20250AB__103295ENR INTRODUCED 2025-02-20 AMENDED_ASSEMBLY 2025-05-05 AMENDED_SENATE 2025-07-15 AMENDED_SENATE 2025-08-29 PASSED_ASSEMBLY 2025-09-12 PASSED_SENATE 2025-09-11 ENROLLED 2025-09-16 2025 AB ENR Introduced by Assembly Members Harabedian and Rivas (Coauthor: Senator Rubio) LEAD_AUTHOR ASSEMBLY Harabedian LEAD_AUTHOR ASSEMBLY Rivas COAUTHOR SENATE Rubio

An act to add

Section 1368.9 to the Health and Safety Code, and to add

Section 10112.97 to the Insurance Code, relating to health care coverage, and declaring the urgency thereof, to take effect immediately. health care coverage, and declaring the urgency thereof, to take effect immediately Coverage for behavioral health visits. 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 health insurers by the Department of Insurance.

Existing law requires a health care service plan contract or health insurance policy 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.

This bill would generally require a large group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2026, to reimburse an eligible enrollee or insured for up to visits with a behavioral health provider if the enrollee or insured lives in a county where a local or state emergency has been declared due to wildfires and the enrollee or insured has experienced a loss, trauma, or displacement because of the fire. The bill would prohibit these benefits from being subject to utilization review.

The bill would require a health care service plan contract or health insurer to provide notice to all affected enrollees of these provisions, as specified. Because a willful violation of these provisions 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.

This bill would declare that it is to take effect immediately as an urgency statute. TWO_THIRDS NO YES YES YES YES NO NO NO NO NO The people of the State of California do enact as follows:

SECTION

Section 1368.9 is added to the Health and Safety Code , to read: 1368.9. (a) (1) (

A) In addition to covering all medically necessary treatment of mental health and substance use disorders, as required by

Section 1374.72, a large group health care service plan contract issued, amended, or renewed on or after January 1, 2026, shall cover or reimburse an eligible enrollee for up to visits with a behavioral health provider if the enrollee lives in a county or counties where a local or state emergency has been declared due to wildfires, and the enrollee has experienced a loss, trauma, or displacement because of the fire. These visits shall not be subject to utilization review, as defined in

Section 1374.721, and shall apply regardless of the network status of the behavioral health provider. (

B) For the purposes of subparagraph (A), “state of emergency” means a declaration by the Governor pursuant to

Section of the Government Code and “local emergency” means an emergency declared pursuant to

Article 14 (commencing with

Section 8630) of

Chapter of Division of Title of the Government Code.

(2) A health care service plan shall assure continuity of care of the benefits required by this

section consistent with

Section 1373.96 and the regulations adopted thereunder.

(3) A noncontracting provider may only collect from the enrollee the in-network cost-sharing amount. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider. Cost sharing shall accrue toward the enrollee’s annual deductible, regardless of the network status of the licensed behavioral health provider.

(4) A noncontracting provider shall be paid consistent with the requirements of this

chapter relating to out-of-network services under

Section 1374.72 and regulations adopted thereunder.

(5) For a health care service plan contract that meets the definition of a “high deductible health plan” set forth in

Section 223(c)(2) of Title of the United States Code, paragraph (1) shall only apply once an enrollee’s deductible has been satisfied for the year. (b)

(1) This

section shall apply to a health care benefit plan or contract entered into with the Board of Administration of the Public Employees Retirement System pursuant to the Public Employees Medical and Hospital Care Act (part 5 (commencing with

Section 22750) of Division of Title of the Government Code) and members of the State Teachers’ Retirement System.

(2) This

section does not apply to a specialized health care service plan contract that covers only dental or vision benefits, a Medicare supplement plan, or coverage under a health care service plan contract for the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C.

Sec. 1395 et seq.).

