Bill > AB980

This bill requires health care service plans and health insurance policies issued, amended, or renewed on or after January 1, 2026, to provide comprehensive coverage for medically necessary treatment of physical conditions and diseases under the same terms and conditions as other medical conditions. The bill defines "medically necessary treatment" as a service that addresses a patient's specific needs, follows generally accepted standards of care, is clinically appropriate, and is not primarily for economic benefit or convenience. It mandates that if necessary services are not available within network, plans must arrange out-of-network coverage at in-network cost-sharing rates. The bill also establishes detailed requirements for utilization review, including using current professional association treatment criteria, conducting interrater reliability testing, and ensuring at least a 90% pass rate in medical necessity decision-making. Health care plans and insurers must base medical necessity determinations on current healthcare standards and cannot limit benefits based on potential coverage by public entitlement programs. The bill allows administrative penalties for violations and applies to most health insurance policies, with exceptions for specific types of policies like dental-only or vision-only plans. Additionally, the bill clarifies the duty of care for health care service plans and managed care entities in arranging medically necessary healthcare services.

Health and Social Services

https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202520260AB980