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	<ns0:Description>
		<ns0:Id>20250AB__142997AMD</ns0:Id>
		<ns0:VersionNum>97</ns0:VersionNum>
		<ns0:History>
			<ns0:Action>
				<ns0:ActionText>INTRODUCED</ns0:ActionText>
				<ns0:ActionDate>2025-02-21</ns0:ActionDate>
			</ns0:Action>
			<ns0:Action>
				<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
				<ns0:ActionDate>2025-04-02</ns0:ActionDate>
			</ns0:Action>
			<ns0:Action>
				<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
				<ns0:ActionDate>2025-05-01</ns0:ActionDate>
			</ns0:Action>
		</ns0:History>
		<ns0:LegislativeInfo>
			<ns0:SessionYear>2025</ns0:SessionYear>
			<ns0:SessionNum>0</ns0:SessionNum>
			<ns0:MeasureType>AB</ns0:MeasureType>
			<ns0:MeasureNum>1429</ns0:MeasureNum>
			<ns0:MeasureState>AMD</ns0:MeasureState>
		</ns0:LegislativeInfo>
		<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Bains</ns0:AuthorText>
		<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthor: Assembly Member Schiavo)</ns0:AuthorText>
		<ns0:AuthorText authorType="COAUTHOR_OPPOSITE">(Coauthors: Senators Cervantes and Hurtado)</ns0:AuthorText>
		<ns0:Authors>
			<ns0:Legislator>
				<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
				<ns0:House>ASSEMBLY</ns0:House>
				<ns0:Name>Bains</ns0:Name>
			</ns0:Legislator>
			<ns0:Legislator>
				<ns0:Contribution>COAUTHOR</ns0:Contribution>
				<ns0:House>ASSEMBLY</ns0:House>
				<ns0:Name>Schiavo</ns0:Name>
			</ns0:Legislator>
			<ns0:Legislator>
				<ns0:Contribution>COAUTHOR</ns0:Contribution>
				<ns0:House>SENATE</ns0:House>
				<ns0:Name>Cervantes</ns0:Name>
			</ns0:Legislator>
			<ns0:Legislator>
				<ns0:Contribution>COAUTHOR</ns0:Contribution>
				<ns0:House>SENATE</ns0:House>
				<ns0:Name>Hurtado</ns0:Name>
			</ns0:Legislator>
		</ns0:Authors>
		<ns0:Title>An act to add Article 3.6 (commencing with Section 1358.30) to Chapter 2.2 of Division 2 of, and to repeal Section 1358.31 of, the Health and Safety Code, relating to health care coverage. </ns0:Title>
		<ns0:RelatingClause>health care coverage</ns0:RelatingClause>
		<ns0:GeneralSubject>
			<ns0:Subject>Behavioral health reimbursement. </ns0:Subject>
		</ns0:GeneralSubject>
		<ns0:DigestText>
			<html:p>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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.</html:p>
			<html:p>This bill would require the plan, as defined, to fully reimburse an enrollee who incurs out-of-pocket
			 costs for behavioral health care services obtained from nonplan providers or facilities or mental health prescription medication obtained from a nonplan pharmacy or nonplan provider on or after May 1, 2022, until the department certifies to the Legislature that
			 the plan has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department. The bill would require an enrollee to submit specified documents for reimbursement and would require the plan to pay the reimbursement within 60 calendar days of an enrollee’s submission of documented expenses. If the plan fails to provide this reimbursement, the bill would require it to pay the original amount plus 10% per annum interest to the enrollee, as well as a $5,000 fine per incident. The bill would require
			 the plan to establish specified procedures, and would require the plan to submit a monthly report to the department with specified information. Because a willful violation of the bill’s provisions would be a crime, the bill would impose a state-mandated local program.</html:p>
			<html:p>This bill would make legislative findings and declarations as to the necessity of a special statute for the specified plan.</html:p>
			<html:p>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.</html:p>
			<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
		</ns0:DigestText>
		<ns0:DigestKey>
			<ns0:VoteRequired>MAJORITY</ns0:VoteRequired>
			<ns0:Appropriation>NO</ns0:Appropriation>
			<ns0:FiscalCommittee>YES</ns0:FiscalCommittee>
			<ns0:LocalProgram>YES</ns0:LocalProgram>
		</ns0:DigestKey>
		<ns0:MeasureIndicators>
			<ns0:ImmediateEffect>NO</ns0:ImmediateEffect>
			<ns0:ImmediateEffectFlags>
				<ns0:Urgency>NO</ns0:Urgency>
