by Senator Polanco

• Status: Status, SB 468, as of 1999-06-25 -- (text)
  
• History: History, SB 468, as of 1999-06-25 -- (text)
  
• Current: SB 468, Current Amended 1999-06-24 [13.5KB] -- (text)
  
• Introduced: SB 468, Introduced 1999-02-17 [9.0KB] -- (text)
  

All bill related documents:

• Analysis, SB 468, Sen. Appropriations committee as of 1999-04-27 [4.5KB] -- (text)
  
• Analysis, SB 468, Sen. Appropriations committee as of 1999-04-27 [4.5KB] -- (text)
  
• Analysis, SB 468, Sen. Health & Human Svcs. committee as of 1999-04-05 [22.5KB] -- (text)
  
• Analysis, SB 468, Sen. Ins. committee as of 1999-04-13 [13.5KB] -- (text)
  
• Analysis, SB 468, Sen. Floor Session as of 1999-05-29 [22.5KB] -- (text)
  
• SB 468, Introduced 1999-02-17 [9.0KB] -- (text)
  
• SB 468, Current Amended 1999-03-22 [18.0KB] -- (text)
  
• SB 468, Current Amended 1999-04-05 [13.5KB] -- (text)
  
• SB 468, Current Amended 1999-04-13 [13.5KB] -- (text)
  
• SB 468, Current Amended 1999-04-27 [13.5KB] -- (text)
  
• SB 468, Current Amended 1999-06-24 [13.5KB] -- (text)
  
• Vote, SB 468, Sen. Appropriations committee as of 1999-05-17 -- (text)
  
• Vote, SB 468, Sen. Appropriations committee as of 1999-05-27 -- (text)
  
• Vote, SB 468, Sen. Health & Human Svcs. committee as of 1999-04-07 -- (text)
  
• Vote, SB 468, Sen. Ins. committee as of 1999-04-21 -- (text)
  
• Vote, SB 468, Sen. Floor Session as of 1999-06-01 -- (text)
  

excerpt from Health care coverage: mental illness text...

Under existing law, a disability insurer or health care
service plan may not discriminate based on race, color,
religion, national origin, ancestry, or sexual orientation. An
insurer is also prohibited from refusing to insure a person or
from charging a different premium because of that person's
blindness.

This bill would require a health care service plan contract
or disability insurance policy issued, amended, or renewed on or
after July 1, 2000, to provide coverage for the diagnosis and
medically necessary treatment of mental illness under the same
rates, terms, and conditions as generally applied to other
medical conditions, as specified.


---

 ~Current Session Legislation~

SB 468 Health care coverage: mental illness.

BILL NUMBER: SB 468 AMENDED 06/24/99

AMENDED IN ASSEMBLY JUNE 24, 1999 AMENDED IN SENATE APRIL 27, 1999 AMENDED IN SENATE APRIL 13, 1999 AMENDED IN SENATE APRIL 5, 1999 AMENDED IN SENATE MARCH 22, 1999

INTRODUCED BY Senators Polanco, Alpert, Figueroa, Ortiz, and Rainey (Coauthors: Assembly Members Cardenas, Ducheny, Firebaugh, Kuehl, Romero, Shelley, and Wildman)

FEBRUARY 17, 1999

An act to add Section 1374.72 to the Health and Safety Code, and to add Section 10144.5 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

SB 468, as amended, Polanco. Health care coverage: mental illness.

Under existing law, a disability insurer or health care service plan may not discriminate based on race, color, religion, national origin, ancestry, or sexual orientation. An insurer is also prohibited from refusing to insure a person or from charging a different premium because of that person's blindness.

This bill would require a health care service plan contract or disability insurance policy issued, amended, or renewed on or after July 1, 2000, to provide coverage for the diagnosis and medically necessary treatment of mental illness under the same rates, terms, and conditions as generally applied to other medical conditions, as specified. These requirements would not apply to a contract between the State Department of Health Services and a health care service plan or a disability insurer for the benefit of enrolled Medi-Cal beneficiaries. These requirements also would not apply to certain types of insurance policies.

Because a willful violation of the bill's provisions relating to health care service plans would be a crime, this bill would impose a state-mandated local program by creating a new crime.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

SECTION 1. Section 1374.72 is added to the Health and Safety Code, to read:

1374.72. Every health care service plan contract issued, amended, or renewed on or after July 1, 2000, that provides hospital, medical, or surgical coverage shall provide coverage for the diagnosis and medically necessary treatment of mental illness under the same rates, terms, and conditions as generally applied to other medical conditions.

(a) Coverage, at a minimum, shall include all of the following:

(1) Inpatient hospital services.

(2) Outpatient services.

(3) Partial hospital services.

(4) Prescription drugs, if the plan contract includes coverage for prescription drugs.

(b) "Mental illness" includes mental disorders defined in the Diagnostic and Statistical Manual IV or subsequent editions published by the American Psychiatric Association, except those codes defining substance abuse disorders (291.0 to 292.9, inclusive, and 303.0 to 305.9, inclusive) and the "V" codes.

