HB 2642 — Removing health coverage barriers to accessing substance use disorder treatment services.

ENGROSSEDH-3881.1HOUSE SUBSTITUTE HOUSE BILL 2642State of Washington66th Legislature2020 Regular SessionByHouseSessionByRepresentatives Health Care & Wellness (originally sponsored by Representatives Davis, Cody, Chopp, Harris, Leavitt, Caldier, Smith, Goodman, Orwall, Thai, Macri, Stonier, Schmick, Tharinger, Riccelli, Robinson, Griffey, Graham, Appleton, Callan, Irwin, Bergquist, Lekanoff, Barkis, Senn, Doglio, Walen, Peterson, Ormsby, and Pollet)READPolletRead FIRSTfirst TIMEtime 02/07/20.AN01/16/20.Referred to Committee on Health Care & Wellness.AN ACT Relating to removing health coverage barriers to accessing substance use disorder treatment services;

and creating a new sections.BEsection.BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:NEW SECTION.  Sec.

A new section is added to chapter 41.05 RCW to read as follows:(1) Except as provided in subsection (2) of this section, a health plan offered to employees and their covered dependents under this chapter issued or renewed on or after Januarythe 1,effective 2021,date of this section may not require an enrollee to obtain prior authorization for substance use disorder treatment services if:(a) The health care provider is licensed or certified under Title 18 RCW;(b) The treatment is within the health care provider's scope of practice;

and(c) The health care provider is employed by a residential treatment facility licensed by the department of health under RCW 71.24.037 to provide withdrawal management services or inpatient substance use disorder treatment services.(2)(a) A health plan offered to employees and their covered dependents under this chapter issued or renewed on or after Januarythe 1,effective 2021,date of this section must:(i) Provide coverage for no less than two business days, including an extension to allow for any intervening weekend days or holidays, in a state-licensed substance use disorder residential treatment facility prior to conducting a utilization review;

and(ii) Provide coverage for no less than threefive days inof state-licensed withdrawal management programsservices, priorincluding an extension to conductingallow for any intervening weekend days or holidays, in a utilizationstate-licensed review.(b)withdrawal management program.(b) The health plan may not require an enrollee to obtain prior authorization for withdrawal management services or residential substance use disorder treatment as a condition for payment of services, prior to the times specified in (a) of this subsection.

Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the program providing services requests continuing substance use disorder treatment services.(c)(i) The substancefacility useproviding disorderthe residentialservices treatmentshall facilityprovide or the withdrawalhealth managementplan programwith mustnotification provideof anadmission, enrollee'sinitial healthassessment, and the initial treatment plan withwithin noticetwo business days of admissionadmission, asincluding soonan asextension practicableto afterallow admittingfor any intervening weekend days or holidays.(ii) Upon receipt of the enrollee,materials butin not(c)(i) laterof thanthis twenty-foursubsection, hoursthe afterplan admittingmay initiate the enrollee.medical necessity review process.

TheIf timea notificationhealth doesplan notdetermines, reducewithin thetwenty-four requirementshours established in (a) of thisreceiving subsection.(ii)the Thematerials, facilitythat providing the servicesadmission shallto provide the healthfacility planwas withnot notificationmedically ofnecessary admission,or initialclinically assessment,appropriate, and the initialhealth treatment plan withinis twonot businessrequired daysto ofpay admission,the includingfacility an extension to allow for anythe interveningservices weekenddelivered daysafter orthe holidays.(iii)initial Uponadmission receiptperiods ofspecified the materials in (c)(ii)(a) of this subsection, thesubject planto may initiate the medicalconclusion necessityof reviewany processfiled basedappeals onof the Americanadverse societybenefit ofdetermination. addiction medicine criteria.

If athe health planplan's determines,medical withinnecessity onereview businessis daycompleted more than twenty-four hours after the receipt of receivingthe materials and the materials,review determines that the admission to the facility was not medically necessary or clinically appropriate, the health plan ismust not required to pay the facility for the services delivered afterfollowing the initialhealth admissionplan's periodsreceipt specifiedof the materials in (a)(c)(i) of this subsection,subsection subjectuntil tothe time at which the conclusionreview ofhas anybeen filedcompleted.(iii) appealsThe enrollee's use of stimulants may not be the adversesole benefitgrounds determination.for determining that an admission to a withdrawal management facility is not medically necessary or clinically appropriate.

