1. (2) The processes, strategies, evidentiary standards, or other factors used to manage the health care benefits required under Insurance Code sections 10144.5, 10144.51, 10144.52, 10144.53, and 10144.57, and this article, and any other health care benefits that an insurer covers for a mental health condition or substance use disorder, shall be comparable to, and designed and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used to manage benefits for diagnoses that do not constitute a mental health condition or substance use disorder.
2. (b) An insurer shall not impose a nonquantitative treatment limitation on a health care benefit for a mental health condition or substance use disorder, including utilization review or a utilization review criterion, that is not compliant with, or for which the insurer has not performed and documented in advance, and updated as necessary, a comparative analysis of the design and application of the nonquantitative treatment limitation that in good faith satisfies the requirements of the Mental Health Parity and Addiction Equity Act.
3. (c) An insurer shall not conduct utilization review more frequently than is reasonably necessary to assess whether the health care benefits under review are medically necessary, recommended by nonprofit professional association clinical practice guidelines or the instruments required by Section 2562.03, or is permissible under Insurance Code section 10144.4.
4. (d) An insurer shall not impose a quantitative treatment limitation on a health care benefit for a mental health condition or substance use disorder or apply a quantitative treatment limitation to a health care benefit that was medically necessary for a for a mental health condition or substance use disorder.

5. (e) For purposes of this section, “health care benefit” includes the set of benefits described in Section 2562.01(g) of this article, for either:

   1. (1) A diagnosis that is a mental health condition or substance use disorder.
   2. (2) A diagnosis that is not a mental health condition or substance use disorder.

(a)(1) Utilization review and utilization review criteria are a nonquantitative treatment limitation as defined by the Mental Health Parity and Addiction Equity Act. An insurer that applies and conducts utilization review of health care benefits for mental health conditions or substance use disorders shall comply with the rule on nonquantitative treatment limitations, both as written and in operation, set forth in subdivision (a)(2) of this section.

Note: Authority cited: Sections 10123.135, 10144.4, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 10123.135, 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).