CommercialReimbursementHigh impact
25-834 Behavioral Health Cost Share Requirements Are Changing
Health Net·CA · Family Medicine, Internal Medicine, Pediatrics +5 more·Reimbursement
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Starting January 1, 2026, Health Net Commercial plans will determine behavioral health benefits and cost shares based on primary diagnosis codes rather than procedure codes alone. This means services like office visits, therapy, radiology, and even surgery will apply behavioral health cost shares when billed with a primary behavioral health diagnosis, affecting how claims are processed and what patients pay.
Action Required
Before January 1, 2026: Billing team must update staff training on how primary diagnosis codes will drive cost share determination for Health Net Commercial members. Educate providers that services billed with primary behavioral health diagnoses will apply behavioral health benefits instead of medical benefits. Update billing workflows to verify correct primary diagnosis coding as it will directly impact patient cost shares. Review and update encounter forms to ensure proper diagnosis code sequencing for behavioral health services.