Section 1374.72 Of Article 5.6. Point-of-service Health Care Service Plan Contracts From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.6.
1374.72
. (a) 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 severe mental
illnesses of a person of any age, and of serious emotional
disturbances of a child, as specified in subdivisions (d) and (e),
under the same terms and conditions applied to other medical
conditions as specified in subdivision (c).
(b) These benefits shall include the following:
(1) Outpatient services.
(2) Inpatient hospital services.
(3) Partial hospital services.
(4) Prescription drugs, if the plan contract includes coverage for
prescription drugs.
(c) The terms and conditions applied to the benefits required by
this section, that shall be applied equally to all benefits under the
plan contract, shall include, but not be limited to, the following:
(1) Maximum lifetime benefits.
(2) Copayments.
(3) Individual and family deductibles.
(d) For the purposes of this section, "severe mental illnesses"
shall include:
(1) Schizophrenia.
(2) Schizoaffective disorder.
(3) Bipolar disorder (manic-depressive illness).
(4) Major depressive disorders.
(5) Panic disorder.
(6) Obsessive-compulsive disorder.
(7) Pervasive developmental disorder or autism.
(8) Anorexia nervosa.
(9) Bulimia nervosa.
(e) For the purposes of this section, a child suffering from,
"serious emotional disturbances of a child" shall be defined as a
child who (1) has one or more mental disorders as identified in the
most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders, other than a primary substance use disorder or
developmental disorder, that result in behavior inappropriate to the
child's age according to expected developmental norms, and (2) who
meets the criteria in paragraph (2) of subdivision (a) of Section
5600.3 of the Welfare and Institutions Code.
(f) This section shall not apply to contracts 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, between the State Department of Health
Services and a health care service plan for enrolled Medi-Cal
beneficiaries.
(g) (1) For the purpose of compliance with this section, a plan
may provide coverage for all or part of the mental health services
required by this section through a separate specialized health care
service plan or mental health plan, and shall not be required to
obtain an additional or specialized license for this purpose.
(2) A plan shall provide the mental health coverage required by
this section in its entire service area and in emergency situations
as may be required by applicable laws and regulations. For purposes
of this section, health care service plan contracts that provide
benefits to enrollees through preferred provider contracting
arrangements are not precluded from requiring enrollees who reside or
work in geographic areas served by specialized health care service
plans or mental health plans to secure all or part of their mental
health services within those geographic areas served by specialized
health care service plans or mental health plans.
(3) Notwithstanding any other provision of law, in the provision
of benefits required by this section, a health care service plan may
utilize case management, network providers, utilization review
techniques, prior authorization, copayments, or other cost sharing.
(h) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for prescription drugs.