1. (a) An insurer shall provide coverage of health care benefits for preventing, diagnosing, and treating mental health conditions and substance use disorders as medically necessary for an insured, in accordance with current generally accepted standards of mental health and substance use disorder care, including but not limited to, the following:

   1. (1) Basic health care services, including the following:

      1. (A) Emergency health care services rendered both inside and outside the service area of the applicable network.
      2. (B) Urgent care services rendered inside the service area of the applicable network.
      3. (C) Physician services, including but not limited to consultation and referral to other health care providers and prescription drugs when furnished or administered by a health care provider or facility.
      4. (D) Hospital inpatient services, including services of licensed general acute care, acute psychiatric, and chemical dependency recovery hospitals.
      5. (E) Ambulatory care services, including but not limited to physical therapy, occupational therapy, speech therapy, and infusion therapy.
      6. (F) Diagnostic laboratory services, diagnostic and therapeutic radiologic services, and other diagnostic and therapeutic services.
      7. (G) Home health care services.
      8. (H) Preventive health care services, regardless of whether an insured has been diagnosed with a mental health condition or substance use disorder.
      9. (I) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, and any amendments or successor provisions, except Subparts A, B, G, and H.
      10. (J) Standard fertility preservation services when a covered treatment may directly or indirectly cause iatrogenic infertility.
   2. (2) Behavioral health crisis services that are provided by a 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services. Behavioral health crisis services shall include crisis prevention, intervention, receiving, stabilization, and poststabilization care delivered in any location or setting, including 23-hour non-hospital observation and crisis residential facility treatment.
   3. (3) Behavioral health treatment for pervasive developmental disorder or autism spectrum disorder pursuant to Insurance Code section 10144.51.
   4. (4) Coordinated specialty care for the treatment of first episode or early psychosis.
   5. (5) Day treatment.
   6. (6) Drug testing, both presumptive and definitive, including for initial and ongoing patient assessment during substance use disorder treatment.
   7. (7) Electroconvulsive therapy.
   8. (8) For gender dysphoria, all health care benefits identified in the most recent edition of the “Standards of Care for the Health of Transgender and Gender Diverse People” developed by the World Professional Association for Transgender Health.

   9. (9) Inpatient services, including but not limited to all the following:

      1. (A) ASAM inpatient levels of care for substance use disorder rehabilitation and withdrawal management, as described in the most recent version of “The ASAM Criteria”:

         1. 1. 3.7, medically monitored intensive (adults) or high-intensity (adolescents) inpatient services.
         2. 2. 4, medically managed intensive inpatient services.
      2. (B) High intensity acute medically managed residential programs (LOCUS and CALOCUS-CASII level 6A, as described in the most recent versions of LOCUS and CALOCUS-CASII).
      3. (C) Medically managed extended care residential programs (LOCUS and CALOCUS-CASII level 6B, as described in the most recent versions of LOCUS and CALOCUS-CASII).
   10. (10) Intensive community-based treatment, including assertive community treatment and intensive case management.
   11. (11) Intensive outpatient treatment.
   12. (12) Medication management.
   13. (13) Narcotic (opioid) treatment programs.
   14. (14) Outpatient prescription drugs, if coverage for outpatient prescription drugs is provided. Outpatient prescription drugs prescribed for mental health and substance use disorder pharmacotherapy, including office-based opioid treatment.
   15. (15) Outpatient professional services, including but not limited to individual, group, and family substance use and mental health counseling.
   16. (16) Partial hospitalization.
   17. (17) Polysomnography.
   18. (18) Psychiatric health facility services, including structured outpatient services as described in Health and Safety Code Section 1250.2.
   19. (19) Psychological and neuropsychological testing.
   20. (20) Reconstructive surgery pursuant to Insurance Code sections 10144.5 and 10123.88. For gender dysphoria, reconstructive surgery of primary and secondary sex characteristics to improve function, or create a normal appearance to the extent possible, for the gender with which the insured identifies, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery who are competent to evaluate the specific clinical issues involved.

