1. (a) “Adverse benefit determination” means any of the following:

   1. (1) Entirely or partially delaying, denying, reducing, terminating, modifying, or otherwise failing to provide or make payment for, a health care benefit resulting from the application of utilization review.
   2. (2) Entirely or partially delaying, denying, reducing, terminating, modifying, or otherwise failing to provide or make payment for, a health care benefit on the basis that it is experimental or investigational.
   3. (3) Reducing, modifying, or terminating an ongoing course of treatment for a mental health condition or substance use disorder that was approved to be provided over a period of time, or for a number of treatments, before the end of such period of time, or before such number of treatments have been provided, based on an asserted absence of medical necessity.
2. (b) “Behavioral health crisis services” has the same meaning as set forth in Government Code section 53123.1.5.
3. (c) “Behavioral health crisis stabilization services” means health care items and services that are necessary to determine if a behavioral health crisis exists and, if a behavioral health crisis does exist, the care and treatment that is necessary to stabilize the behavioral health crisis, as the term “stabilize” is defined by Insurance Code section 10144.57, that is within the capability of the 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services.
4. (d) “Coverage document” means a contract, policy, evidence of coverage, certificate of coverage, schedule of benefits, rider, endorsement, amendment, insert policy page, or any other form, document, or written instrument of insurance coverage.
5. (e) “Coordinated specialty care” means a recovery-oriented, team-based, multi-element approach to treating first episode or early psychosis that promotes easy access to care and shared decision-making among specialists, and where services must include, but are not limited to, case management, individual and group psychotherapy, family education and support, and medication management.

6. (f) “Emergency health care services” means and includes any of the following:

   1. (1) Emergency services, as defined by Insurance Code section 10112.7.
   2. (2) Emergency medical transportation, as defined by Insurance Code section 10126.6.
   3. (3) Behavioral health crisis stabilization services and poststabilization care that is provided by a 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services for a nonemergency or emergency mental health or substance use condition.
   4. (4) Prevention, intervention, receiving, stabilization, and observation services for an emergency medical condition that are delivered in any location or setting, or that constitute urgent care services and are delivered in any location or setting outside the applicable network's service area, as described in subdivision (f)(5) of this section.
   5. (5) Urgent care services that are delivered outside the applicable network's service area in any location or setting to prevent serious deterioration of an insured's health resulting from an unforeseen condition, or unforeseen complications or symptoms of an existing condition, for which treatment cannot be delayed until the insured returns to the network's service area.
7. (g) “Emergency medical condition” means an emergency medical condition as that term is defined by Health and Safety Code section 1317.1.
8. (h) “Generally accepted standards of mental health and substance use disorder care” means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, addiction medicine and counseling, and behavioral health treatment pursuant to Insurance Code section 10144.51. Valid, evidence-based sources establishing generally accepted standards of mental health and substance use disorder care include peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit health care provider professional associations, specialty societies and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.
9. (i) “Health care benefit” or “benefit” means any health care item, service, procedure, medication, prescription drug, treatment modality, service intensity, or level of care for the diagnosis, prevention, or treatment of a mental health condition or substance use disorder.
10. (j) “Health care facility” or “facility” means a facility setting of care, including a health care facility that is operated by or on behalf of a public entity, a facility holding a valid license or certification from a state agency to furnish or deliver health care items and services on an emergency, urgent, inpatient, residential, or outpatient basis, or that is a nonresidential location where health care items and services are rendered under the scope of a health care provider's license or certification under applicable state law. This term shall include a provider of behavioral health crisis services that is a facility as defined in this subdivision.

11. (k) “Health care provider” or “provider” means any of the following:

    1. (1) A person who is licensed under Division 2 (commencing with section 500) of the Business and Professions Code.
    2. (2) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Business and Professions Code section 4980.43.3.
    3. (3) A qualified autism service provider, qualified autism service professional, or qualified autism service paraprofessional, as defined in Insurance Code section 10144.51.
    4. (4) An associate clinical social worker functioning pursuant to Business and Professions Code section 4996.23.2.
    5. (5) An associate professional clinical counselor, or professional clinical counselor trainee, functioning pursuant to Business and Professions Code section 4999.46.3.
    6. (6) A registered psychological associate, as described in Business and Professions Code section 2913.
    7. (7) A psychology trainee or person supervised as set forth in Business and Professions Code section 2910 or 2911.
    8. (8) A 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services that is described in another provision of this subdivision (k).
12. (l) “Iatrogenic infertility” means infertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment. For purposes of the immediately preceding sentence, a direct or indirect cause of infertility means medical treatment with a possible side effect of infertility, as established by the American Society of Clinical Oncology or the American Society for Reproductive Medicine.
13. (m) “Intermittent,” for purposes of eligibility for home health care services, means skilled nursing care that is either provided or needed on fewer than seven days each week, or less than eight hours of each day, for an expected period of 21 days or less, with extensions as medically necessary when the need for additional care is finite and predictable.

