1. (a) An insurer shall maintain a provider and facility network with sufficient capacity to provide for the prevention, diagnosis, and treatment of mental health conditions and substance use disorders as medically necessary, including all the health care benefits required by Insurance Code section 10144.5 and this article, in a geographically accessible and timely manner consistent with good professional practice, as required by Insurance Code sections 10133.5 and 10133.54, and Article 6 of Subchapter 2 of this Chapter 5 (commencing with Section 2240).

   1. (2) If Article 6 of Subchapter 2 of this chapter does not specify a geographic access standard for a requested health care benefit, for purposes of subdivision (b)(1) of this section an insurer shall adhere to the standard that it uses in demonstrating to the Department that its network complies with subdivision (c)(6) of Section 2240.1. In the absence of such a Section 2240.1(c)(6)-compliant standard, an insurer shall identify network and out-of-network health care providers or facilities, as applicable, that are located within reasonable proximity of the insured's residence or workplace, taking into consideration health condition and disability, transportation mode, travel conditions, and any other factors affecting an insured's ability to access services at a particular location.

   2. (3) When an insurer receives a request for assistance in identifying health care provider or facility that can provide care or timely follow-up care for a mental health condition or substance use disorder, the insurer shall do the following:

      1. (A) Refer the insured, or the insured's authorized representative or provider, to at least three in-network providers or facilities, as appropriate, that can deliver medically necessary and clinically appropriate health care benefits and follow-up care within the applicable geographic and timely access standards specified in Insurance Code section 10133.54, Article 6 of Subchapter 2 of this chapter, and this section. An insurer shall not provide a referral in response to a request for assistance unless it has confirmed availability as provided in subdivision (b)(3)(B) of this section.

         1. 1. If an insurer identifies fewer than three in-network providers or facilities that can deliver care consistent with subdivision (a)(2)(A) of this section, the insurer shall refer the insured, or their authorized representative, to the in-network providers or facilities that have been so identified.
         2. 2. If an insurer identifies fewer than three in-network providers or facilities that can deliver care consistent with subdivision (a)(2)(A) of this section, the insurer shall notify the Department of the type of provider or facility that was the subject of the insured's request, the geographic location, and identify to the Department which providers or facilities it referred the insured person to.
      2. (B) Notify the providers or facilities that are the subject of the referral of the applicable timely access standard and confirm and document that the providers or facilities have the capacity to deliver the requested care within the timely access standard. An insurer shall treat a request for assistance in identifying a health care provider or facility as a request to which subdivision (b)(1) of this section applies if, as part of satisfying the request for assistance, the insurer determines that the requested care is inaccessible from an in-network provider or facility within the applicable geographic and timely access standards.
      3. (C) If medically necessary and clinically appropriate care is ultimately inaccessible within the applicable timely access standard from at least one of the three providers or facilities that was the subject of a referral, then the insurer shall comply with subdivision (d) of Insurance Code section 10144.5 and this section.

   (b)(1) An insurer shall provide access to health care benefits for the prevention, diagnosis, and treatment of mental health conditions and substance use disorders delivered by in-network health care providers or facilities within the geographic and timely access standards specified in Insurance Code section 10133.54 and Article 6 of Subchapter 2 of this chapter. If medically necessary health care benefits are not available in-network within applicable geographic or timely access standards, an insurer shall, upon request from an insured, an insured's authorized representative, or an insured's provider, arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary follow-up services that, to the maximum extent possible, meet applicable geographic and timely access standards.

2. (c) As used in this section, to “arrange coverage to ensure the delivery of medically necessary out-of-network services” includes, but is not limited to, providing assistance to secure medically necessary and clinically appropriate out-of-network health care benefits that are available to the insured within applicable geographic and timely access standards, to the maximum extent possible. Arranging coverage shall include, at a minimum, all the following:

   1. (1) Providing the insured with a confirmed list of health care providers or facilities with the capacity and expertise to provide medically necessary and clinically appropriate health care benefits that are accepting new patients, reasonably accessible, as described in subdivision (b)(3) of Section 2240.1, located within the applicable geographic accessibility standards, and able to provide services within the applicable timely access standard.

