Bill Text: CA SB238 | 2023-2024 | Regular Session | Introduced

California Senate Bill 238 (Prior Session Legislation)

NOTE: There are more recent revisions of this legislation. Read Latest Draft

Bill Title: Health care coverage: independent medical review.

Spectrum: Partisan Bill (Democrat 4-0)

Status: (Engrossed - Dead) 2023-09-01 - September 1 hearing: Held in committee and under submission. [SB238 Detail]

Download: California-2023-SB238-Introduced.html

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Senate Bill

No. 238

Introduced by Senator Wiener
(Coauthor: Senator Newman)
(Coauthor: Assembly Member Garcia)

January 24, 2023

An act to add Section 1374.37 to the Health and Safety Code, and to add Section 10169.6 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

SB 238, as introduced, Wiener. Health care coverage: independent medical review.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of disability insurers by the Department of Insurance. Existing law establishes the Independent Medical Review System within each department, under which an enrollee or insured may seek review if a health care service has been denied, modified, or delayed by a health care service plan or disability insurer and the enrollee or insured has previously filed a grievance that remains unresolved after 30 days.

This bill would require a decision regarding a disputed health care service to be automatically submitted to the relevant Independent Medical Review System if the decision is to deny, modify, or delay specified mental health care services for an enrollee or insured 0 to 21 years of age, inclusive. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES

The people of the State of California do enact as follows:

SECTION 1.

The Legislature finds and declares all of the following:

(a) Disputed health care service decisions under commercial health care coverage are already subject to review like the state’s Independent Medical Review System, but appeals must be initiated by enrollees and insureds.

(b) Mental health resources in California are disproportionately hard to access for low-income and minority children, and the online form to file an independent medical review is in English and Spanish only.

(c) The Legislature recently approved Chapter 151 of the Statutes of 2020, a mental health parity law that requires commercial health care service plan contracts and disability insurance policies to provide medically necessary mental health treatment.

(d) In California, 13 percent of children 3 to 17 years of age, inclusive, reported having at least one mental, emotional, developmental, or behavioral health problem, and 8 percent of children have a serious emotional disturbance that limits participation in daily activity.

(e) In 2021, mental health disorder diagnosis cases made up 48 percent of all total youth independent medical reviews, up from 36 percent in 2017.

(f) Since 2017, the percentage of health care service plan and disability insurer decisions about youth mental health disorders that were overturned by the Independent Medical Review System has more than doubled to 79 percent.

(g) Like older adults, children and youth represent a vulnerable population. However, children and youth covered by commercial health care coverage do not have the protections afforded by Medicare procedures. If a Medicare Advantage (Part C) health plan upholds its initial adverse organization determination to deny a drug or service, the plan must automatically submit the case file and its decision for review by the Part C Independent Review Entity.

SEC. 2.

Section 1374.37 is added to the Health and Safety Code, to read:

1374.37.

A health care service plan’s decision regarding a disputed health care service shall be automatically submitted to the Independent Medical Review System if the decision is to deny, modify, or delay either of the following for an enrollee 0 to 21 years of age, inclusive:

(a) A mental health care service based on consideration of medical necessity.

(b) The use of experimental or investigational therapies, drugs, devices, procedures, or other therapies if the enrollee has a seriously debilitating or life-threatening mental health condition, as defined in Section 10145.3, and one of the following is true:

(1) A physician has certified that standard therapies have not been effective in improving the condition of the enrollee.

(2) Standard therapies would not be medically appropriate for the enrollee.

(3) There is no more beneficial standard therapy covered by the plan.

SEC. 3.

Section 10169.6 is added to the Insurance Code, to read:

10169.6.

A disability insurer’s decision regarding a disputed health care service shall be automatically submitted to the Independent Medical Review System if the decision is to deny, modify, or delay either of the following for an insured 0 to 21 years of age, inclusive:

(a) A mental health care service based on consideration of medical necessity.

(b) The use of experimental or investigational therapies, drugs, devices, procedures, or other therapies if the insured has a seriously debilitating or life-threatening mental health condition, as defined in Section 1370.4, and one of the following is true:

(1) A physician has certified that standard therapies have not been effective in improving the condition of the insured.

(2) Standard therapies would not be medically appropriate for the insured.

(3) There is no more beneficial standard therapy covered by the insurer.

SEC. 4.

No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.