28 CA ADC § 1300.74.72
28 CCR s 1300.74.72
Cal. Admin. Code tit. 28, s 1300.74.72
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.74.72. Mental Health Parity.
(a) The mental health services required for the diagnosis, and treatment
of conditions set forth in Health and Safety Code section 1374.72 shall
include, when medically necessary, all health care services required under
the Act including, but not limited to, basic health care services within
the meaning of Health and Safety Code sections 1345(b) and 1367(i), and
section 1300.67 of Title 28. These basic health care services shall, at a
minimum, include crisis intervention and stabilization, psychiatric
inpatient hospital services, including voluntary psychiatric inpatient
services, and services from licensed mental health providers including,
but not limited to, psychiatrists and psychologists.
(b) A plan shall provide coverage for the diagnosis and medically
necessary treatment of conditions set forth in Health and Safety Code
section 1374.72 through health care providers within the meaning of Health
and Safety Code section 1345(i) who are:
(1) acting within the scope of their licensure, and
(2) acting within their scope of competence, established by education,
training and experience, to diagnose, and treat conditions set forth in
Health and Safety Code section 1374.72.
(c) A diagnosis within the meaning of Health and Safety Code section
1374.72 shall be made in accordance with professionally recognized
diagnostic criteria including, but not limited to, the diagnostic criteria
set forth in the Diagnostic and Statistical Manual for Mental Disorders -
IV - Text Revision (June 2000).
(d) A preliminary or initial diagnosis made by a primary care physician,
mental health provider or pediatrician meeting the requirements of
subsection (b) above, that an enrollee has one or more of the conditions
set forth in Health and Safety Code section 1374.72, shall constitute the
diagnosis for the length of time necessary to make a final diagnosis,
whether or not the final diagnosis confirms the preliminary or initial
diagnosis.
(e) "Pervasive Developmental Disorders" shall include Autistic Disorder,
Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder
and Pervasive Developmental Disorder Not Otherwise Specified (including
Atypical Autism), in accordance with the Diagnostic and Statistical Manual
for Mental Disorders - IV - Text Revision (June 2000).
(f) A plan's referral system shall provide enrollees timely access and
ready referral, in a manner consistent with good professional practice, to
mental health services for the purpose of diagnosis and medically
necessary treatment of conditions set forth in Health and Safety Code
section 1374.72 and for related health care services as appropriate upon
referral from a primary care physician, mental health provider or
pediatrician meeting the requirements of subsection (b) above.
(g) If a plan contracts with a specialized health care service plan for
the purpose of providing Health and Safety Code section 1374.72 services,
the following requirements shall apply:
(1) the specialized health care service plan shall maintain a telephone
number that an enrollee may call during normal business hours to obtain
information about benefits, providers, coverage and any other relevant
information concerning an enrollee's mental health services;
(2) if the plan issues identification cards to enrollees, the
identification cards shall include the telephone number required to be
maintained above and a brief statement indicating that enrollees may call
the telephone number for assistance about mental health services and
coverage;
(3) the plan shall monitor the continuity and coordination of care that
enrollees receive, and take action, when necessary, to assure continuity
and coordination of care, in a manner consistent with professionally
recognized evidence-based standards of practice, across the health care
network;
(4) the plan shall monitor, as often as necessary, but not less frequently
than once every year, the collaboration between medical and mental health
providers including, but not limited to, the following:
(A) exchange of information,
(B) appropriate diagnosis, treatment and referral, and
(C) access to treatment and follow-up for enrollees with co-existing
medical and mental health disorders;
(5) the plan shall retain full responsibility for assuring continuity and
coordination of care, in accordance with the requirements of this
subsection, notwithstanding that, by contract, it has obligated a
specialized health care service plan to perform some or all of these
activities.
(h) Nothing in this section shall be construed to mandate coverage of
services that are not medically necessary or preclude a plan from
performing utilization review in accordance with the Act.
(i) A plan shall include in its Evidence of Coverage or Combined Evidence
of Coverage and Disclosure Form a list of mental conditions required to be
covered pursuant to Health and Safety Code section 1374.72.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Sections 1345, 1367 and 1374.72, Health and Safety Code.
HISTORY
1. New section filed 9-23-2003; operative 10-23-2003 (Register 2003, No.
39).
28 CA ADC s 1300.74.72
END OF DOCUMENT
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