Kaiser, Don't Deny

As a mental health patient, you have certain rights under the law. These rights include: 

1. Right to timely access to care

In California, HMOs like Kaiser Permanente are required to offer you an initial non-urgent mental health appointment within 10 business days of when you request one and, starting July 1, 2022, a follow-up mental health appointment within 10 business days unless the treating therapist determines that a longer wait will not have a detrimental impact on your health.

Timely Access Regulations – California Code of Regulations 1300.67.2.2(c)(5)

Provider	Appointment Type	Elapsed Time Standard
Non-MD Mental Health Provider	Routine	10 business days
MD Mental Health Provider	Routine	15 business days
Non-MD Mental Health Provider	Urgent	2 days
Non-MD Mental Health Provider	Follow-up * * Section 1300.67.2.2(c)(1)	10 business days unless the treating therapist determines that a longer wait will not be detrimental to your health

2. Right to mental health parity

Under both California and federal law, health plans are required to provide equal coverage for mental health treatment and physical illness/injury. For example, if your health plan policy covers hospitalization of unlimited duration for a physical condition, then your policy cannot limit treatment in an inpatient mental health facility to a specific number of days. Similarly, you cannot be charged a higher copay for an outpatient office visit with a mental health professional than for an office visit with a primary care provider.

In California, state law requires commercial health insurers (outside of Medi-Cal) to cover all medically necessary mental health and substance abuse addiction treatment including outpatient services, inpatient hospital services, partial hospital services, residential treatment, partial hospitalization, and intensive outpatient treatment. There are no annual visit limits or limits on the duration of time you can be in ongoing therapy as long as it’s determined to be medically necessary.

Additionally, California law requires health plans to ensure that patients who are referred out to an external provider network receive timely and nearby access to the same medically necessary treatment without any additional cost.

From dmhc.ca.gov (PDF version):

Mental Health and Substance Use Disorder Care

A new law that took effect on January 1, 2021 strengthens California’s mental health parity statute with the goal of improving access to quality mental health and substance use disorder services. SB 855 (Wiener, 2020) requires all commercial health plans to cover ALL mental health and substance use conditions at the same cost as physical health conditions.

Health plans must cover the full spectrum of all medically necessary treatment in all settings. This includes the following settings, when medically necessary:

• Sessions with a therapist
• Medication to manage your condition
• Out-patient Intensive Treatment
• In-patient Residential treatment

The law also mandates that if an enrollee cannot find an appropriate mental health provider in their health plan network, the health plan must arrange and pay for out-of-network services at no additional cost to the enrollee.

The law includes other financial protections as well. Health plans cannot charge more for mental health and substance use disorder services than for physical health conditions. This includes enrollee cost-sharing obligations for:

• co-pays
• deductibles
• maximum annual and lifetime benefits
• other out-of-pocket expenses

Health plan enrollees having trouble accessing behavioral health care treatment or services, should first contact their health plan at the member services phone number on their health plan member card. Their health plan will review the grievance and should ensure the enrollee is able to timely access medically necessary care. If the enrollee does not agree with their health plan’s response, they should contact the DMHC Help Center at www.HealthHelp.ca.gov or by calling 1-888-466-2219. The enrollee should contact the DMHC immediately if they are facing an urgent issue.

3. Right to clinically appropriate care

Under California law, HMOs are required to deliver care in a timely manner that meets the clinical needs of their enrollees and is consistent with good professional practice. This is known as the “clinical appropriateness standard.” The California Code of Regulations (28 CCR § 1300.67.2.2) states: “Plans shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. Plans shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard.”

California’s largest HMO, Kaiser Permanente, has been cited by the state of California for violating this standard by failing to provide patients with frequent enough treatment appointments in mental health.

4. Right to Receive Care in the Emergency Room

Federal law, through the Emergency Medical Treatment and Active Labor Act, requires anyone coming into an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.

5. Right to file a complaint with your health plan

Under California law, health plans are required to maintain an internal “grievance” process in order to handle patient complaints. Through this process, you can voice your concerns about quality of care, financial issues, and decisions by your health plan to delay or deny appointments, referrals, or other types of care. (See our separate page on “Filing Complaints”).

6. Right to file an external complaint with a state or federal oversight agency

If filing an internal grievance with your health plan does not resolve your concern, you have the right to file a consumer complaint or request an Independent Medical Review. (See our separate page on “Filing Complaints”).