Mental Health as an essential benefit under ACA Health Care Reform 
Parity Laws – Mental Health must be equal to Medical Benefits

#California Mental Health Insurance Parity

Summary:

• Senate Bill 855 – Mental Health as a Medical Necessity
  • Our webpage on Medical Necessity
  • Insurers Begin To Tackle Complex Mental Health Compliance Rules  kff September 2024 
• AB 88 CA Insurance Code §§10144.5.  Health and Safety Code§1374.72  requrires that severe mental illness for children be covered and also prohibits health plans from basing medical necessity denials on whether the admission for mental health services was voluntary or involuntary, WIC 5150 hold  ^{CA Legislator *} or on the method of transportation of the patient to the health facility.
• AB 88 also requires Insurance Companies  that offer mental health services (Individual & Families * Medi-Cal * Employer Groups)  to have information on their website that will assist enrollees in accessing mental health services.  ^{SB 1553  §1368.015, §1367.015Health & Safety Code Blue Cross / Anthem Mental Health Procedures}

SB 221   Return Visit Guarantees 

SB 221   requires that Mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits. ^{CA HealthLine}  *  ^{CA Health Line 11.24.2021} *

Our webpage on how to read a contact and Insurance Policy

Severe Mental Illness Coverage
AB 88 – Insurance Code §10144.5

(a) Every policy of disability (health) insurance that covers hospital, medical, or surgical expenses in this state* … 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, … under the same terms and conditions applied to other medical conditions,

(b) These benefits shall include the following:

(1) Outpatient services.

(2) Inpatient hospital services.

(3) Partial hospital services.

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

How to obtain, get or find these benefits?

(c) The terms and conditions applied to the benefits required by this section that shall be applied equally to all benefits under the disability (Health, Medical)  insurance policy shall include, but not be limited to, the following:

(1) Maximum lifetime benefits.

(2) Co-payments and coinsurance.

(3) Individual and family deductibles.

 (d) For the purposes of this section, “severe mental illnesses” shall include [these diagnosis]:

(1)  schizophrenia.com/ *

(2) Schizoaffective disorder. ***  WedMD

(3) Bipolar disorder (manic-depressive illness). bipolar.com/***  WebMD

(4) Major depressive disorders. ***  WebMD

(5) Panic disorder. ***  WebMD

(6) Obsessive-compulsive disorder.***  WebMD

(7) Pervasive developmental disorder WebMD  or autism. *** Web MD

(8) Anorexia nervosa. *** WebMD

(9) Bulimia nervosa.  ***   WebMD

(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 …

Mental Health Parity at a Crossroads

California Law Aims to Strengthen Access to Mental Health Services

Maximum #a190 Medicare Psychiatric Inpatient Days?

• If one is mentally #ill, has Medicare and Medi Cal, is constantly in and out of inpatient care, will Medi Cal pay if Medicare doesn’t as the person maxed out his inpatient days and used up the lifetime limit?
  • • Yes, Medicare pays or doesn’t pay and then Medi Cal is the secondary payer.  ^{§ 1300.67.13. Coordination of Benefits (“COB”)}.
    • References & Links
    • Our webpages on:
    • What is covered under Medicare Parts A & B
    • Appeals & Grievances
    • Dual Coverage
      • Which Pays first Medi Cal or other coverage?
      • Medicare 
        • Medicare #DualCoverage
          # 02179  
        •  
        • most health care costs are covered if you qualify for both Medicare and Medicaid.  Medicaid never pays first for services Medicare covers. It only pays after Medicare has paid Page 11
        • Choose Medi Cal HMO
    • SSI, SSDI & Automatic Medicare Coverage

  Medicare Benefit Period – CA Health Care Advocates

  Medicare & You Publication 10050  Page # 121

  Benefit period

  The way that Original Medicare measures your use of hospital and skilled nursing facility services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

  Mental health care (inpatient)  Medicare.Gov  Medicare & You page 27

  However, if you’re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.

  • Try Medi Cal for additional days

• LA Care EOC Evidence of Coverage and Member Handbook

  Coordination of Benefits (COB): The process of determining which insurance coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment and payment responsibilities for members with more than one type of health insurance coverage.

  The LA Care EOC page 49  states:

  Other Medi-Cal programs and services

  Other services you can get through Fee-For-Service (FFS) Medi-Cal or other Medi-Cal programs

  Sometimes L.A. Care does not cover services, but you can still get them through FFS Medi-Cal or other Medi-Cal programs. This section lists these services. To learn more, call L.A. Care Member Services at 1-888-839-9909 (TTY/TDD 711).

• Medi Cal coverage – County Mental Health

• Specialty mental health services

  Some mental health services are provided by county mental health plans instead of L.A. Care. These include specialty mental health services (SMHS) for Medi-Cal members who meet medical necessity rules. SMHS may include these outpatient, residential and inpatient services:

  • Inpatient services:
  ° Acute psychiatric inpatient hospital services
  ° Psychiatric inpatient hospital professional services
  ° Psychiatric health facility services

  To learn more about specialty mental health services the county mental health plan provides, you can call your county mental health plan.

• To find all counties’ toll-free telephone numbers online, visit dhcs.ca.govMHPContact List

  • • • Medi-Cal Specialty Mental Health Services
        • ​​​​​​CalAIM 1115 Demonstration & 1915(b) Waiver
      • Medi Cal and Social Service Contacts for Assistance
      • dmh.lacounty.gov
      • Evidence of Coverage D SNP – Page 77
      • CBO.gov THE INPATIENT PSYCHIATRIC HOSPITAL BENEFIT UNDER MEDICARE  July 1993
      • Medi Cal Inpatient Mental Health Services Program
      • chcf.org/Medi Cal Explained Behavioral Health.pdf 
      • ‘Go on Medi-Cal to get that’: Why Californians with mental illness are dropping private insurance to get taxpayer-funded treatment
      • Advocates Guide to Medi Cal – Mental Health
      • Cal. Code Regs. Tit. 9, § 1820.205 – Medical Necessity Criteria for Reimbursement of Psychiatric Inpatient Hospital Services
      • MHSUDS INFORMATION NOTICE NO.: 19-026