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California Senate Bill 855 (SB 855) Overview

California Senate Bill 855 (SB 855) requires health insurers and health plans to provide coverage for mental health and substance use disorders under the same terms and conditions applied to other medical conditions for Blue Shield of California ’s fully insured lines of business.

Key Highlights:
• Effective Date: January 1, 2021
• Coverage Requirements:

o Medically necessary treatments of mental health and substance use disorders.

o Determinations must be based on current, generally accepted standards of mental health and substance use disorder care . o Utilization review of all mental health and substance use disorder covered services and benefits must apply the criteria and guidelines in the most recent versions of treatment criteria developed by relevant nonprofit professional associations identified by the Department of Managed Health Care and the California Department of Insurance, except when the services are outside the scope of the criteria or in instances related to advancements in technology not covered in these sources.

• Scope: Applies to conditions listed in the DSM

• 5 (Diagnostic and Statistical Manual of Mental Disorders) and ICD (International Classification of Diseases), including inpatient, outpatient, residential, and crisis services.

  Provider Rights Under SB 855

  Under SB 855, Blue Shield is required to:
  • Provide free of cost, including paper copies, those clinical guidelines and educational materials Blue Shield uses to make medical necessity determinations for mental health and substance use disorder services to members, authorized representatives, and providers.

  • Ensure transparency in coverage decisions based on medical necessity. i How to Access Guidelines

  If you would like access to the clinical guidelines and/or educational materials: Call Blue Shield
  Provider Services at (800) 541- 6652 , between 6 A.M. and 6:30 P.M. (Pacific Time) , Monday through Friday .

  1 SB 855, Stats. 2020, Ch. 151, referenced above includes Health & Safety Code sections 1367.045, 1374.72, and 1374.721, and Insurance Code sections 10144.5 and 10144.52 . In addition, when SB 855 is referenced above, it also includes all California Code of Regulations promulgated by the California Department of Insurance and Department of Managed Health Care pursuant to SB 855, as applicable to the type of health benefit plan or insurance policy in which a plan member is enrolled .