Minimum Health Benefits Under California Law

Minimum Health Benefits Under California Law

Laws in California require health insurance providers to provide minimum policy benefits. Under the Patient Protection and Affordable Care Act (commonly referred to as “Obamacare”), these basic minimum benefits are referred to as “essential health benefits.” These benefits are as follows: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Your Evidence of Coverage Section In Your Insurance Policy Contains Benefit Information

If you have a health plan through your employment with a public entity, such as teachers, police officers and fireman, then the best place to look for your benefits is in your Evidence of Coverage. Also, if you are looking to understand your Medicare benefits than the best resource is Medicare.gov, to understand your Veterans Affairs’ benefits than the best place to look is VA.gov, and to understand Medi-cal then the best place it look is http://www.dhcs.ca.gov/services/medi-cal/Pages/MediBen_Svcs.aspx.

California Law Often Adds To Your Entitled Benefits

There are many benefits to which you can be entitled under your health plan policy pursuant to California law but which the policy does not explicitly describe. Health insurance companies and managed health plan providers will often deny coverage for such benefits and merely hope that the subscriber or insured is too ignorant to know their rights. This most commonly happens when a consumer seeks mental health treatment coverage.

In 1999, the California legislature passed a law most commonly referred to as the Mental Health Parity Act. The act requires health care plans and health insurance companies to provide coverage for the diagnosis and treatment of people with severe mental illness under the same terms that they apply to other medical conditions. Such severe mental illnesses include: Schizophrenia; Schizoaffective disorder; Bipolar disorder (manic-depressive illness); Major depressive disorders; Panic disorder; Obsessive-compulsive disorder; Pervasive developmental disorder or autism; Anorexia nervosa; Bulimia nervosa.

This law requires insurance companies and health plan providers to provide treatment for persons with severe mental illness, regardless of whether or not that person’s policy explicitly states that the policy provides such coverage. Despite this law, many health plan providers and insurance companies have patterns and practices of informing members and insureds that certain treatments are not covered because those treatments are not explicitly mentioned in the evidence of coverage.

For example, our offices represented some parents of children with autism spectrum disorder who sought medically necessary behavioral therapy from a large managed health care provider. We learned during the course of these lawsuits that the health care provider had explicitly taught their benefits representatives to tell inquiring members that the important treatment was not covered by the members’ policies. However, under the Mental Health Parity Act coverage for the treatment was a necessity. It is for this reason that it is important to know your rights and to not accept any coverage determination that a managed health plan manager or health insurance companies makes just on its face.