July 9, 2024
California Department of Insurance
Attn: Sarah Sullivan, Attorney III
Health Equity and Access Office
300 Capitol Mall, Suite 1700
Sacramento, CA 95814
Via email CDIRegulations@insurance.ca.gov
Re: Mental Health and Substance Use Disorder Coverage Requirements, Article 15.2 (commencing with section 2652.1) of Subchapter 3 of Chapter 5 of Title 10 of the California Code of Regulations, pursuant to the authority granted by Insurance Code sections 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, and 10144.57
We appreciate the opportunity to comment on California Department of Insurance’s Notice of Proposed Action for the Department’s Mental Health and Substance Use Disorder Parity in Health Insurance Rulemaking (REG-2021-00008) dated May 24, 2024, to implement Senate Bill 855 (Wiener, Chapter 151, 2020) and Assembly Bill 988 (Bauer-Kahan, Chapter 747, 2022). We are grateful for the Department’s engagement with us on numerous issues related to the drafted regulations. The Department’s proposed Rule lessens the possibility that disability insurers will exploit ambiguities to inappropriately limit insureds’ access to mental health and substance use disorder (MHSUD) care
We encourage this comprehensive Rulemaking to be finalized as soon as possible and offer support for the following key provisions, as currently drafted:
● Use of nonprofit professional association utilization review criteria and gap-filling criteria aligned with generally accepted standards of care (GASC). The exclusive use of nonprofit professional association criteria, unmodified, is essential to ensuring that insureds receive the appropriate intensity and duration of services to meet their specific needs in a manner consistent with generally accepted standards of care. The proposed Rule clearly states that it is the responsibility of disability insurers to use nonprofit professional association utilization review criteria in a manner established or approved by the association and to document how the plan is meeting these requirements.
We also support the Department’s development of gap-filling criteria for use when there are not established nonprofit professional association utilization review criteria for a MHSUD condition or service. All criteria, including gap-filling criteria, should be consistent with GASC to ensure that every MHSUD condition is measured against appropriate clinical standards. These standards are squarely in-line with the intent and letter of the law.
● Obligation of health insurers to arrange and pay for out-of-network care and insureds’ rights to arranging out-of-network coverage, including requirements that insurers must be required to enter into an agreement with out-of-network providers when geographic and timely access standards are not met. We support the Department’s specificity on obligations of insurers in arranging out-of-network care, including:
○ The insurer’s obligation to identify and secure out-of-network health care providers or facilities within time and distance standards;
○ The insured’s right to timely authorization of out-of-network services;
○ The insured’s right to in-network cost-sharing for out-of-network benefits when an insurer fails to secure in-network care;
○ Where appointments/admissions are not available within 90 calendar days, that an insured shall be allowed to schedule the appointment/admission beyond this timeframe;
○ The insurer’s explicit responsibility to cover the entire course of medically necessary treatment;
○ Transitioning an insured to an in-network provider or facility should involve “clear and convincing evidence” that such a transition is in the best interest of the patient, and not for the convenience or cost-savings of the insurer.
● Explicit coverage requirements for crisis services, including those accessed through 988, including mandates that emergency crisis services be covered:
○ without medical necessity reviews;
○ without prior authorization;
○ without regard to provider network status; and
○ that insureds are subject to only in-network cost sharing on these claims.
● Requirements that utilization reviewers have appropriate qualifications. We support the Department’s inclusion of qualifications and standards for utilization reviewers conducting reviews on MHSUD claims. Utilization reviewers should have proper training and experience in the field of behavioral health care that is under review. We further appreciate the Department’s specificity on qualifications for SUD reviews, a field in which the practice of unqualified utilization reviewers results in disproportionately high denials for SUD care. We encourage the Department to consider adding such specificity for other specialty areas with high rates of denials, such as eating disorder care, gender affirming care, and treatment for autism spectrum disorders.
● Ensuring continuity of care by requiring insurers to bear the burden of demonstrating by clear and convincing evidence that ongoing MHSUD services arranged out-of-network (due to network inadequacy) are interrupted only in accordance with generally accepted standards of care. The Department’s explicit requirements that an insurer reimburse for the entire course of treatment is aligned with the intent of the law and the clinical standards for MHSUDs.
● Formal education programs, including requiring insurers to sponsor a formal education program created by relevant nonprofit professional associations. Ensuring insurers are using relevant nonprofit professional association trainings, as available, ensures alignment and proper use of clinical review criteria in the manner in which the clinical association intended. Such trainings should include targeted outreach and be made available to both in and out-of-network providers and facilities, as well as members.
● Transparency in utilization review and training, by requiring insurers make education materials, trainings, and utilization review criteria available to network providers, group policyholders, insureds and their authorized representatives, and out-of-network providers.
● Definition of health care provider that is aligned with statute and inclusive of often-denied providers such as associates and trainees. Providers continue to report claim denials when associates appropriately provide medically necessary services under existing laws. Aligning the definition of health care provider with how it is defined in statute makes unambiguous that the use of associate providers is permitted under the statute.
