Plain English Breakdown
The official text mentions 'specified reason' regarding reimbursement but does not define what that specific reason is within the provided summary or digest.
Limits on Reviewing Substance Use Disorder Coverage
Starting January 1, 2027, health plans cannot review or delay coverage for the first 28 days of certain in-network substance use disorder treatments.
What This Bill Does
- Prohibits concurrent and retrospective reviews of medical necessity for the first 28 days of an inpatient or residential stay at a specified licensed facility during each plan year, starting January 1, 2027.
- Allows health plans to conduct concurrent review of these same services only after day 29 of a treatment plan.
- Prohibits prior authorization for outpatient prescription drugs used to treat substance use disorder if the prescribing physician or psychiatrist determines they are medically necessary.
- Excludes Medi-Cal behavioral health delivery systems and managed care contracts from these new rules.
- States that willful violations by health care service plans remain criminal offenses under existing law.
Who It Names or Affects
- Health care service plans regulated by the Department of Managed Health Care
- Health insurers regulated by the Department of Insurance
- Patients receiving in-network substance use disorder treatment
Terms To Know
- Prior authorization
- A rule requiring a patient to get approval from their health plan before starting a specific service.
- Concurrent review
- Checking if medical care is necessary while the treatment is happening.
- Retrospective review
- Looking back at records after a service has been provided to check if it was medically necessary.
Limits and Unknowns
- The rules only apply starting on January 1, 2027.
- The bill does not change how Medi-Cal behavioral health services are managed.
- The text states no state reimbursement is required for local agencies but lists the reason as 'specified' without explaining it.