24-978 Comply With Senate Bill 855 Network Adequacy Requirements
Date: 09/25/24
Ensure you meet requirements for behavioral health/substance use disorder providers
On January 12, 2024, the Office of Administrative Law approved the Department of Managed Health Care’s (DMHC’s) proposed regulation implementing SB 855. This regulation took effect April 1, 2024, and is codified in California Code of Regulations (CCR), title 28, sections 1300.74.72, 1300.74.72.01 and 1300.74.721. It mandates requirements for network adequacy, scope of services, and use of nonprofit criteria that health plans and their delegated participating physician groups (PPGs) must comply with. These requirements also apply to delegated behavioral health (BH) PPGs.
PPG requirements
In addition, the requirements in 28 CCR section 1300.74.72 mandate that health plans and delegated PPGs shall maintain a provider network sufficient to provide all medically necessary services, including BH/substance use disorder (SUD) services, within geographic and timely access standards, pursuant to the Knox-Keene Act and its regulations. The Plan and delegated PPGs must also arrange coverage for medically necessary BH/SUD services from an out-of-network provider if such BH/SUD services are not available to an enrollee in accordance with geographic and timely access standards such as those required by rule 1300.67.2.2 and rule 1300.67.2.1.
Written notice to the enrollee
In such cases involving an out-of-network provider, the Plan (or PPG, if delegated) must issue a written notice to the enrollee that includes a required statement specified in the regulation that describes the Plan’s or the delegated PPG’s responsibilities regarding arranging for the enrollee’s obtaining services from an out-of-network physician or other out-of-network provider.
The regulation further describes additional requirements for the Plan and delegated PPG to follow in arranging for such services.
Criteria to determine medical necessity for certain services
Health plans and their delegated PPGs must use the latest criteria from nonprofit professional associations to determine medical necessity for select medical services related to BH conditions and SUDs. This information was described in provider update 24-765, Non-Profit Criteria for Select Medical Behavioral Health Conditions and Substance Use Disorders, distributed July 17, 2024.
Access the full regulation and view text for enrollee notice
View CCR title 28, section 1300.74.72.
If you have any questions, contact Provider Engagement.
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
Behavioral health providers can call 844-966-0298.
Line of business | Phone number | |
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO |
This information applies to Participating Physician Groups (PPGs) and Behavioral Health PPGs.