CurrentPremera BluecrossPolicy N/A

ENGROSSED SUBSTITUTE HOUSE BILL 2642

State of Washington legislation (Engrossed Substitute House Bill 2642) establishing requirements for health plans, employer plans, managed care organizations and Medicaid MCOs effective Jan 1, 2021 to limit prior authorization and utilization management for withdrawal management and inpatient/residential substance use disorder (SUD) treatment in licensed behavioral health agencies, require notification and timelines, require payment during transfer arrangements, and direct development of a standard medical necessity criteria and action plan.

Policy Summary

PayerPremera Bluecross

PolicyENGROSSED SUBSTITUTE HOUSE BILL 2642

Policy CodePolicy N/A

Change TypeAdded statutory protections and timing requirements

Effective DateJan 1, 2021

Next Review Date

Key ActionBehavioral health agencies must notify the enrollee's health plan/MCO within 24 hours of admission and provide an initial assessment and treatment plan within two business days (three days for withdrawal management).

SourceLink

POLICY UPDATE CHANGES

Prohibition on requiring prior authorization for withdrawal management and inpatient/residential SUD treatment in licensed behavioral health agencies for plans issued or renewed on/after Jan 1, 2021.

Notification and documentation timeframes for behavioral health agencies (notify within 24 hours; submit assessment/treatment plan within 2 business days or 3 days for withdrawal management).

Requirement that plans/MCOs pay current facility until seamless transfer is complete and prohibition on balance billing.

Mandate for Health Care Authority to develop an action plan and adopt a single standard set of medical necessity criteria and levels of care by Jan 1, 2021.

2Minimum business days covered (inpatient/residential)

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3Minimum days covered (withdrawal management)

24hMax notification time

2021-01-01Effective date for coverage changes

Policy summary and scope

ESHB 2642 (Washington State) prohibits requiring prior authorization for withdrawal management services and inpatient or residential substance use disorder (SUD) treatment provided in behavioral health agencies licensed or certified under RCW 71.24.037 for plans/MCOs and employer/commercial/Medicaid MCOs issued or renewed on or after January 1, 2021. The law requires health plans, managed care organizations, and Medicaid MCOs to provide minimum coverage periods before initiating utilization review: no less than two business days for inpatient/residential SUD treatment and no less than three days for withdrawal management services. Behavioral health agencies must notify the enrollee's plan as soon as practicable but no later than 24 hours after admission and provide an initial assessment and treatment plan within two business days (or three days for withdrawal management). After the minimum coverage period and receipt of materials, plans/MCOs may initiate a medical necessity review using the single standard set of criteria to be developed; if the review is not completed within one business day of its start and receipt of materials, the plan/MCO must pay for services from admission until the review is completed. The act also requires plans/MCOs to pay the current facility until a seamless transfer is arranged when network placement is unavailable and prohibits balance billing as defined in RCW 48.43.005. The Health Care Authority and Office of the Insurance Commissioner are directed to develop an action plan and adopt a single standard set of medical necessity criteria and levels of care by January 1, 2021.

Minimum inpatient/residential coverage period>= 2 business days (excluding weekends and holidays)

Minimum withdrawal management coverage period>= 3 days

Notification timeframeNotify plan as soon as practicable, but not later than 24 hours after admission

Initial assessment/treatment plan timeframeProvide initial assessment and treatment plan within 2 business days of admission (3 days for withdrawal management)

Medical necessity review decision targetPlan must decide within 1 business day from start of review and receipt of materials to avoid retro nonpayment; if review completes >1 business day, plan must pay from admission until decision

Applicability: ESHB 2642 applies to health plans, plans offered to employees, managed care organizations, and Medicaid managed care organizations in the State of Washington for services delivered in behavioral health agencies licensed or certified under RCW 71.24.037; the requirements explicitly do not apply to treatment provided in out-of-state facilities (see RCW references).

Coverage rules and medical necessity / timing criteria

Prohibition on prior authorization and required coverage timing

Except as provided, health plans and managed care organizations may not require prior authorization for specified services; plans must provide minimum coverage prior to utilization review:

Health plan/managed care organization may not require prior authorization for withdrawal management services or inpatient or residential SUD treatment services in a behavioral health agency licensed or certified under RCW 71.24.037.

Applies to plans issued or renewed on or after January 1, 2021 (for employer plans and commercial plans) and managed care organizations beginning January 1, 2021.

Provide coverage for minimum periods prior to utilization review

Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential SUD treatment prior to conducting a utilization review.>= 2 business days (excluding weekends/holidays)

Referenced statutes and citations

Referenced statutory citationsmixed

RCW 71.24.037	Behavioral health agency licensing/certification referenced for applicability
RCW 48.43.005	Definition of balance billing referenced

Statutory citations are referenced throughout the policy to establish applicability to behavioral health agencies licensed or certified under RCW 71.24.037 and to reference the definition and prohibition on balance billing in RCW 48.43.005.

Immediate actions, documentation & billing implications for behavioral health agencies

Documentation Required

Notify plan within 24 hours of admission

Behavioral health agency must notify the enrollee's health plan or MCO as soon as practicable and no later than 24 hours after admitting the enrollee.

Documentation Required

Provide initial assessment and treatment plan

Provide the health plan/MCO with the agency's initial assessment and initial treatment plan within two business days of admission (excluding weekends/holidays), or within three days for agencies providing withdrawal management services.

Prior Authorization

No prior authorization required before minimum coverage period

Plans and MCOs may not require prior authorization as a condition of payment for services provided during the minimum coverage periods — at least two business days for inpatient/residential SUD treatment and at least three days for withdrawal management — after which utilization review may begin.

