BILL ANALYSIS
SB 296
Page 1
Date of Hearing: July 7, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
SB 296 (Lowenthal) - As Amended: June 30, 2009
SENATE VOTE : 25-12
SUBJECT : Mental health services.
SUMMARY : Requires health care service plans (health plans) and
health insurers that provide professional mental health services
to issue identification cards to all enrollees and insureds
containing specified information by July 1, 2011, and provide
specified information relating to their policies and procedures
on their Internet Web sites by January 1, 2012. Specifically,
this bill :
1)Requires, on or before July 1, 2011, every health plan,
including a specialized health plan, and health insurer that
provides professional mental health services to issue an
identification card to each enrollee and insured to assist the
enrollee or insured with accessing health benefits coverage
information, including, but not limited to, in-network
provider access information, and claims processing
information.
2)Specifies that the identification card must at least include
the following:
a) The name of the health plan or health insurer issuing
the card;
b) The enrollee's or insured's identification number;
c) A telephone number that enrollees or insureds may call
for assistance with health coverage information described
in 1) above;
d) A telephone number that enrollees or insureds may call
to access assessment services for the purpose of referral
to an appropriate level of care or appropriate health
provider; and,
e) The health plan's or health insurer's Internet Web site
address.
3)Requires the identification card required by this bill to be
issued by a health plan, a specialized health plan, or health
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insurer to an enrollee upon enrollment or insured upon
commencement of coverage or upon any change in the enrollee's
or insured's coverage that impacts the data content or format
of the card.
4)Specifies that nothing in this bill requires a health plan or
health insurer to issue a separate identification card for
professional mental health services coverage if a card for
health care coverage in general is already issued and the card
complies with the information required by this bill.
5)Directs a contractor or agent that is delegated by a health
plan, specialized health plan, or health insurer to issue the
identification card required by this bill to comply with the
requirements of this bill.
6)Clarifies that nothing in this bill be construed to prohibit a
health plan, specialized health plan, or health insurer from
meeting the standards of the Workgroup for Electronic Data
Interchange (WEDI) or other national uniform standards with
respect to identification cards, as long as the minimum
requirements in this bill have been met.
7)Requires, on or before January 1, 2012, every health plan and
health insurer, including a specialized health plan, that
covers professional mental health services, to disclose on its
Internet Web site, or provide a link to, the following
information:
a) A telephone number that the enrollee or provider can
call, during normal business hours, for assistance
obtaining mental health benefits coverage information,
including the extent to which benefits have been exhausted,
in-network provider access information, and claims
processing information;
b) A link to prescription drug formularies, as specified;
c) A detailed summary describing the process by which the
plan reviews and authorizes or approves, modifies, or
denies requests for health care services, as specified;
d) Lists of in-network providers;
e) A detailed summary of the enrollee grievance process
required under existing law;
f) A detailed summary of how an enrollee may request
continuity of care, as specified;
g) Information concerning the right, and applicable
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procedure, of an enrollee to request an independent medical
review pursuant to existing law;
h) A link to the Department of Managed Health Care's (DMHC)
final report of the plan's periodic review, or to the
California Department of Insurance's (CDI) market conduct
examination, as specified; and,
i) Provider manual templates containing specified
information.
8)Requires the material described in 7) i) above to be updated
within 30 days of any material change and an electronic
notification of material changes to be communicated to
applicable contract providers immediately.
9)Requires the information prescribed in 7) above to be updated
at least quarterly, to be made available through a secured
Internet Web site accessible only to enrollees, and to be made
available to enrollees in hard copy upon request.
10)Clarifies that nothing in this bill precludes a health plan
or health insurer from including additional information on its
Internet Web site, as specified.
11)Requires DMHC and CDI to include on their respective Internet
Web sites a link to the Internet Web site of each health plan,
specialized health plan, or health insurer.
12)Requires, on or before January 1, 2012, every health insurer
that covers professional mental health services to establish
an Internet Web site that must include information similar to
the Internet Web site disclosures required for every health
plan that covers professional mental health services in 7)
above.
13)Exempts from the provisions of this bill specialized health
insurance policies, except for behavioral health-only
policies, Medicare supplement, short-term limited duration
health insurance, vision-only, Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS)-supplement
insurance, TRI-CARE supplement, or hospital indemnity,
accident-only, and specified disease insurance.
