25-834 Behavioral Health Cost Share Requirements Are Changing
Date: 08/15/25
Certain services will shift from medical to behavioral health cost shares based on primary diagnosis—aligning with new federal parity rules.
Effective January 1, 2026, capitated/delegated participating physician groups (PPGs) and capitated/delegated hospitals must ensure claims payments for applicable services comply with the Mental Health Parity and Addiction Equity Act (MHPAEA) and the final rule issued on September 9, 2024.
Affects 2026 claims for members with Commercial plans
For 2026, the requirements described below only affect benefit and cost share determinations as part of claims payment for Health Net members who have Health Net Commercial employer group and individual plans. Current Division of Financial Responsibility (DOFR) categories are not impacted by this benefit and cost share update. Risk determination logic will remain unchanged.
This information does not impact Medicare or Medi-Cal plans.
Benefit and cost share for behavioral health services
Behavioral/mental health benefits will incorporate the primary diagnosis and procedure code as a primary driver for benefit categorization and cost share application.
These changes will result in additional services applying a behavioral/mental health cost share, where previously they would have applied a medical cost share.
Examples include, but are not limited to, the following:
- Example 1: A primary care physician who bills for an office visit with a primary behavioral health diagnosis code will apply a Mental Health Office Visit cost share.
- Example 2: Outpatient habilitative therapy session billed with a primary behavioral health diagnosis will apply the Mental Health Outpatient-Other cost share.
- Example 3: Inpatient facility services are driven by the bed type (revenue code) billed on the claim. A mental health bed-type revenue code will apply the Mental Health Inpatient benefit and cost share.
- Example 4: Gender affirming surgery performed in an inpatient setting and billed with a primary mental health diagnosis (i.e., gender dysphoria) will apply the Mental Health Inpatient benefit and cost share instead of the medical surgery benefit and cost share.
- Example 5: Diagnostic radiology services billed with a primary behavioral health diagnosis will apply the Mental Health Outpatient-Other benefit and cost share, instead of the medical radiology benefit cost share.
- Example 6: Physical, occupational and/or speech therapy billed with a primary behavioral health diagnosis (e.g., autism) will apply the Mental Health Outpatient-Other benefit and cost share, instead of the medical PT/OT/ST cost share.
View the final rule online
Access the final rule (PDF).
Additional information
Relevant sections of Health Net’s provider operations manuals will be revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
Provider Services
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 Hospitals.
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