   21. (21) Residential treatment facility services, including all the following:

       1. (A) Intensive short-term residential services (LOCUS and CALOCUS-CASII level 5A, as described in the most recent versions of LOCUS and CALOCUS-CASII).
       2. (B) Moderate intensity intermediate stay residential treatment programs (LOCUS and CALOCUS-CASII level 5B, as described in the most recent versions of LOCUS and CALOCUS-CASII).
       3. (C) Moderate intensity long-term residential treatment programs (LOCUS and CALOCUS-CASII level 5C, as described in the most recent versions of LOCUS and CALOCUS-CASII).

       4. (D) ASAM residential levels of care, as described in the most recent version of “The ASAM Criteria”:

          1. 1. 3.1, clinically managed low intensity residential services.
          2. 2. 3.3, clinically managed population-specific high intensity residential services.
          3. 3. 3.5, clinically managed high intensity (adults) or medium intensity (adolescents) residential services.
   22. (22) Schoolsite services for a mental health condition or substance use disorder that are delivered to an insured at a schoolsite pursuant to Insurance Code section 10144.53.
   23. (23) Transcranial magnetic stimulation.

   24. (24) Withdrawal management services, including all the following ASAM levels, or as described in the most recent version of “The ASAM Criteria”:

       1. (A) 1-WM, ambulatory withdrawal management without extended on-site monitoring.
       2. (B) 2-WM, ambulatory withdrawal management with extended on-site monitoring.
       3. (C) 3.2-WM, clinically managed residential withdrawal management.
       4. (D) 3.7-WM, medically monitored inpatient withdrawal management.
       5. (E) 4-WM, medically managed intensive inpatient withdrawal management.

2. (b) Home health care services.

   1. (1) An insurer shall cover home health care services if all the following conditions are satisfied:

      1. (A) An insured is confined to the home except for infrequent or relatively short duration absences, or when absences are attributable to the need to receive medical treatment, due to a mental health condition or substance use disorder.
      2. (B) Skilled nursing care on an intermittent basis, physical therapy, occupational therapy, or speech-language pathology services are medically necessary for the evaluation or treatment of an insured's mental health condition or substance use disorder or its symptoms. For purposes of this subdivision (b)(1)(B), skilled care shall be medically necessary to improve an insured's current condition, maintain an insured's current condition, or prevent or slow further deterioration of an insured's condition.
      3. (C) An insured's physician, physician assistant, nurse practitioner, or clinical nurse specialist attests that the conditions in subdivisions (b)(1)(A) and (b)(1)(B) of this section are met, and establishes, and periodically reviews no less frequently than once every 60 days, a plan of care that includes the services specified in subdivision (b)(2) and the frequency and duration of visits.

   2. (2) An insurer shall cover all the following home health care services as specified in the plan of care prepared by the insured's physician, physician assistant, nurse practitioner, or clinical nurse specialist:

      1. (A) Part-time skilled nursing care, including by a registered nurse, licensed practical nurse under the supervision of a registered nurse, or psychiatrically trained nurse.
      2. (B) Part-time home health aide services for personal care.
      3. (C) Physical therapy.
      4. (D) Speech-language pathology.
      5. (E) Occupational therapy.
      6. (F) Medical social services.
      7. (G) Medical supplies provided by a home health agency while an insured is under a home health plan of care.
      8. (H) Durable medical equipment while an insured is under a home health plan of care.
   3. (3) For purposes of subdivision (b)(2) of this section, part-time means both skilled nursing services and home health aide services furnished any number of days per week, provided that the skilled nursing services and home health aide services, combined, are furnished less than eight hours per day and 35 hours per week. If an insurer covers more than the foregoing number of hours for conditions other than mental health conditions or substance use disorders, it shall cover an equivalent or greater number of hours for a mental health condition or substance use disorder.
   4. (4) Any quantitative or nonquantitative treatment limitations on eligibility for coverage of home health care services shall be consistent with those limitations permitted under this article and Medicare, shall not be more restrictive than such limitations permitted under this article, and shall be subject to prior review by the Department.