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EXISTING LAW :
1)Provides for the regulation of health plans by DMHC under the
Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene)
and regulation of health insurers by CDI under the Insurance
Code.
2)Requires health plans to maintain a Web site, and allows
enrollees to file a grievance with the health plan online.
The requirement to maintain a Web site does not apply to
health plans that primarily serve Medi-Cal or Healthy Families
Program enrollees.
3)Prescribes for health plans specific Web site content,
disclosures and specific links for each plan's Web site on
which enrollees can file a grievance with the health plan.
4)Requires the Internet Web sites of health plans that provide
coverage for professional mental health services to include,
but not be limited to, providing information for subscribers,
enrollees, and providers on accessing mental health services.
5)Establishes a "mental health parity" (MHP) requirement for
every health plan contract or health insurance policy that
provides hospital, medical, or surgical coverage to provide
coverage for the diagnosis and medically necessary treatment
of severe mental illnesses (SMIs) of a person of any age, and
of serious emotional disturbances (SEDs) of a child, under the
same terms and conditions applied to other medical conditions,
as specified.
6)Requires mental health benefits provided pursuant to 4) above
to include outpatient services, inpatient hospital services,
partial hospital services, and prescription drugs, if the plan
contract includes coverage for prescription drugs.
7)Prohibits health plans from basing decisions on provider
claims or prior authorization for mental health services on
either of the following: a) whether a patient was admitted on
a voluntary or involuntary basis; or, b) based on the mode of
the patient's transportation to the health facility.
8)Requires under the federal Emergency Economic Stabilization
Act (EESA) of 2008 all group health plans, whether governed by
state laws, or subject to federal regulation under the
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Employee Retirement and Income Security Act, to ensure that if
the plan offers any benefits for mental health or substance
abuse, the benefits do not differ in their design (such as day
or annual limits, separate deductibles, co-payments, or
co-insurance) from the physical health benefits contained in
the plan. In addition, EESA requires a health plan that
offers coverage for out-of-network providers to also provide
out-of-network coverage for mental health and substance abuse
benefits.
FISCAL EFFECT : The current provisions of this bill have not
yet been analyzed by a fiscal committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The author states that this bill is
intended to help the millions of insured Californians enrolled
in health plans and insurance policies access the necessary
mental health benefits they pay for. The author asserts that,
every day, mental health benefits are being denied to insured
consumers and some consumers are led into complicated
telephone trees with long wait times, given outdated lists of
providers to choose from, or asked to retroactively pay for
services that they believed were covered in their plan or
policy. Additionally, the sponsors of this bill, the
California Association of Marriage and Family Therapists and
the California Society for Clinical Social Work, contend that
health plans, health insurers, and their respective regulators
have failed to ensure that patients have timely access to
mental health care services and health benefit information, or
to ensure that health care providers are actually available to
provide these services.
2)MENTAL HEALTH PARITY IN CALIFORNIA . In 1999, the Legislature
passed and the Governor signed AB 88 (Thomson), Chapter 534,
Statutes of 1999, requiring health plans and health insurers
to provide coverage for the diagnosis and medically necessary
treatment of certain SMIs of a person of any age, and of SEDs
of a child, as defined, under the same terms and conditions
applied to other medical conditions. Nine specific diagnoses
are considered SMI: schizophrenia; schizoaffective disorder;
bipolar disorder; major depressive disorder; panic disorder;
obsessive compulsive disorder; pervasive developmental
disorders or autism; anorexia nervosa; and, bulimia nervosa.
For covered conditions, health plans are required to eliminate
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benefit limits and share-of-cost requirements that have
traditionally rendered mental health benefits less
comprehensive than physical health coverage. Current law
requires MHP benefits to include outpatient services,
inpatient hospital services, partial hospital services, and
prescription drugs, if the health plan contract includes
coverage for prescription drugs. DMHC promulgated MHP
regulations that took effect in 2003 requiring MHP to provide
at least, in addition to all basic and other health care
services required by Knox-Keene, coverage for crisis
intervention and stabilization, psychiatric inpatient
services, including voluntary inpatient services, and services
from licensed mental health providers, including but not
limited to psychiatrists and psychologists.
In 2005, DMHC conducted a focused survey of seven large health
plans (representing approximately 85% of the 16 million
consumers enrolled in DMHC-regulated commercial managed care).
While DMHC found that health plans had established policies
and procedures, contracts, and coverage documents related to
MHP and had developed programs to expand and improve mental
health services, the survey also identified problem areas.
