Plain English Breakdown
The official text does not specify the exact 'specified reason' why no reimbursement is required, only that it provides such a provision.
Health Care Coverage for Medically Necessary Physical Treatment
This law requires health plans to cover medically necessary treatment for physical conditions under the same rules as other medical care and sets standards for denying or delaying services.
What This Bill Does
- Requires health insurance policies issued, amended, or renewed on or after January 1, 2026, to cover medically necessary treatment for physical conditions and diseases under the same terms applied to other medical conditions.
- Mandates that plans provide out-of-network care if in-network providers cannot meet geographic distance or timely access standards.
- Requires insurers to use specific clinical criteria and guidelines when reviewing requests for coverage of physical health services.
- Defines 'medically necessary health care service' as legally prescribed medical care that is reasonable and follows the standard used by the medical community.
- Allows state officials to charge administrative or civil penalties against plans that violate these utilization review rules.
Who It Names or Affects
- Health care service plan contracts regulated by the Department of Managed Health Care.
- Health insurance policies regulated by the Insurance Commissioner.
- Subscribers and enrollees who need treatment for physical conditions or diseases.
- Local agencies that may face state-mandated costs due to criminal penalties for willful violations.
Terms To Know
- Utilization review
- The process where a health plan approves, modifies, delays, or denies requests for medical services based on whether they are medically necessary.
- Out of network
- Health care providers who do not have a contract with the specific insurance plan to provide discounted rates.
- Duty of ordinary care
- The legal requirement for health plans to arrange necessary medical services and avoid causing harm through denial or delay of treatment, under existing law.
Limits and Unknowns
- This law only applies to contracts issued, amended, or renewed on or after January 1, 2026.
- The bill states that no state reimbursement is required for local agencies regarding costs mandated by this act.