CA SB855

Requires health care service plans and disability insurers to provide coverage for medically necessary treatment of all mental health and substance use disorders (as defined in DSM-5 or ICD-11) under the same terms as other medical conditions, effective January 1, 2021.

Prohibits plans and insurers from limiting mental health and substance use disorder benefits to short-term or acute treatment and requires coverage of intermediate services including residential treatment, partial hospitalization, and intensive outpatient treatment.

Mandates that medical necessity determinations and utilization review for mental health and substance use disorders be based on current generally accepted standards of care and specific clinical criteria from nonprofit professional associations; prohibits plans from applying more restrictive criteria than those sources.

Requires health care plans and insurers to conduct staff training on clinical review criteria, provide criteria and training materials at no cost to providers and patients, track utilization decisions, and achieve 90 percent interrater reliability testing pass rates.

Voids any contract provisions that reserve discretionary authority to plans or insurers to determine eligibility or interpret terms in ways inconsistent with California law; authorizes civil penalties up to $5,000 per violation ($10,000 if willful).