Among the most common deficiencies were delays or denials for
payment of emergency room claims; ineffective monitoring of
access to after-hours services; and, a lack of clear and
concise explanations in denial letters. DMHC found that
incorrect denial for emergency mental health services occurred
most often in claims received from facilities that were out of
the health plan's network. DMHC also noted that the problem
was exacerbated when health plans contracted with a specialty
managed behavioral health organization or subsidiary.
Finally, DMHC found that health plan internal policies were
not consistently applied. As a result of the survey, DMHC
imposed corrective actions on the health plans, including,
among other requirements: expanded after-hours access
monitoring to ensure that consumer calls for help are answered
and emergency information is provided; established and
published standards for enrollee access to after-hours care;
and, improved handling and approval processes for emergency
mental health claims, including mandatory internal audit
processes, the results of which are required to be reported to
DMHC.
3)WEDI . WEDI, referenced in this bill and existing law, is
pronounced "wee dee," and is a not-for-profit user group in
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the United States for users of Electronic Data Interchange
(EDI) in public and private health care. The organization is
sometimes referred to by other names that include some or all
of the words: Workgroup for Electronic Data Interchange.
According to the group's Internet Web site, WEDI was
established to provide leadership and guidance to the health
care industry on how to use and leverage its collective
knowledge, expertise, and information resources to improve the
quality, affordability, and availability of health care via
forums, conferences, and online resources, especially in
matters of conformance to EDI standards required by the
federal Health Insurance Portability and Accountability Act
(HIPAA) of 1996. HIPAA is intended to ensure that all medical
records, medical billing, and patient accounts meet certain
consistent standards with regard to documentation, handling
and privacy. In addition, HIPAA requires that all patients be
able to access their own medical records, correct errors or
omissions, and be informed how personal information is shared
and used.
4)SUPPORT . The California Psychiatric Association (CPA),
co-sponsor of this bill, states that the changes suggested by
this bill can be valuable to the patient and increase their
access to information and services. CPA argues that requiring
a specific number on a benefits card related to mental health
services can help avoid situations in which the complexity of
phone trees and call transfers between different corporate
entities cause consumers to simply hang up and forego access
to information and/or services. The California Society for
Clinical Social Work, co-sponsor of this bill, states that
requiring health plans and insurers to provide the Web site
information required by this bill is critical to accessing
mental health services, especially during a time of crisis.
The National Association of Social Workers (NASW), California
Chapter, supports this bill and points out that nearly a
decade after passage of the first mental health parity law (AB
88, (Thomson)) access issues continue to be unresolved and
overlooked, creating a situation where true parity for mental
health services is simply impossible to achieve. According to
NASW, although occasional and incremental progress has been
made working with the regulators and health plans, the
guarantees promised in AB 88 have been impeded by the
inability to ensure timely and accurate access to care.
The California Board of Behavioral Sciences (BBS), under the
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California Department of Consumer Affairs, writes in support
that this bill improves access to mental health services and
will provide consumers, patients, and providers with plan
information, and the benefits card will indicate a phone
number at which enrollees can receive assistance in
understanding their coverage. BBS is responsible for state
regulation of Marriage and Family Therapists (MFTs); Licensed
Clinical Social Workers; Licensed Educational Psychologists;
MFT Interns; and Associate Clinical Social Workers.
5)OPPOSE UNLESS AMENDED . America's Health Insurance Plans
(AHIP) is opposed to the provisions of this bill that require
health insurers to provide access to certain information
through Internet Web sites and to the requirement of a
standard identification card. Regarding the disclosure, AHIP
states that as currently drafted, this bill requires
disclosure of volumes of documents that will confuse consumers
by requiring the posting of unnecessary and irrelevant
information. AHIP notes that currently health insurance
carriers provide electronic access to many of the same
documents in a simplified format. As to the standard
identification card, AHIP states that this is unnecessary in
light of national efforts by WEDI, a collaboration that is
developing standards for nation electronic data exchange and
eventual implementation of a standard health insurance
benefits card. According to AHIP, state specific standards
developed prematurely will increase confusion among providers
and stall these national efforts, whereas awaiting a
standardized national card will ensure portability and ease of
use. The Association of California Life and Health Insurance
Companies (ACLHIC) is also opposed unless this bill is amended
and states that the proposed new requirements will increase
health care costs while not enhancing transparency.
