§ 1300.74.72.01. Scope of Required Benefits for Mental Health and Substance Use Disorders.
28 CA ADC § 1300.74.72.01Barclays Official California Code of RegulationsEffective: April 1, 2024
Effective: April 1, 2024
28 CCR § 1300.74.72.01
§ 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:
(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.
(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.
(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.
(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.
(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.
(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.
Credits
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.
History
1. New section filed 1-12-2024; operative 4-1-2024 (Register 2024, No. 2).
This database is current through 4/19/24 Register 2024, No. 16.
Cal. Admin. Code tit. 28, § 1300.74.72.01, 28 CA ADC § 1300.74.72.01
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