While the above-mentioned components of Rulemaking offer strong protections for insureds seeking MHSUD care, we provide the following comments to further bolster insureds’ rights and lessen their burden in obtaining medically necessary MHSUD care. We hope the Department will consider the following comments for inclusion in its Final Rulemaking.
● Coverage requirements for frequently denied care. While we appreciate the proposed Rule’s clarity on the exclusive use of nonprofit professional association utilization review criteria, we encourage the Department to consider listing coverage requirements for frequently denied services and levels of care.
● Frequency and duration of treatment reviews. 28 CCR 1300.74.721(d) states that “a health plan shall not conduct repeated utilization review of a case at intervals more frequent than those prescribed or recommended by the relevant nonprofit professional association criteria or guidelines.” We encourage the Department to adopt similar language limiting the frequency and duration of treatment reviews, to align with the statute’s definition of medically necessary treatments that are “clinically appropriate in terms of type, frequency, extent, site, and duration.”
● Out-of-state provider coverage for out-of-network care. While we support the Department’s specificity on insureds’ rights to out-of-network coverage, we request further specificity that insureds’ rights to arranging out-of-network care are not limited to in-state providers once a plan has failed to arrange for in-network coverage. The state has limited facilities appropriate for certain populations. For example, there is a shortage of longer-term residential facilities as well as high quality programs that can address needs of specific populations; the state’s Department of Education has responded well to this issue by creating a list of out-of-state schools that can additionally serve special youth populations under IEP. Out of state status should not be a disqualifying issue for receiving medically necessary MHSUD care if appropriate care cannot be found in-state.
● Inclusion of nonprofit clinical criteria for eating disorder care. The REDC Level of Care Criteria are the most detailed, up to date, clinical level of care guidelines for eating disorder care. These criteria define eating disorder levels of care and criteria for admission for each level of care and were vetted across clinical and research evidence as well as across the eating disorders field to gain clinical consensus. We encourage the Department to list these criteria as part of its allowed nonprofit clinical criteria.
● Instituting reporting requirements to track compliance including yearly insurer reporting requirements on timely access and out-of-network referrals. Regular data collection efforts will allow the Department to proactively identify compliance issues without relying on trends in insured complaints to understand violations of these laws.
● Distributing department-produced educational materials on SB 855 and AB 988 to insureds including know-your-rights materials. We additionally encourage the Department to add a requirement that health plans provide insureds with copies of these Department-produced materials to better ensure insureds receive such information, as well as including them in the Evidence of Coverage manual.
● Requiring plans to incorporate the list of services into their evidences of coverage. While we appreciate the requirements in the proposed rules related to evidences of coverage, we believe more should be required of plans in order to ensure that enrollees get access to necessary information regarding covered services. CDI should require plans to include a list of all the services outlined in Section 2562.05 in their evidences of coverage and to explain that all of those services are covered when meeting the medical necessity criteria. In addition, plans should be required to add a statement emphasizing that the list is not exhaustive and that other MHSUD services not listed in the evidence of coverage are covered when medically necessary.
● Allowed health care providers. Health plans and insurers often disallow certain eligible providers from providing and billing services; associates, trainees, and autism providers, for example, are frequently not considered eligible providers, despite their clear inclusion in statute, resulting in continued denials for claims for medically necessary MHSUD care under current law. We support the Department’s definition of “health care provider” and believe it is clearly inclusive of these often-denied providers. To ensure adherence to the statute, we request that the Department include clarifying language that confirms listed providers cannot be denied reimbursement for MHSUD services rendered on the basis of their provider status (as associates, trainees, etc.).
● Issuing Notices/Bulletins/General Counsel opinion letters upon adoption of final Rules regarding particular areas of enforcement concern.
We encourage the consideration of our above-stated comments and the swift promulgation of comprehensive regulations. Once again, we thank you for considering our comments and considerations for finalization of the proposed Rules. As always, our organizations stand ready to assist you in any way we can.
If you have any questions, please contact Lauren Finke (lauren@thekennedyforum.org). For matters requiring physical or printed communication, please send to 1121 L Street, Sacramento, California 95814 suite #300.
Sincerely,
Adrienne Shilton
California Alliance of Child and Family Services
Robb Layne
California Association of Alcohol and Drug Program Executives, Inc
Joy Alafia
California Association of Marriage and Family Therapists
Chad Costello
California Association of Social Rehabilitation Agencies
Tyler Rinde
California Psychological Association
Paul Yoder
California State Association of Psychiatrists
Danny Thirakul
California Youth Empowerment Network
Alison Ivie
Eating Disorders Coalition
REDC
Karen Fessel
Mental Health & Autism Insurance Project
Heidi Strunk
Mental Health America of California
Jessica Cruz, MPA/HS
National Alliance on Mental Illness
Héctor Hernández-Delgado
National Health Law Program
Benjamin Eichert
NUHW
Randall Hagar
Psychiatric Physicians Alliance of California
John Drebinger III
Steinberg Institute
Lauren Finke
The Kennedy Forum
CC:
Ricardo Lara, Stesha Hodges, Department of Insurance
Senator Scott Wiener
Assemblymember Bauer-Kahan