6)OPPOSITION . The California Association of Health Plans (CAHP)
states that this bill would require extensive website
disclosure by plans, increase administrative costs for health
plans and would not provide meaningful information to
enrollees. CAHP states that it is unclear how this
information will help consumers or be in a format that is
easily understandable.
7)RELATED AND PRIOR LEGISLATION .
a) AB 244 (Beall) requires health plans and health insurers
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to cover the diagnosis and medically necessary treatment of
a mental illness, as defined, of a person of any age,
including a child, not limited to coverage for SMI as in
existing law.
b) SB 1553 (Lowenthal) Chapter 722, Statutes of 2008
requires the websites of health plans that provide coverage
for professional mental health services to include, but not
be limited to, providing information for subscribers,
enrollees, and providers on accessing mental health
services.
c) AB 1887 (Beall) of 2008 and AB 423 (Beall) of 2007 would
have expanded the mental health parity coverage requirement
for certain health plan contracts and health insurance
policies to include the diagnosis and treatment of a mental
illness of a person of any age and would have defined
mental illness for this purpose as a mental disorder as
defined in the Diagnostic and Statistical Manual IV. Both
bills were vetoed by Governor Schwarzenegger. In his veto
messages, the Governor stated that while he shared the
author's intent to improve access to mental health and
substance abuse services, he remained concerned that
mandates are a significant driver of costs and means that
some individuals may lose their coverage and not receive
health care at all.
d) AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires
DMHC to develop and adopt regulations to ensure that
enrollees have access to needed health care services in a
timely manner. AB 2179 also requires DMHC to develop
indicators of timeliness of access to care and specifies
three indicators for the department to consider.
e) AB 88 (Thomson), Chapter 534, Statutes of 1999, requires
health plans and health insurers to provide coverage for
the diagnosis and medically necessary treatment of certain
SMIs, as defined, and of SEDs of a child, as defined, under
the same terms and conditions applied to other medical
conditions.
8)AUTHOR'S AMENDMENTS . The author intends to offer amendments
in committee which the author reports address the opposition
of AHIP. The proposed amendments do the following:
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a) Clarify that information about accessing assessment
services for the purpose of referral to a provider need
only be provided if assessment services are provided by the
plan, and that information on the Web site need only be
updated quarterly if it has been modified;
b) Deems a health plan or insurer that complies with WEDI
standards, or other unspecified national standards,
compliant with the requirements of this bill that apply to
the identification cards, as long as the minimum
requirements of this bill are met;
c) Allows a health plan or insurer to provide a link to the
drug formulary or instructions on how to obtain the
formulary, and to provide a list of providers or
instructions on how to obtain the provider list; and,
d) Eliminates the requirement that the Web sites provide a
link to health plan annual surveys by DMHC and insurer
market conduct examinations by CDI, and deletes the
requirement that health plans and insurers include
non-proprietary provider manuals on the Web site.
9)SUGGESTED AMENDMENTS .
a) Scope of this bill . As a practical matter, this bill
will apply to all health plans and health insurers, as well
as to specialized mental health plans and insurers, because
under California's mental health parity law, all health
plans and insurers must provide at least some coverage for
mental health services consistent with the parity
requirements. The author may wish to amend this bill to
require all health plans and insurers to meet the
requirements, without the language that suggests it only
applies to a subset of plans that provide coverage for
professional mental health services.
b) Change to proposed author's amendments . The proposed
author's amendments would limit the requirement to provide
access to telephone support for assessment services to
instances when "such services are provided by the insurer."
Generally speaking, health plans and insurers are not
direct providers of services like assessment. Should the
language be changed to require telephone support that
provides access to assessment services if covered by the
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health plan or health insurer?
c) Technical amendment . The Insurance Code sections of
this bill exempt Medicare supplement policies but the
Knox-Keene provisions do not. This bill should be
consistent. As a policy matter, it is unclear why Medicare
supplement should be exempt from the basic consumer
information and protections in this bill.
REGISTERED SUPPORT / OPPOSITION :
Support
California Psychiatric Association (cosponsor)
California Society for Clinical Social Work (cosponsor)
California Board of Behavioral Sciences
California Psychological Association
NAMI California
National Association of Social Workers
Oppose unless amended
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
Oppose
California Association of Health Plans
Analysis Prepared by : Cassie Rafanan / HEALTH / (916)
319-2097