14. (n) “Medically necessary,” or “medical necessity,” with respect to a mental health condition or substance use disorder, means a service or product addressing the specific needs of a patient for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all the following:

    1. (1) In accordance with generally accepted standards of mental health and substance use disorder care.
    2. (2) Clinically appropriate in terms of type, frequency, extent, site, and duration.
    3. (3) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.
15. (o) “Mental health condition or substance use disorder” means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organization's “International Statistical Classification of Diseases and Related Health Problems,” or that is listed in the most recent version of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders.” Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” or the World Health Organization's “International Statistical Classification of Diseases and Related Health Problems” shall not affect the conditions that are covered by Section 10144.5 or this article as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.
16. (p) “Mental Health Parity and Addiction Equity Act” means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all rules, regulations, and guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
17. (q) “Nonprofit professional association” means a not-for-profit or tax-exempt scientific organization, or a membership association of health care professionals, excluding a charitable organization, or professional or trade association, of the health insurance or health plan industry. For purposes of this article, a nonprofit professional association means one that is not owned, organized, controlled, or directed by a for-profit entity, including but not limited to a health insurer or health plan, including an affiliate, parent, investor, shareholder, or subsidiary of a health insurer or health plan conducting business in this or another state.
18. (r) “Nonquantitative treatment limitation” means a limitation on the scope or duration of coverage of a health care benefit that is not a quantitative treatment limitation.
19. (s) “Poststabilization care” means, with respect to behavioral health crisis services, medically necessary care provided after a behavioral health crisis has been stabilized, as the term “stabilized” is defined by Insurance Code section 10144.57.
20. (t) “Public entity” means the State of California, the Regents of the University of California, the Trustees of the California State University and the California State University, a county, city, district, public authority, public agency, and any other political subdivision or public corporation in the State.
21. (u) “Quantitative treatment limitation” means a limitation on the scope or duration of coverage of a health care benefit that is expressed numerically.
22. (v) “Standard fertility preservation services” means procedures consistent with the established medical practices and professional guidelines published by the American Society of Clinical Oncology or the American Society for Reproductive Medicine.
23. (w) “Urgent care services” means medical or behavioral health care or treatment for which a delay in immediate access, in the opinion of an attending health care provider with knowledge of an insured's medical condition, poses a serious threat to the health of an insured, including but not limited to, severe pain, the potential loss of life, limb, or major bodily function, or serious deterioration of the insured's health. Any determination made by an insurer of whether medical or behavioral health care or treatment, including poststabilization care, constitutes urgent care services within the meaning of this definition shall defer to the opinion of an insured's attending health care provider.

24. (x) “Utilization review” means either of the following:

    1. (1) Prospectively, retrospectively, or concurrently reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests by health care providers, insureds, or their authorized representatives for coverage of health care services prior to, retrospectively or concurrent with the provision of health care services to insureds.
    2. (2) Evaluating the medical necessity, appropriateness, level of care, service intensity, efficacy, or efficiency of health care services, benefits, procedures, or settings, under any circumstances, to determine whether a health care service or benefit subject to a medical necessity coverage requirement in a disability insurance policy is covered as medically necessary for an insured.
25. (y) “Utilization review criteria” means any criteria, standards, protocols, or guidelines used by an insurer to conduct utilization review.

The following definitions apply for purposes of this article:

Note: Authority cited: Sections 10123.135, 10144.4, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 790.035, 10112.7, 10112.281, 10123.135, 10123.147, 10123.191, 10123.193, 10123.195, 10123.197, 10123.201, 10126.6, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53 and 10144.57, Insurance Code; Sections 1317.1 and 1374.551, Health and Safety Code; Sections 500 et seq., 2909.5, 2910, 2911, 2913, 4980.43.3, 4996.23.2 and 4999.46.3, Business and Professions Code; and Section 53123.1.5, Government Code.

History

1. New section filed 6-26-2025; operative 6-26-2025 pursuant to Government Code section 11343.4(b)(3) (Register 2025, No. 26).