				<ns0:TaxLevy>NO</ns0:TaxLevy>
				<ns0:Election>NO</ns0:Election>
				<ns0:UsualCurrentExpenses>NO</ns0:UsualCurrentExpenses>
				<ns0:BudgetBill>NO</ns0:BudgetBill>
				<ns0:Prop25TrailerBill>NO</ns0:Prop25TrailerBill>
			</ns0:ImmediateEffectFlags>
		</ns0:MeasureIndicators>
	</ns0:Description>
	<ns0:Bill id="bill">
		<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
		<ns0:BillSection id="id_1AAACF05-F43F-4003-918C-81B6A98CA8DE">
			<ns0:Num>SECTION 1.</ns0:Num>
			<ns0:ActionLine action="IS_ADDED" ns3:href="urn:caml:codes:HSC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'2.2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'ARTICLE'%20and%20caml%3ANum%3D'3.6.'%5D)" ns3:label="fractionType: LAW_SPREAD||commencingWith: 1358.30" ns3:type="locator">
				Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the 
				<ns0:DocName>Health and Safety Code</ns0:DocName>
				, to read:
			</ns0:ActionLine>
			<ns0:Fragment>
				<ns0:LawHeading id="id_55536FFE-B3A1-452D-BA98-9A924FAE1079" type="ARTICLE">
					<ns0:Num>3.6.</ns0:Num>
					<ns0:LawHeadingVersion id="id_D68FAACB-A001-419E-9B5A-FCBBE2A41523">
						<ns0:LawHeadingText>Behavioral Health Reimbursement </ns0:LawHeadingText>
					</ns0:LawHeadingVersion>
					<ns0:LawSection id="id_E62F05AD-70A0-4644-8062-5833531CD28F">
						<ns0:Num>1358.30.</ns0:Num>
						<ns0:LawSectionVersion id="id_5472C599-2EE9-48FE-BC31-8A88B5EFCF8E">
							<ns0:Content>
								<html:p>For purposes of this article:</html:p>
								<html:p>
									(a)
									<html:span class="EnSpace"/>
									“Behavioral health care” includes behavioral health services, psychiatric services, psychological services, counseling, addiction services, and related prescription medications that are offered by the plan.
								</html:p>
								<html:p>
									(b)
									<html:span class="EnSpace"/>
									“Out-of-pocket costs” means any expenses paid directly by an enrollee, including all of the following:
								</html:p>
								<html:p>
									(c)
									<html:span class="EnSpace"/>
									“Plan” means a health care service plan identified in the Department of Managed Health Care’s Enforcement Matter Number 22-496 and 2022 Non-Routine Survey 933-0055.
								</html:p>
								<html:p>
									(1)
									<html:span class="EnSpace"/>
									Copayments.
								</html:p>
								<html:p>
									(2)
									<html:span class="EnSpace"/>
									Deductibles.
								</html:p>
								<html:p>
									(3)
									<html:span class="EnSpace"/>
									Prescription medication costs.
								</html:p>
								<html:p>
									(4)
									<html:span class="EnSpace"/>
									Provider visit fees.
								</html:p>
								<html:p>
									(5)
									<html:span class="EnSpace"/>
									Telehealth consultation fees.
								</html:p>
								<html:p>
									(6)
									<html:span class="EnSpace"/>
									Transportation costs directly related to obtaining behavioral health care.
								</html:p>
							</ns0:Content>
						</ns0:LawSectionVersion>
					</ns0:LawSection>
					<ns0:LawSection id="id_0E7E8DC7-DA6B-4108-ACB7-51E1BD0C5CD3">
						<ns0:Num>1358.31.</ns0:Num>
						<ns0:LawSectionVersion id="id_C9A65D4E-9115-447A-B6A9-06AB02D8BFE9">
							<ns0:Content>
								<html:p>
									(a)
									<html:span class="EnSpace"/>
									The plan shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from nonplan providers or facilities.
								</html:p>
								<html:p>
									(b)
									<html:span class="EnSpace"/>
									The
						  plan shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a nonplan pharmacy or nonplan provider.
								</html:p>
								<html:p>
									(c)
									<html:span class="EnSpace"/>
									Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollee’s submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to
						  the plan:
								</html:p>
								<html:p>
									(1)
									<html:span class="EnSpace"/>
									Receipts or invoices showing actual costs paid.
								</html:p>
								<html:p>
									(2)
									<html:span class="EnSpace"/>
									Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.