   2. (2) Confirming that an appointment or admission is available for the insured with the health care provider or facility that was selected by the insured. The appointment or admission shall be available within the following time limits, as applicable, unless subparagraph (b)(5)(H) of Insurance Code section 10133.54 applies:

      1. (A) For a non-urgent primary care appointment, within ten business days of a request for assistance.
      2. (B) For a non-urgent initial or follow-up appointment with a non-physician mental health or substance use disorder provider, within ten business days of a respective request for assistance or prior appointment for an insured who is undergoing a course of treatment for an ongoing mental health condition or substance use disorder.
      3. (C) For a non-urgent appointment with a specialist physician, within 15 business days of a request for assistance.
      4. (D) For a non-urgent appointment for ancillary services for the diagnosis or treatment of a mental health condition or substance use disorder, within 15 business days of a request for assistance.
      5. (E) For an urgent appointment, or a facility admission, when prior authorization is not required, within 48 hours of a request for assistance.
      6. (F) For an urgent appointment, or a facility admission, when prior authorization is required, within 96 hours of a request for assistance.
   3. (3) Once an insured has selected a health care provider or facility, within 5 calendar days of selection, negotiating and entering into a single case agreement or similar arrangement with the out-of-network health care provider or facility. The limit on the insured's financial obligation under subdivision (d) of Insurance Code section 10144.5 shall be set forth in the written agreement between the health insurer and out-of-network provider or facility. An insurer shall not delay an insured's care beyond the applicable timely access standard due to the lack of an agreement being in effect. If an agreement between the insurer and out-of-network health care provider or facility is not in effect on the dates of the insured's care, then the insurer shall hold the insured harmless for any charges exceeding the in-network cost sharing amount until an agreement is in effect.

   4. (4) Within 5 calendar days of selection, providing a written authorization to the insured or insured's authorized representative and selected out-of-network health care provider or facility, specifying, at a minimum, the authorization identification number; benefits authorized; date range of the authorization; negotiated reimbursement rate(s); and contact, claims submission, and provider dispute resolution information.

      (d)(1) An insurer shall treat out-of-network health care benefits obtained pursuant to this section and subdivision (d) of Insurance Code section 10144.5, and subdivision (d)(2) of Insurance Code section 10144.57, as in-network, including by ensuring that the insured pays no more in cost sharing than the insured would pay for the same covered services if the services had been received from an in-network health care provider or facility. Any cost sharing paid by an insured for out-of-network health care benefits obtained pursuant to this section and subdivision (d) of Insurance Code section 10144.5, or subdivision (d)(2) of Insurance Code section 10144.57, shall be calculated based on the amount as determined under subdivision (d)(2) or (d)(3) of this section, as applicable, and accrue to the in- network deductible, if any, and the in-network limit on annual out-of-pocket expenses.

   5. (2) Deductible and coinsurance amounts under subdivision (d) of Insurance Code section 10144.5 shall be calculated based on the lesser of the amount negotiated between the insurer and the provider or facility and the in-network rate. Unless another methodology is required by state law, an insurer shall determine the in-network rate using the methodology for the qualifying payment amount in Part 149 of Subchapter B of Subtitle A of Title 45 of the Code of Federal Regulations. This paragraph is not intended to affect the reimbursement rate that is paid to an out- of-network provider or facility for health care benefits obtained pursuant to subdivision (d) of Insurance Code section 10144.5, Insurance Code section 10144.57, or this section.
   6. (3) This subdivision shall apply to behavioral health crisis services, including stabilization and poststabilization care for a nonemergency or emergency mental health condition or substance use disorder, that is provided by a 988 center, mobile crisis team, facility, or other provider of behavioral health crisis services that is an out-of-network provider or facility, except that the amount from which deductible and coinsurance amounts shall be calculated shall be the lesser of the amount billed by the provider or facility; the amount negotiated between the insurer and the provider or facility (if any); and the in-network rate as determined under subdivision (d)(2) of this section.
3. (e) For health care benefits obtained by an insured pursuant to this section and subdivision (d) of Insurance Code section 10144.5, or this section and subdivision (d)(2) of Insurance Code section 10144.57, an insurer shall be liable for any charges exceeding the in-network cost sharing amount that is owed by the insured.

