(4)
(5)
(6)
(j)(1)An enrollee, subscriber, or in-network or out-of-network provider on behalf of an enrollee or subscriber may bring a civil action in a court of competent jurisdiction individually or on behalf of a class against a health care service plan for a violation of this section or Section 1374.73 or 1374.76.
(2)The remedies in a civil action brought pursuant to this section include, independent of causation or damages, a five-thousand-dollar ($5,000) statutory penalty per act or offense, general and special damages, which may be trebled for knowing conduct, injunctive relief, restitution
of premium, and attorney’s fees and costs, including expert expenses.
(3)If a claim is litigated on a class basis, the same act or offense shall be counted with respect to each class member.
(4)An administrative action taken or not taken by the department with regard to the health care service plan’s conduct shall not provide an affirmative defense in the court’s consideration of the claim. A claimant shall be promptly notified in writing by the health care service plan and by the department of any administrative action, including the final outcome, against a health care service plan as a result of the claimant’s complaint.
SEC. 5.
Section 1374.75 is added to the Health and Safety Code, to read:1374.75.
(a) A health care service plan shall base any medical necessity determination or the utilization review criteria that the plan, and any entity acting on the plan’s behalf, applies to determine the medical necessity of health care services and benefits for the diagnosis, prevention, and treatment of mental health and substance use disorders on current generally accepted standards of medical and behavioral health care practice. Current generally accepted standards of medical and behavioral health care practice are evidence-based sources of standards of care and clinical practice that are generally accepted by health care providers practicing in relevant clinical specialties, including peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of health care provider professional associations, and specialty societies and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.(l)(1)An enrollee, subscriber, or in-network or out-of-network provider acting on behalf of an enrollee or subscriber may bring a civil action in a court of competent jurisdiction, individually or on behalf of a class, against a health care service plan for a violation of this section.
(2)The remedies in a civil action brought pursuant to this subdivision include, independent of causation or damages, a five-thousand-dollar ($5,000) statutory penalty per act or offense, general and special damages, which may be trebled for knowing conduct, injunctive relief, restitution of premium, and attorney’s fees and costs, including expert expenses.
(3)If a claim is litigated on a class basis, the same act or offense shall be counted with respect to each class member.
(4)An administrative action taken or not taken by the department with regard to the health care service plan’s conduct shall not provide an affirmative defense in the court’s consideration of the claim. A claimant shall be notified promptly, in writing, by the health care service plan and by the department, of any administrative action, including the final outcome, against a health care service plan as a result of the claimant’s complaint.
(m)
SEC. 6.
Section 10144.5 of the Insurance Code is repealed.SEC. 7.
Section 10144.5 is added to the Insurance Code, to read:10144.5.
(a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(4)
(5)
(6)
(j)(1)An insured, policyholder, or in-network or out-of-network provider on behalf of an insured or policyholder may bring a civil action in a court of competent jurisdiction individually or on behalf of a class against a disability insurer for a violation of this section.
(2)The remedies in a civil action brought pursuant to this section include, independent of causation or damages, a five-thousand-dollar ($5,000) statutory penalty per act or offense, general and special damages, which may be trebled for knowing conduct, injunctive relief, restitution of premium, and attorney’s fees and costs, including expert expenses.
(3)If a claim is litigated on a class basis, the same act or offense shall be counted with respect to each class member.
(4)An administrative action taken or not taken by the department with regard to the disability insurer’s conduct shall not provide
an affirmative defense in the court’s consideration of the claim. A claimant shall be promptly notified in writing by the disability insurer and by the department of any administrative action, including the final outcome, against a disability insurer as a result of the claimant’s complaint.
(k)
SEC. 8.
Section 10144.52 is added to the Insurance Code, to read:10144.52.
(a) A disability insurer that provides hospital, medical, or surgical coverage shall base any medical necessity determination or the utilization review criteria that the insurer, and any entity acting on the insurer’s behalf, applies to determine the medical necessity of health care services and benefits for the diagnosis, prevention, and treatment of mental health and substance use disorders on current generally accepted standards of medical and behavioral health care practice. Current generally accepted standards of medical and behavioral health care practice are evidence-based sources of standards of care and clinical practice that are generally accepted by health care providers practicing in relevant clinical specialties, including peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of health care provider professional associations, and specialty societies and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.(l)(1)An insured, policyholder, or in-network or out-of-network provider acting on behalf of an insured or policyholder may bring a civil action in a court of competent jurisdiction, individually or on behalf of a class, against a disability insurer for a violation of this section.
(2)The remedies in a civil action brought pursuant to this subdivision include, independent of causation or damages, a five-thousand-dollar ($5,000) statutory penalty per act or offense, general and special damages, which may be trebled for knowing conduct, injunctive relief, restitution of premium, and attorney’s fees and costs, including expert expenses.
(3)If a claim is litigated on a class basis, the same act or offense shall be counted with respect to each class member.
(4)An administrative action taken or not taken by the department with regard to the disability insurer’s conduct shall not provide an affirmative defense in the court’s consideration of the claim. A claimant shall be notified promptly, in writing, by the disability insurer and by the department, of any administrative action, including the final outcome, against a disability insurer as a result of the claimant’s complaint.
(m)
(n)