								</html:p>
								<html:p>
									(3)
									<html:span class="EnSpace"/>
									A signed statement affirming that the expense was incurred due to the enrollee’s inability to obtain timely and appropriate care through the plan.
								</html:p>
								<html:p>
									(d)
									<html:span class="EnSpace"/>
									Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after May 1,
						  2022.
								</html:p>
								<html:p>
									(e)
									<html:span class="EnSpace"/>
									This section shall remain in effect only until the department certifies to the Legislature by providing a detailed and publicly available report posted on its internet website that the plan has successfully completed implementation of any corrective action work plan resulting from
						  Department of Managed Health Care’s Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055, and as of that date is repealed.
								</html:p>
							</ns0:Content>
						</ns0:LawSectionVersion>
					</ns0:LawSection>
					<ns0:LawSection id="id_A4883768-CB15-496A-A3E7-3E1BB790B19E">
						<ns0:Num>1358.32.</ns0:Num>
						<ns0:LawSectionVersion id="id_81FE4388-FCFA-4071-A797-A314E6D2F831">
							<ns0:Content>
								<html:p>
									(a)
									<html:span class="EnSpace"/>
									The plan shall establish procedures for all of the following actions pursuant to Section 1358.31:
								</html:p>
								<html:p>
									(1)
									<html:span class="EnSpace"/>
									Enrollee submission of reimbursement requests in either online or paper form.
								</html:p>
								<html:p>
									(2)
									<html:span class="EnSpace"/>
									The plan’s processing of reimbursement requests.
								</html:p>
								<html:p>
									(3)
									<html:span class="EnSpace"/>
									Appeals of denied reimbursement requests in either online or paper form.
								</html:p>
								<html:p>
									(4)
									<html:span class="EnSpace"/>
									Statistical monitoring of submitted, approved, and denied reimbursement requests.
								</html:p>
								<html:p>
									(b)
									<html:span class="EnSpace"/>
									The department shall review and determine if the plan has fulfilled the requirements pursuant to subdivision (a), and shall report its findings to the Legislature in compliance with Section 9795 of the Government Code.
								</html:p>
								<html:p>
									(c)
									<html:span class="EnSpace"/>
									The
						  plan shall submit a monthly report to the department that includes all of the following:
								</html:p>
								<html:p>
									(1)
									<html:span class="EnSpace"/>
									Number of reimbursement requests received.
								</html:p>
								<html:p>
									(2)
									<html:span class="EnSpace"/>
									Total amount reimbursed.
								</html:p>
								<html:p>
									(3)
									<html:span class="EnSpace"/>
									Average processing time for reimbursement requests.
								</html:p>
								<html:p>
									(4)
									<html:span class="EnSpace"/>
									Number of denied reimbursement requests and reasons for denial.
								</html:p>
							</ns0:Content>
						</ns0:LawSectionVersion>
					</ns0:LawSection>
					<ns0:LawSection id="id_86250978-0256-4E09-9BDD-6F3BD118EDF2">
						<ns0:Num>1358.33.</ns0:Num>
						<ns0:LawSectionVersion id="id_FDDCCE51-8C75-43E4-AA3F-EE08004DBE71">
							<ns0:Content>
								<html:p>In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:</html:p>
								<html:p>
									(a)
									<html:span class="EnSpace"/>
									Payment of the original amount plus 10 percent per annum interest to the enrollee.
								</html:p>
								<html:p>
									(b)
									<html:span class="EnSpace"/>
									A fine of five thousand dollars ($5,000) per incident.
								</html:p>
							</ns0:Content>
						</ns0:LawSectionVersion>
					</ns0:LawSection>
				</ns0:LawHeading>
			</ns0:Fragment>
		</ns0:BillSection>
		<ns0:BillSection id="id_85AFD12D-0040-4901-9843-1AEAB438198E">
			<ns0:Num>SEC. 2.</ns0:Num>
			<ns0:Content>
				<html:p>The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in the plan’s behavioral health care services, until
				the plan fully corrects the deficiencies identified in the Department of Managed Health Care’s Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055.</html:p>
			</ns0:Content>
		</ns0:BillSection>
		<ns0:BillSection id="id_AD98C12A-96B6-4609-A613-81CA4427CF1A">
			<ns0:Num>SEC. 3.</ns0:Num>
			<ns0:Content>
				<html:p>
					No reimbursement is required by this act pursuant to Section 6 of Article XIII
					<html:span class="ThinSpace"/>
					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
					<html:span class="ThinSpace"/>
					B of the California Constitution.
				</html:p>
			</ns0:Content>
		</ns0:BillSection>
	</ns0:Bill>
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