Substance use disorder coverage.

Plain English Breakdown

The official summary and digest do not provide specific details on penalties for violations beyond stating they would be treated as willful violations of existing laws, which are crimes.

Substance Use Disorder Coverage

AB-669 prohibits health insurance companies from reviewing the medical necessity of substance use disorder treatments during the first 28 days for inpatient, residential, and intensive outpatient or partial hospitalization services, starting January 1, 2027.

What This Bill Does

• Prohibits health insurance companies from conducting concurrent or retrospective reviews of medical necessity for in-network health care services related to substance use disorder treatments during the first 28 days of an inpatient or residential stay at a specified licensed facility.
• Prevents health insurance companies from reviewing the medical necessity retrospectively for the first 28 days of intensive outpatient or partial hospitalization services for substance use disorders.
• Prohibits prior authorization requirements for medically necessary outpatient prescription drugs to treat substance use disorder, as determined by the prescribing physician.

Who It Names or Affects

• People with health insurance who need treatment for substance use disorder
• Health insurance companies that provide coverage for substance use disorder treatment

Terms To Know

Prior Authorization

A process where a doctor needs to get approval from an insurance company before providing certain treatments.

Utilization Management

The practice of reviewing whether medical care is necessary and appropriate, often by health insurers or managed care organizations.

Limits and Unknowns

• Does not apply to Medi-Cal behavioral health delivery systems or Medi-Cal managed care plan contracts.
• Requires health insurance companies to follow these rules starting in 2027.

Official Summary Text

AB 669, as amended, Haney.
Substance use disorder coverage.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or health insurer to use prior authorization and other utilization management functions, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law requires health care service plan contracts and health insurance policies that provide hospital, medical, or surgical coverage and are issued, amended, or renewed on or after January 1,
2021, to provide coverage for medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions, as specified.
On and after January 1, 2027, this bill would prohibit concurrent or retrospective review of medical necessity of in-network health care services and benefits (1) for the first 28 days of
an
a treatment plan for
inpatient or residential substance use disorder stay
at a specified licensed facility
during each plan or policy year or (2) for outpatient
services provided by specified certified programs for
substance use disorder visits, except as specified. The bill would authorize, after the 29th day, in-network health care services and benefits for inpatient or residential substance use disorder care to be subject to concurrent review. On and after January 1, 2027, the bill would prohibit retrospective review of medical necessity for the first 28 days of intensive outpatient or partial hospitalization services for substance use disorder, but would
require specified
authorize concurrent or retrospective
review for day 29 and days thereafter of that stay or service.
On and after January 1, 2027, the bill would prohibit the imposition of prior authorization or other prospective utilization management requirements for in-network coverage of outpatient prescription drugs to treat substance use disorder that are determined medically necessary by the enrollee’s or insured’s prescribing physician or psychiatrist.
With respect to health care service plans, the bill would specify that its provisions do not apply to Medi-Cal behavioral health delivery systems or Medi-Cal managed care plan contracts. Because a willful violation of the bill’s requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
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.

Current Bill Text

Download Bill PDF