1. (a) A coverage document shall state the following:

   1. (1) Coverage is provided for medically necessary health care benefits to prevent, diagnose, and treat mental health conditions and substance use disorders under the same terms and conditions that are applied to other medical conditions and in accordance with the federal Mental Health Parity and Addiction Equity Act.
   2. (2) Coverage is provided for the full range of levels of care and may not be limited to short-term treatment or alleviation of only acute symptoms.

   3. (3) All utilization review coverage determinations concerning service intensity, level of care placement, continued stay, and transfer or discharge of a covered person diagnosed with a mental health condition or substance use disorder must be made using the most recent versions of the following instruments:

      1. (A) For a primary substance use disorder diagnosis in adolescents and adults, “The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions” by the American Society of Addiction Medicine.
      2. (B) For a primary mental health diagnosis in adults nineteen (19) years of age and older, “Level of Care Utilization System” (LOCUS) by the American Association for Community Psychiatry.
      3. (C) For a primary mental health diagnosis in children six (6) to eighteen (18) years of age, “Child and Adolescent Level of Care/Service Intensity Utilization System” (merged CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry, or “Child and Adolescent Service Intensity Instrument” (CASII) by the American Academy of Child and Adolescent Psychiatry.
      4. (D) For a primary mental health diagnosis in children five (5) years of age and younger, “Early Child Service Intensity Instrument” (ECSII) by the American Academy of Child and Adolescent Psychiatry.
   4. (4) The requirements in subdivisions (d)(2) and (d)(3) of Section 2562.06.
   5. (5) The notice required by subdivision (b) of Section 2562.08.

2. (b) A coverage document shall include the following definitions, as set forth in Insurance Code sections 10144.5, 10144.52, and 10144.57, and this article:

   1. (1) Adverse benefit determination.
   2. (2) Behavioral health crisis services.
   3. (3) Behavioral health crisis stabilization services.
   4. (4) Emergency health care services.
   5. (5) Emergency medical condition.
   6. (6) Generally accepted standards of mental health and substance use disorder care.
   7. (7) Health care benefit.
   8. (8) Health care facility.
   9. (9) Health care provider.
   10. (10) Iatrogenic infertility.
   11. (11) Intermittent.
   12. (12) Medically necessary or medical necessity.
   13. (13) Mental health condition or substance use disorder.
   14. (14) Poststabilization care, with respect to behavioral health crisis services under Insurance Code section 10144.57.
   15. (15) Standard fertility preservation services.
   16. (16) Urgent care services.
   17. (17) Utilization review.
   18. (18) Utilization review criteria.

3. (c) A coverage document shall disclose coverage of the following health care benefits:

   1. (1) The health care benefits described in Section 2562.05.
   2. (2) Any other health care benefits that are generally recognized as medically necessary to prevent, diagnose, or treat a mental health condition or substance use disorder by health care providers practicing in relevant clinical specialties.

4. (d) A coverage document shall list covered health care benefits for mental health conditions and substance use disorders under the following Mental Health Parity and Addiction Equity Act benefit classifications to specify the applicable cost sharing:

   1. (1) Inpatient.
   2. (2) Outpatient, or if outpatient benefits are subclassified, office visits and all other outpatient items and services.
   3. (3) Emergency health care services.
   4. (4) Prescription drugs.

5. (e) A coverage document shall include the following network disclosures:

   1. (1) Medically necessary health care benefits for preventing, diagnosing, and treating mental health conditions and substance use disorders must be accessible from in-network health care providers and facilities within network standards for geographic and timely access. If a medically necessary health care benefit for a mental health condition or substance use disorder is unavailable in-network within applicable geographic or timely access standards, an insurer must arrange for an available and accessible out-of-network provider or facility to provide care. Cost sharing for out-of-network care that is arranged by an insurer due to network inaccessibility is limited to the amount that would have been due to an in-network provider or facility. Cost sharing paid for arranged out-of-network care will accrue to any applicable in-network deductible and to the in-network out-of- pocket maximum.
   2. (2) The geographic and timely access standards set forth in Insurance Code section 10133.54, Article 6 of Subchapter 2 of this chapter (commencing with Section 2240), and Section 2562.06.
   3. (3) A complete and accurate description of the process for requesting assistance, providing in-network referrals, and arranging out-of-network coverage as set forth in subdivisions (b)(3) and (c) of Section 2562.06.
   4. (4) A complete and accurate description of the requirements in subdivisions (e) through (h) of Section 2562.06.
6. (f) Cost sharing that applies to health care benefits for mental health and substance use disorders shall comply with Insurance Code section 10144.4, and such compliance shall be continuously maintained and demonstrated in a quantitative analysis submitted with policy forms for authorization, or upon request by the Department.
7. (g) Nonquantitative treatment limitations that are imposed on health care benefits for mental health conditions or substance use disorders shall comply with Insurance Code section 10144.4, and such compliance shall be continuously maintained and demonstrated in a comparative analysis submitted with policy forms for authorization, or upon request by the Department.

Note: Authority cited: Sections 10144.4, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 10270.6, 10270.9, 10290, 10291, 10291.5, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53 and 10144.57, 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).