Substance use disorder coverage.

Assembly Member Haney's substance use disorder treatment legislation would remove utilization management requirements for the first 28 days of inpatient care and outpatient services starting January 1, 2027. The bill prohibits health plans and insurers from conducting concurrent or retrospective medical necessity reviews during this initial treatment period, with medical necessity determined solely by the patient's physician.

For inpatient care beyond 28 days, plans may implement concurrent reviews no more frequently than every two weeks. If continued care is deemed not medically necessary, plans must provide 24-hour notice and maintain coverage during expedited appeals. The bill also bars prior authorization requirements for outpatient prescription drugs used to treat substance use disorders when prescribed by a physician or psychiatrist.

The legislation establishes specific protections for intensive outpatient and partial hospitalization programs, prohibiting retrospective reviews for the first 28 days while allowing medical necessity reviews using American Society of Addiction Medicine criteria thereafter. Plans cannot reduce or deny these benefits based on the presence of additional diagnoses. The provisions apply to all health plans and insurers in California, excluding county Drug Medi-Cal organized delivery systems.

The measure creates parallel requirements in both the Health and Safety Code for health care service plans and the Insurance Code for health insurers. Willful violations by health plans would constitute a crime under existing law, though the bill requires no state reimbursement to local agencies for enforcement costs.