Behavioral Health Care

Behavioral Health Care

Introduction

Both state and federal laws require health plans to provide treatment for mental health and substance use disorder conditions. The DMHC refers to treatment and services provided to treat mental health and substance use conditions as behavioral health care.

Both state and federal laws require health plans to provide treatment for mental health and substance use disorder conditions. The DMHC refers to treatment and services provided to treat mental health and substance use conditions as behavioral health care.

Most recently amended in 2020, California’s Mental Health Parity Act requires commercial health plans and insurers to provide full coverage for the treatment of all mental health conditions and substance use disorders. It also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines.

The federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires commercial health plans that offer mental health and substance use disorder benefits to do so in a manner comparable to medical and surgical benefits.

MHPAEA prevents health plans that provide mental health or substance use disorder benefits from placing limits on those benefits that are less favorable than the limits placed on medical/surgical benefits. More specifically, health plans must ensure that financial requirements, such as copayments, coinsurance, and deductibles, and treatment limitations, such as the number and frequency of visits, which are applied to mental health or substance use disorder benefits are not more restrictive than the predominant requirements applied to most of the medical and surgical benefits.

Know Your Rights

California’s Mental Health Parity Act, as amended in 2020, requires all state-regulated commercial health plans and insurers to provide full coverage for the treatment of all mental health conditions and substance use disorders.

Commercial health plans regulated by the state that provide hospital, medical or surgical coverage in the individual, small group, or large group markets must:

  • Cover medically necessary treatment of mental health and substance use disorders listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders
  • Cover the full spectrum of all medically necessary treatment in all settings, including inpatient and outpatient treatment.
  • Not limit benefits or coverage to short-term or acute treatment.
  • Arrange coverage for out-of-network services for medically necessary treatment when services are not available in-network. This provision does not alter the plan’s obligation to ensure its contracted network provides readily available and accessible health care services to each of the plan’s enrollees throughout its service area.
  • Not limit benefits or coverage for medically necessary services on the basis that those services may be covered by a public entitlement program.

Prior to the 2020 amendments to California Mental Health Parity Law, the federal Affordable Care Act required health plan coverage of mental health conditions and substance use disorders to commercial health plans in the individual and small group markets.

The following link will connect you to more information on your health care rights.

How to Get Care

You can ask for a referral from your primary care doctor, your behavioral health care provider, or your health plan. In some health plans, you may be able to make an appointment directly with a behavioral health care provider. In other health plans, you may need to first obtain authorization from your primary care doctor and/or your health plan to be referred to see a behavioral health care provider.

Read your Evidence of Coverage or call the phone number on your Health Plan Membership Card to ask your health plan to see a behavioral health care provider.

Mental Health and Substance Use Disorder Care for Medi-Cal Members

The information above describes the mental health and substance use disorder conditions and treatments that must be provided to people with commercial coverage. Most of these mental health and substance use disorder benefits are also available for people in Medi-Cal. Services covered by Medi-Cal include outpatient mental health services such as individual or group counseling, outpatient specialty mental health services, inpatient mental health services, outpatient substance use disorder services, residential treatment services, and voluntary inpatient detoxification. To find out how to get mental health or substance use disorder treatment through Medi-Cal, contact your Medi-Cal managed care plan or call the Medi-Cal Mental Health Care Ombudsman at (800) 896-4042 and ask for an assessment or needed services.

Regional Centers

Another option for some people with developmental disabilities is to receive mental health care through a regional center. A regional center is a nonprofit, private corporation that contracts with the California Department of Developmental Services to provide or coordinate services. California has 21 regional centers with more than 40 offices located throughout the state.

To be eligible for regional center services, you must have a substantial disability that began before your 18th birthday and is expected to continue indefinitely. Infants and toddlers up to age 36 months who are at risk of having developmental disabilities or who have a developmental delay may also be eligible for regional center services. Persons interested in regional center services must first obtain a diagnosis and assessment of their disability from a regional center.

For more information on regional center services, supports, and eligibility, go to https://www.dds.ca.gov/rc/.

Questions and Answers

What should I do if I can’t get an appointment with a behavioral health care provider, or if my health plan denies behavioral health care treatment?

If you are having trouble accessing behavioral health care treatment or services, you should first contact your health plan at the member services phone number on your health plan membership card. Your health plan will review the grievance and ensure you are able to timely access medically necessary care.

If you do not agree with your health plan’s response or your health plan denies treatment, you can file a complaint with your health plan.

Will I have to pay more for behavioral health care than other health care?

Health plans cannot charge more for mental health and substance use disorder services than for physical health conditions. This includes enrollee cost-sharing obligations for: co-pays, deductibles, maximum annual and lifetime benefits, and other out-of-pocket expenses.

What if the medicine I need is not covered?

Ask if there is a similar drug that is covered that you can try. If your doctor thinks you need a drug that is not covered, your doctor must make a special request to your plan. If your plan still says you cannot get the drug, you can file a complaint with your health plan.

Does the California Mental Health Parity Law cover children?
Yes. California’s mental health parity law has the same coverage requirements for children. California law also requires all plans to cover behavioral health treatment for autism or pervasive development disorder, which is frequently identified during childhood.

Will my health plan cover residential treatment?

Plans must cover medically necessary residential treatment. A residential treatment center provides long-term treatment and 24-hour supervision for individuals requiring ongoing and a more structured therapy environment. It is usually less restrictive than a psychiatric hospital.

A few questions to ask your provider or your health plan include the following:

  1. How long could residential treatment last?
  2. Is residential treatment covered for my mental health condition?
  3. What will I have to pay?
  4. Where is residential treatment provided?
  5. What are the names of contracted facilities?

You will need prior approval from your health plan before you or a family member receives residential care treatment. If your plan says the treatment is not medically necessary, you can file a complaint with your health plan.

What if I have Medi-Cal?

Medi-Cal provides mental health care and substance use disorder services. If you are in a Medi-Cal managed care plan, call your plan or call the Medi-Cal Mental Health Care Ombudsman at (800) 896-4042.

What if I have Medicare?

Call your health plan and ask what mental health care services it covers. The California Mental Health Parity Law and the federal MHPAEA do not apply to Medicare plans.

Mental Health Resources

  • Review these additional resources for Behavioral Health information and help.
  • Consumer Fact Sheet and Press Release on the amended California Mental Health Parity Act.
  • DMHC All Plan Letter directing commercial full-service health plans and specialized health plans offering behavioral health services to demonstrate compliance with the amended California Mental Health Parity Act (SB 855, 2020).
  • See Behavioral Health Care Compliance for more information on the DMHC’s efforts to ensure health plans comply with federal and state behavioral health care laws.