(3) This

section shall not apply to Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to

Chapter 7 (commencing with

Section 1400) of, and

Chapter 8 (commencing with

Section 14200) of, Part of Division of the Welfare and Institutions Code. (

c) This

section does not excuse a health care service plan from complying with

Section 1374.72 or any other requirement set forth under this chapter, including, but not limited to, medically necessary treatment of mental health and substance use disorders as required by

Section 1374.72, which requires health plans to provide an enrollee with medically necessary mental health and substance use disorder services within specific time and distance standards, without arbitrary or discriminatory limits on the number of visits. (

d) For the purposes of this section, “behavioral health provider” means a health care provider as defined in

Section 1374.72. (e)

(1) Upon implementation of this

section or within days of when a local or state emergency due to wildfires has been declared, the health care service plan shall provide notice to all affected enrollees of this provision, and that an enrollee can access the services under this

section from any behavioral health provider.

(2) The notice shall also specify that an enrollee’s rights and benefits under this

section are separate and distinct from those in

Section 1374.72, including, but not limited to, the right to medically necessary treatment of mental health and substance use disorders as required by

Section 1374.72, the requirement to provide the enrollee with all medically necessary mental health and substance use disorder services within specified time and distance standards, without arbitrary or discriminatory limits on the number of visits, as well as their right under

Section 1374.72 to receive out-of-network care if in-network care is not available within the time or geographic standards set by law or regulation and the obligation of the health care service plan to arrange those services. The notice may be in the following form: In response to the recent emergency declaration due to wildfires in (County Name), you may be eligible for direct visits with a behavioral health care provider of your choice under

Section 1368.9 of the Health and Safety Code. This benefit is meant for those who have experienced displacement, loss, or trauma due to the recent wildfires. You may receive up to visits with a behavioral health provider, even if they are out of network. These visits may be covered directly by your plan or reimbursed after payment. Please contact your insurer in advance to confirm coverage and billing details. This new benefit is in addition to your existing rights under

Section 1374.72 of the Health and Safety Code. Under

Section 1374.72 of the Health and Safety Code, you are eligible for medically necessary mental health and substance use disorder services within specific time and distance standards, without arbitrary or discriminatory limits on the number of visits. Reiterating your rights under this new provision: you are eligible for up to visits with a behavioral health provider, even if the provider is not part of our network. If you have questions or need assistance, please contact Member Services. (

f) The department may issue guidance to health care service plans until the emergency is terminated. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code). (

g) This

section shall not be construed to limit the Governor’s authority under the California Emergency Services Act (Chapter 7 (commencing with

Section 8550) of Division of Title of the Government Code), or the director’s authority under any provision of this chapter.

SEC.

Section 10112.97 is added to the Insurance Code , to read: 10112.97. (a) (1) (

A) In addition to covering all medically necessary treatment of mental health and substance use disorders, as required by

Section 10144.5, a large group health insurance policy issued, amended, or renewed on or after January 1, 2026, shall cover or reimburse an eligible insured for up to visits with a behavioral health provider if the insured lives in a county or counties where a local or state emergency has been declared due to wildfires, and the insured has experienced a loss, trauma, or displacement because of the fire. These visits shall not be subject to utilization review, as defined in

Section 10144.52, and shall apply regardless of the network status of the behavioral health provider. (

B) For the purposes of subparagraph (A), “state of emergency” means a declaration by the Governor pursuant to

Section of the Government Code and “local emergency” means an emergency declared pursuant to

Article 14 (commencing with

Section 8630) of

Chapter of Division of Title of the Government Code.

(2) An insurer shall assure continuity of care for the benefits required by this

section consistent with

Section 10133.56 and the regulations adopted thereunder. (3) (

A) A noncontracting provider may only collect from the insured the in-network cost-sharing amount. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider. Cost sharing shall accrue toward the insured’s annual deductible, regardless of the network status of the behavioral health provider. (

B) A health insurer or a provider may seek relief in any court for the purpose of resolving a payment dispute. A provider is not prohibited from using a health insurer’s existing dispute resolution process.

