Mental Health and Substance Use Disorder Information (SB855)
Health coverage: mental health or substance use disorders. Senate Bill 855 was signed by California Governor Gavin Newsom on September 25th, 2020. Effective 1/1/2021, SB 855 amends existing California statutes and adds provisions relating to coverage of mental health and substance use disorder treatment.
- Balance by CCHP provides coverage for the medically necessary treatment of all mental health (MH) and substance use disorder (SUD) under the same terms and other conditions applied to other medical conditions.
Balance applies the definition of “mental health and substance use disorders” as those conditions listed in the most recent edition of either the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM). - Balance defines “medically necessary treatment of a mental health or substance use disorder” as “a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms” that is:
- “In accordance with the generally accepted standards of mental health and substance use disorder care”;
- “Clinically appropriate in terms of type, frequency, extent, site, and duration”; and
- “Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.
- When conducting utilization review of MH/SUD services, Balance applies clinical guidelines developed by the following nonprofit professional association for the relevant clinical specialty for utilization management. Balance shall continually monitor these nonprofit entities for updated treatment plans.
- Balance includes peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of health care professional associations, specialty societies and federal government agencies, and drug labeling approved by the U.S. Food and Drug Administration when the recommended course of treatment for a specific MH/SUD condition is outside the scope of the criteria identified by the following non-profits: American Society of Addiction Medicine (ASAM), American Association of Community Psychiatrists and/or American Academy of Child & Adolescent Psychiatry and World Professional Association for Transgender.
Criteria and Guidelines for Mental Health (MH) and Substance Use Disorder (SUD) Services
When conducting utilization review of MH/SUD services, Balance uses criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty.
Plan uses the following criteria/guidelines for mental health, substance use disorder, and gender dysphoria in accordance with DMHC recommendation:
| Clinical Specialty | Nonprofit Professional Association | Criteria or Guideline |
| Substance Use Disorder Any Age |
American Society of Addiction Medicine (ASAM) | ASAM 3rd Edition |
| Mental Health Disorders Patients 18 and Older |
American Association of Community Psychiatrists (AACP) | Level of Care Utilization System (LOCUS) |
| Mental Health Disorders Patients 6 to 17 Years of Age |
American Association of Community Psychiatrists (AACP)
American Academy of Child & Adolescent Psychiatry (AACAP) |
Child and Adolescent Level of Care Utilization System (CALOCUS)
Child and Adolescent Service Intensity Instrument (CASII) CALOCUS-CASII |
| Mental Health Disorders Patients 0 to 5 Years of Age |
American Academy of Child and Adolescent Psychiatry | Early Childhood Service Intensity Instrument (ECSII) |
| Gender Dysphoria | World Professional Association for Transgender Health (WPATH) | WPATH Standards of Care Version 8 |
Balance will cover Mental Health/Substance use disorder (MH/SUD) clinical review criteria and training materials or resources for members at no cost. For more information on the of levels of criteria and guidelines of Mental Health or Substance Use Disorders, please contact Member Services Center at 1-888-775-7888.