4. (f) If, following a request by an insured or an insured's authorized representative or provider, an insurer fails to arrange coverage within the geographic and timely access standards set forth in Insurance Code section 10133.54, Article 6 of Subchapter 2 of this chapter, and this section, that are applicable to the urgency and nature of the insured's condition and requested health care benefit, then the insurer shall cover any health care provider or facility selected by the insured as if that care had been arranged by the insurer.

   1. (1) If neither Insurance Code section 10133.54 nor Article 6 of Subchapter 2 of this chapter specifies a timely access standard for the requested health care benefit, then an insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services in a timely manner appropriate for the nature of the insured's condition, consistent with good professional practice. If an insurer fails to arrange coverage with a geographically accessible health care provider or facility within 21 calendar days of the date of an insured's request for assistance, then the insurer shall cover any health care provider or facility that is selected by the insured as if that care had been arranged by the insurer.
   2. (2) Upon expiration of the time allotted to arrange coverage with a geographically accessible out-of-network provider or facility set forth in Insurance Code section 10133.54, Article 6 of Subchapter 2 of this chapter, and this section, as applicable, an insured may select any health care provider or facility, regardless of network participation, and schedule an initial appointment or admission to occur within 90 calendar days of the date of the insured's initial request for assistance. If an appointment or admission is unavailable from the provider or facility selected within 90 calendar days of the insured's initial request for assistance, then an insured may arrange for an appointment or admission to occur on the earliest possible date outside the 90-day window, provided that the appointment or admission was confirmed within 90 days.
   3. (3) An insurer shall not rely on a limitation or exclusion in an insured's coverage document, including but not limited to benefit design or network limitations, to deny coverage for health care benefits that were delivered to an insured by an out-of-network health care provider or facility that was selected by an insured under this subdivision. Nothing in this subdivision shall be construed to absolve an insurer of its duty to arrange coverage pursuant to Insurance Code section 10144.5(d).

5. (g) If an insurer cannot provide access to clinically appropriate health care benefits at the level of care or service intensity determined by an instrument required by subdivision (a) of Section 2562.03, either delivered by an in-network health care provider or facility or an out-of-network provider or facility, within applicable geographic and timely access standards, an insurer shall do the following:

   1. (1) For an initial level of care or service intensity coverage determination, or a reassessment requiring a higher level of care or service intensity, cover the next highest level of care or service intensity that is available within applicable geographic and timely access standards.
   2. (2) For a reassessment to a lower level of care or service intensity, not effectuate a discharge or step down until the lower level of care or service intensity is available within applicable geographic and timely access standards.

6. (h) For health care benefits obtained pursuant to this section and subdivision (d) of Insurance Code section 10144.5, an insurer shall provide continuity of care and cover the entire course of medically necessary treatment delivered by an out-of-network provider or facility, including follow-up care, except to the extent that the requirements of this subdivision (h) are satisfied by clear and convincing evidence.

   1. (1) An insurer may transition an insured to a geographically accessible in-network provider or facility if the in-network provider or facility is able to provide timely access to clinically appropriate care and follow-up care, and the insured's current provider agrees that the transition will not harm the insured's health and is within the standard of care for the insured's condition at the time of the transition. An insurer that transitions an insured to an in-network provider or facility shall retain a record of the determination, including all underlying supporting documentation, that the requirements of this subdivision (h) were satisfied by clear and convincing evidence.