(4) For a health insurance policy that meets the definition of a “high deductible health plan” set forth in

Section 223(c)(2) of Title of the United States Code, paragraph (1) shall only apply once an insured’s deductible has been satisfied for the year. (b)

(1) This

section shall apply to insureds of a health care benefit plan or contract entered into with the Board of Administration of the Public Employees Retirement System pursuant to the Public Employees Medical and Hospital Care Act (Part 5 (commencing with

Section 22750) of Division of Title of the Government Code) and members of the State Teachers’ Retirement System.

(2) This

section does not apply to a specialized health insurance policy that covers only dental or vision benefits, a Medicare supplement insurance policy, or coverage under a health care service plan contract for the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C.

Sec. 1395 et seq.). (

c) This

section does not excuse a health insurer from complying with Sections 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, and 10144.57, or any other requirement set forth under this code. Nothing in this

section shall be construed to limit any rights conferred upon insureds under this code, including, but not limited to, rights to medically necessary treatment of mental health and substance use disorders as required by

Section 10144.5, which requires health insurers to provide an insured with medically necessary behavioral health care services within specific time and distance standards, without arbitrary or discriminatory limits on the number of visits. (

d) For the purposes of this section, “behavioral health provider” means a health care provider as defined in

Section 10144.5. (e)

(1) Upon implementation of this

section or within days of when a local or state emergency due to wildfires has been declared, the insurer shall provide notice to all affected insureds of this provision, and that insured can access the services under this

section from any health care provider.

(2) The notice shall also specify that an insured’s rights and benefits under this

section is separate from and distinct from those in

Section 10144.5, including, but not limited to, the right to medically necessary treatment of mental health and substance use disorders as required by

Section 10144.5, the requirement to provide an insured with all medically necessary behavioral health care services within specified time and distance standards, without arbitrary or discriminatory limits on the number of visits, as well as their right under

Section 10144.5 to receive out-of-network care if in-network care is not available within the time or geographic standards set by law or regulation and the obligation of the insurer to arrange those services. The notice may be in the following form: In response to the recent emergency declaration due to wildfires in (County Name), you may be eligible for direct visits with a behavioral health care provider of your choice under

Section 10112.97 of the Insurance Code. This benefit is meant for those who have experienced displacement, loss, or trauma due to the recent wildfires. You may receive up to visits with a behavioral health provider, even if they are out of network. These visits may be covered directly by your plan or reimbursed after payment. Please contact your insurer in advance to confirm coverage and billing details. This new benefit is in addition to your existing rights under

Section 10144.5 of the Insurance Code. Under

Section 10144.5 of the Insurance Code, you are eligible for medically necessary mental health and substance use disorder services within specific time and distance standards, without arbitrary or discriminatory limits on the number of visits. Reiterating your rights under this new provision: you are eligible for up to visits with a behavioral health provider, even if the provider is not part of our network. If you have questions or need assistance, please contact Member Services. (

f) The department may issue guidance to insurers until the emergency is terminated. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code). (

g) This

section shall not be construed to limit the Governor’s authority under the California Emergency Services Act (Chapter 7 (commencing with

Section 8550) of Division of Title of the Government Code), or the director’s authority under any provision of this chapter.

SEC. 3. No reimbursement is required by this act pursuant to

Section 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 of the Government Code, or changes the definition of a crime within the meaning of

Section of

Article XIII B of the California Constitution.

SEC. 4. This act is an urgency statute necessary for the immediate preservation of the public peace, health, or safety within the meaning of

Article IV of the California Constitution and shall go into immediate effect. The facts constituting the necessity are: Because the destruction and loss of one’s home, belongings, and surrounding community, and the threat to personal safety and the safety of loved ones, can have significant consequences on survivors’ behavioral health, which persist for years after, it is necessary for this act to take effect immediately.