Key definitions

Definition — Withdrawal management services: For purposes of this act, "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.

Background: The legislature enacted ESHB 2642 to remove utilization management barriers and improve rapid access to SUD treatment, strengthen transitions between levels of care, and create a mandated action plan and a single standard set of medical necessity criteria and levels of care to be adopted by January 1, 2021.

Material changes and timeline

2021-01-01added - minimum coverage periods

Specifies minimum coverage periods before utilization review (2 business days inpatient/residential; 3 days withdrawal management).

2021-01-01added - prior authorization prohibition

Prohibition on requiring prior authorization for withdrawal management and inpatient/residential SUD treatment in licensed behavioral health agencies for plans issued or renewed on or after Jan 1, 2021.

2021-01-01added - notification and documentation timeframes

Policy Summary

PayerPremera Bluecross

PolicyENGROSSED SUBSTITUTE HOUSE BILL 2642

Policy CodePolicy N/A

Change TypeAdded statutory protections and timing requirements

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.

The health plan may not require prior authorization as a condition for payment of services provided prior to the times specified above; once those time periods pass, the plan may initiate utilization management review procedures.

Utilization review may be initiated after the minimum coverage period if services continue or transfer is pending.

Notification and documentation requirements by behavioral health agency

Behavioral health agency must notify and provide assessments/plan within set timeframes:

Behavioral health agency must notify the enrollee's health plan/managed care organization as soon as practicable after admission, but not later than 24 hours after admitting the enrollee.<= 24 hours after admission

The time of notification does not reduce minimum coverage periods.

Behavioral health agency must provide the health plan/MCO with its initial assessment and initial treatment plan within two business days of admission, excluding weekends and holidays, or within three days for agencies providing withdrawal management services.<= 2 business days (3 days for withdrawal management)

Medical necessity review timing and payment obligation: After the minimum time period and receipt of the initial assessment/treatment plan, the plan/MCO may initiate a medical necessity review based on the standard criteria; if the plan determines within one business day from the start of the review and receipt of materials that the admission was not medically necessary and advises the agency in writing, the plan is not required to pay for services delivered after the start of the review (subject to appeal).<= 1 business day decision target to avoid retro nonpayment

If the medical necessity review completes more than one business day after the review start and receipt of materials, the plan must pay for services from admission until the review is completed and the agency is advised in writing.

Behavioral health agency shall document to the plan/MCO the patient's need for continuing care and justification for level of care placement following the current treatment period using the standard criteria, with documentation recorded in the medical record.

Transfers and payment during seamless transfer

When approved treatment plan involves transfer or lower level of care:

Care coordination unit of the plan/MCO shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care.

The plan/MCO shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete.

Seamless transfer may include same or next appointments for outpatient care and does not include payment for non-treatment services such as housing. If placement within network unavailable, plan/MCO shall pay current agency until seamless transfer arranged.

Network/out-of-network billing and balance billing

Payment rate and balance billing restrictions for out-of-network agencies:

If the behavioral health agency is not in the enrollee's network, the health plan/MCO is not responsible for reimbursing the agency at a greater rate than would be paid had the agency been in-network.

The behavioral health agency may not balance bill, as defined in RCW 48.43.005.

Reference: RCW 48.43.005 defines balance billing.

Scope, exceptions and definitions

Applicability and definition of withdrawal management services:

The requirements do not apply to treatment provided in out-of-state facilities.

Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.

Definition: Withdrawal management services: 'Withdrawal management services' means 24-hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.

Action plan and standard criteria development

Health Care Authority obligations and standard criteria development:

Health Care Authority shall develop an action plan to support admission to and improved transitions between levels of care for adults and adolescents.

Action plan to be developed in partnership with the Office of the Insurance Commissioner, Medicaid MCOs, commercial health plans, SUD providers, and Indian health care agencies.

Action plan content elements: Action plan must include identification of barriers to transfers and specific actions to remove barriers; facilitate transfers from hospitals and jails; address denial based on drug of choice; explore reimbursement options to allow continued stay until seamless transfer (including administrative rates/equivalent mechanisms); and establish minimum medical information required for utilization reviews in withdrawal management settings.

Includes exploring options to allow higher acuity withdrawal management facilities to bill for appropriate lower levels of care while maintaining financial stability.

Health Care Authority and Office of the Insurance Commissioner must independently review regulations and practices and adopt a single standard set of criteria to define medical necessity for SUD treatment and levels of care by January 1, 2021; Health Care Authority may promulgate rules if necessary.Effective date: 2021-01-01

Billing Rule

Payment during transfer arrangements

When an approved plan calls for transfer to a different facility or lower level of care, the plan/MCO must pay the current agency for the cost of care until a seamless transfer is complete, and behavioral health agencies may not balance bill patients.

Non-treatment services (for example, housing) are excluded from transfer payment.

Denial Risk

Medical necessity review and potential nonpayment

After submission of initial materials and once the minimum period elapses, the plan/MCO may initiate a medical necessity review; the plan can avoid paying for services delivered after the start of the review only if it determines the admission was not medically necessary and provides written notice within one business day of the start of the review (subject to appeal).

Sets medical necessity review timelines and payment obligations if review extends beyond one business day.

2021-01-01added - payment during transfer

Clarifies payment when network placement unavailable and excludes non-treatment services from transfer payment.

2021-01-01added - action plan and standard criteria

Mandate for Health Care Authority to develop an action plan and adopt a single standard set of medical necessity criteria and levels of care by Jan 1, 2021.

Policy effective date: 2021-01-01. Status: CURRENT.