3. (c) Preventive health care services, including the following:

   1. (1) Screening, brief intervention and referral to treatment, primary care-based interventions, and specialty services for persons with hazardous, at-risk, or harmful substance use who do not meet the diagnostic criteria for a substance use disorder, or persons for whom there is not yet sufficient information to document a substance use or addictive disorder, as described in ASAM level of care 0.5, as described in the most recent version of “The ASAM Criteria.”
   2. (2) Basic services for prevention and health maintenance, including: screening for mental health and developmental disorders and adverse childhood experiences; multidisciplinary assessments; expert evaluations; referrals; consultations and counseling by mental health clinicians; emergency evaluation, brief intervention and disposition; crisis intervention and stabilization; community outreach prevention and intervention programs; mental health first aid for victims of trauma or disaster; and health maintenance and violence prevention education, as described in LOCUS and CALOCUS-CASII level of care zero, as described in the most recent versions of LOCUS and CALOCUS-CASII.
   3. (3) Preventive health care services for a mental health condition or substance use disorder that are required under Insurance Code section 10112.2. Any permissible scope of coverage limitations on health care benefits required under Insurance Code section 10112.2 shall not provide a basis to limit coverage for medically necessary treatment of a mental health or substance use disorder in a manner inconsistent with Insurance Code sections 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, or 10144.57, or this article.

4. (d) An insurer shall cover the following for a mental health condition or substance use disorder:

   1. (1) A health care benefit that is medically necessary under the requirements of this article and is furnished or delivered by, or under the direction of, a health care provider or facility acting within the scope of practice of a provider's license or certification under applicable state law.
   2. (2) Emergency health care services, including behavioral health crisis services, that are furnished or delivered by, or under the direction of, a health care provider or facility acting within the scope of practice of a provider's license or certification under applicable state law, including by or at a health care provider or facility owned or operated by, employed by, or contracted with, a public entity to provide emergency health care services or behavioral health crisis services, regardless of whether the insurer is contracted with the health care provider, facility, or public entity to furnish emergency health care services or behavioral health crisis services to its insureds.

   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, regardless of whether an emergency medical condition existed.

      1. (A) An insurer shall not deny coverage for behavioral health crisis stabilization services unless it reasonably determines that the care was not rendered.
      2. (B) An insurer that requires prior authorization for poststabilization care shall not deny coverage for that care if it did not comply with the requirements and conditions set forth in subdivisions (b)(3), (b)(4), and (c) of Insurance Code section 10144.57.
5. (e) An insurer shall apply cost sharing that is compliant with Insurance Code section 10144.4 to a health care benefit whenever a benefit is furnished or delivered to prevent, diagnose, or treat a mental health condition or substance use disorder.
6. (f) An insurer shall not impose quantitative treatment limitations, other than limitations for home health care services as specified in subdivision (b)(3) of this section that were submitted to the Department for review in advance, or annual or lifetime limits on the dollar value of health care benefits for a mental health condition or substance use disorder. This subdivision does not prohibit a group health insurance policy from placing annual or lifetime per-insured limits on specific covered benefits that are not essential health benefits as defined under Insurance Code section 10112.27, for a health condition that is not a mental health condition or substance use disorder.
7. (g) An insurer shall not limit coverage of health care benefits for a mental health condition or substance use disorder to short-term treatment or alleviation of only acute symptoms.
8. (h) An insurer shall not limit coverage of health care benefits for a mental health condition or substance use disorder, by contract or through any other means, on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term or formal or informal policy or practice that limits or excludes health care benefits on the basis that those services should be or could be covered by such a public entitlement program.

9. (i) An insurer shall not require prior authorization or precertification for any of the following:

   1. (1) Emergency health care services, including prescription drugs.
   2. (2) Items and services, including prescription drugs, that are provided by a 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services to stabilize a mental health or substance use disorder condition.
   3. (3) A health care benefit that may not be subjected to prior authorization or concurrent review pursuant to Section 2562.10 or the Mental Health Parity and Addiction Equity Act rule on nonquantitative treatment limitations set forth in subdivision (c)(4) of Section 146.136 of Title 45 of the Code of Federal Regulations.

Note: Authority cited: Sections 10144.4, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 10112.1, 10112.2, 10112.27, 10112.281, 10112.7, 10123.51, 10123.88, 10123.191, 10123.193, 10123.195, 10123.201, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, 10144.57, 10290 and 10291, Insurance Code; and Sections 1250.2, 1345(b) and 1374.551, Health and Safety 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).