Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(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.
(4) Day treatment.
(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.
(17)
Polysomnography.
(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.
(C) Physical
therapy.
(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.
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.