   2. (2) Before an insurer may transition an insured to an in-network provider or facility, the insurer shall provide the insured or insured's authorized representative, and the insured's current provider, with at least 90 calendar days' advance written notice of the transition. The notice shall include the following:

      1. (A) The name, address, and contact information of the proposed network provider or facility and the date of the transition, which shall not occur until at least 90 calendar days have elapsed since advance written notice of the transition was provided.
      2. (B) Information on how a provider may submit a complaint to the insurer and the Department. This information shall include notice that the current provider must agree that the transition would not harm the insured's health and is within the standard of care for the insured's condition at the time of the transition.
      3. (C) Information on how an insured may submit a complaint to the insurer and the Department. This information shall include notice that the current provider must agree that the transition would not harm the insured's health and is within the standard of care for the insured's condition at the time of the transition.
7. (i) An insurer shall include a prominent disclosure on its print and online provider directories published and maintained pursuant to Insurance Code section 10133.15 of its duty to arrange coverage when medically necessary health care benefits are not available in-network within applicable geographic or timely access standards, as provided in this section and subdivision (d) of Insurance Code section 10144.5. The disclosure shall be included within the “Timely Access to Care” section of a provider directory that is required by Insurance Code section 10133.53 and shall also include the geographic accessibility standards specified in this section and Article 6 of Subchapter 2 of this chapter.
8. (j) An insurer shall document and retain a record of all communications that are made relating to this section, including but not limited to, communications with an insured, provider, or facility; a description of requested services; name and location of providers or facilities contacted; dates of contact; type of provider or facility; benefits authorized for coverage and the duration of authorization; and appointment or admission dates. If an insurer fails to arrange coverage within the geographic and timely access standards set forth in Insurance Code section 10133.54, Article 6 of Subchapter 2 of this chapter, and this section, as applicable, it shall document such failure and the date of expiration of the 90-calendar day period afforded to an insured to schedule care with any out-of-network provider or facility the insured selects. An insurer shall act as necessary to ensure that claims submitted under this section are fairly adjudicated in compliance with this section and applicable law.

9. (k) An insurer shall not do any of the following:

   1. (1) Adopt, impose, or enforce terms in its coverage documents, policies and procedures for provider and facility credentialing and network admission, or health care provider or facility agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of Insurance Code section 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, or 10144.57, or this article.
   2. (2) Discriminate in health care provider or facility credentialing or network admission, including with respect to a licensed or certified provider or facility owned or operated by, employed by, or under contract with, a public entity to deliver health care benefits required by Insurance Code section 10144.5, 10144.51, 10144.52, 10144.53, or 10144.57, or this article, in a manner that is inconsistent with Insurance Code section 10133.5, 10133.54, 10133.55, 10133.56, 10133.65, 10133.66, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, or 10144.57, the requirements set forth in Article 6 of Subchapter 2 of this chapter, or this article.
   3. (3) Impose restrictions that limit the scope or duration of health care benefits based on geographic location, facility type, provider specialty, provider or facility characteristics, state or federal licensure standards, or any other similar criteria in a manner that is inconsistent with Insurance Code section 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, or 10144.57.
   4. (4) Fail or refuse to directly reimburse an out-of-network health care provider or facility, in compliance with Insurance Code section 10123.13 or 10123.147, as applicable, for covered health care benefits delivered by the provider or facility when requiring an assignment is prohibited by law, or pursuant to a valid assignment of benefits made by an insured to the provider or facility, irrespective of any conflicting anti-assignment provisions included in an insured's coverage document.

Note: Authority cited: Sections 10133.5, 10133.54, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 520, 10325, 10112.8, 10112.81, 10112.82, 10123.13, 10123.147, 10130, 10133, 10133.15, 10133.5, 10133.53, 10133.54, 10133.55, 10133.56, 10133.65, 10133.66, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, 10144.57 and 10176, Insurance 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).