(c) "Rates, terms, and conditions" means any lifetime limits, annual payment limits, episodic limits, inpatient or outpatient service limits, out-of-pocket limits, coinsurance, copayments, or any other cost sharing or benefit limitations, or other limitations that restrict access to services which are medically necessary and clinically appropriate.

(d) The commissioner may disapprove any contract that the commissioner determines to be inconsistent with the purposes of this section.

(e) Subject to conformance to the requirement that the same rates, terms, and conditions shall apply to mental illness as generally apply to other medical conditions, nothing in this section shall be construed to do any of the following:

(1) Prohibit a health care service plan from negotiating separate reimbursement rates and service delivery systems for mental illness coverage, including, but not limited to, a mental health carve-out program.

(2) Prohibit a health care service plan from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to ensure that coverage is provided only for those services for mental illness that are medically necessary and clinically appropriate. The methods shall not be utilized to deny or limit access to services that are medically necessary and clinically appropriate.

(3) Prohibit the use of a case management program for mental illness benefits to evaluate and determine medically necessary and clinically appropriate care and treatment for each patient.

(4) Restrict coverage only to those services provided by physicians and surgeons or to alter the scope of practice of any health care professional.

(f) A health care service plan shall not be in violation of this chapter if the plan applies different limits or entirely excludes from coverage any of the following:

(1) Marital, family, educational, or training services, unless those services are medically necessary or clinically appropriate.

(2) Care that is substantially custodial in nature.

(3) Services and supplies that are not medically necessary or clinically appropriate.

(g) This section does not apply to contracts between the State Department of Health Services and a health care service plan for the benefit of enrolled Medi-Cal beneficiaries that are entered into pursuant to Chapter 7 (commencing with Section 14000), or Chapter 8 (commencing with Section 14200), of Division 9 of Part 3 of the Welfare and Institutions Code.

(h) No person suffering from a mental illness covered by this section shall be denied benefits for that mental illness because the person also has a disease or condition that is not covered by this section.

SEC. 2. Section 10144.5 is added to the Insurance Code, to read:

10144.5. Every Except as provided in subdivisions (g) and (h), every policy of disability insurance that covers hospital, medical, or surgical expenses and that is issued, amended, or renewed on or after July 1, 2000, shall provide coverage for the diagnosis and medically necessary treatment of mental illness under the same rates, terms, and conditions as generally applied to other medical conditions.

(a) Coverage, at a minimum, shall include all of the following:

(1) Inpatient hospital services.

(2) Outpatient services.

(3) Partial hospital services.

(4) Prescription drugs, if the policy includes coverage for prescription drugs.

(b) "Mental illness" includes mental disorders defined in the Diagnostic and Statistical Manual IV or subsequent editions published by the American Psychiatric Association, except those codes defining substance abuse disorders (291.0 to 292.9, inclusive, and 303.0 to 305.9, inclusive) and the "V" codes.

(c) "Rates, terms, and conditions" means any lifetime limits, annual payment limits, episodic limits, inpatient or outpatient service limits, out-of-pocket limits, coinsurance, copayments, or any other cost sharing or benefit limitations, or other limitations that restrict access to services which are medically necessary and clinically appropriate.

(d) The commissioner may disapprove any contract that the commissioner determines to be inconsistent with the purposes of this section.

(e) Subject to conformance to the requirement that the same rates, terms, and conditions shall apply to mental illness as generally apply to other medical conditions, nothing in this section shall be construed to do any of the following:

(1) Prohibit an insurer from negotiating separate reimbursement rates and service delivery systems for mental illness coverage, including, but not limited to, a mental health carve-out program.

(2) Prohibit an insurer from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to ensure that coverage is provided only for those services for mental illness that are medically necessary and clinically appropriate. The methods shall not be utilized to deny or limit access to services that are medically necessary and clinically appropriate.

(3) Prohibit the use of a case management program for mental illness benefits to evaluate and determine medically necessary and clinically appropriate care and treatment for each patient.

(4) Restrict coverage only to those services provided by physicians and surgeons or to alter the scope of practice of any health care professional.

(f) An insurer shall not be in violation of this part if the insurer applies different limits or entirely excludes from coverage any of the following:

(1) Marital, family, educational, or training services, unless those services are medically necessary or clinically appropriate.

(2) Care that is substantially custodial in nature.

(3) Services and supplies that are not medically necessary or clinically appropriate.

(g) This section does not apply to contracts between the State Department of Health Services and an insurer for the benefit of enrolled Medi-Cal beneficiaries that are entered into pursuant to Chapter 7 (commencing with Section 14000), or Chapter 8 (commencing with Section 14200), of Division 9 of Part 3 of the Welfare and Institutions Code.

(h) This section shall not apply to accident only, specified disease, hospital indemnity, Medicare supplement, dental only, or vision only insurance policies.

(i) No person suffering from a mental illness covered by this section shall be denied benefits for that mental illness because the person also has a disease or condition that is not covered by this section.

SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.