IfThe theenrollee's healthdecision plan'sto medicalbegin necessitymedication reviewassisted istreatment completedfor moreopioid thanuse onedisorder businessmay daynot afterbe the receiptsole ofgrounds thefor materialsdetermining and the review determines that thean admission to thea withdrawal management facility wasis not medically necessary or clinically appropriate,appropriate.(3) the health plan must pay for the services delivered following the health plan's receipt of the materials in (c)(ii) of this subsection until the time at which the review has been completed.(3)(a) The treating provider shall documentdetermine to the health plan the patient's need for continuing care and justification of treatment placement after stabilization, based on the American society of addiction medicine criteria for determining medical necessity with documentation recorded in the patient's medical record.(b)record.(4) NothingWhen in this section prevents a healthpatient carrieris fromat denyingan coverageaddiction basedstabilization onfacility insuranceand fraud.(c) If the healthrecommended plan coversof out-of-networktreatment services,involves andplacement thein enrolleea isdifferent admittedfacility toor anat out-of-networka facilitylower orlevel programof locatedcare, inthe Washington,care coordination unit of the health plan mustshall paywork forwith athe coveredcurrent modeprovider ofto transfermake toarrangements anfor in-networka facilityseamless ortransfer programas withoutsoon requiringas paymentpossible orto costan sharingappropriate fromand theavailable enrollee.facility.

TransportThe must be provided by an in-network transportation provider.(d) A health plan isshall notcontinue required to cover transportationthe fromcost anof out-of-statecare treatmentat programthe orcurrent facility ifuntil the enrolleeseamless elects to transfer to an in-state, in-network treatment program or facility.(4) If the facility providing the services is notcomplete. in the enrollee's network:(a) The health plan is not responsible for reimbursing the facility at a greater rate than would be paid had the facility been in the enrollee's network;

and(b)If Theplacement facilitywith maya notprovider balancethat bill,offers asproper definedmedically innecessary RCWor 48.43.005.(5)clinically Whenappropriate acare patientin isthe athealth anplan's addictionnetwork stabilizationis facilitynot andavailable, the treatmenthealth plan approvedshall bycontinue to pay the healthaddiction planstabilization involvesfacility placementuntil insuch aan differentalternate facilityarrangement oris atmade.(5) aFor lowerthe levelpurposes of care,this thesection:(a) care"Addiction coordinationstabilization unitservices" ofmeans theintensive healthservices planprovided shallby worka withresidential thetreatment currentfacility providerlicensed to makeprovide arrangementswithdrawal formanagement aor seamlessinpatient transferaddiction astreatment soonand asinclude possibletwenty-four tohour anobservation appropriate and availablesupervision; facility.

The health plan shall continue to cover the cost of care at the current facility until the seamless transfer to the appropriate facility or level of treatment is complete.

A seamless transfer to an appropriate level of care may include same day or next day appointments for outpatient care, but does not include nontreatment services, such as housing services.

If placement with a provider that offers proper medically necessary or clinically appropriate care in the health plan's network is not available, the health plan shall continue to pay the addiction stabilization facility until such an alternate arrangement is made.(6) Nothing in this section applies to a facility providing services outside of Washington state.(7) For the purposes of this section:(a) "Addiction stabilization services" means intensive services provided by a residential treatment facility licensed to provide withdrawal management or inpatient addiction treatment and include twenty-four hour observation and supervision;

A new section is added to chapter 48.43 RCW to read as follows:(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or Januaryafter 1,the 2021,effective date of this section may not require an enrollee to obtain prior authorization for substance use disorder treatment services if:(a) The health care provider is licensed or certified under Title 18 RCW;(b) The treatment is within the health care provider's scope of practice;

and(c) The health care provider is employed by a residential treatment facility licensed by the department of health under RCW 71.24.037 to provide withdrawal management services or inpatient substance use disorder treatment services.(2)(a) A health plan issued or renewed on or after Januarythe 1,effective 2021,date of this section must:(i) Provide coverage for no less than two business days, including an extension to allow for any intervening weekend days or holidays, in a state-licensed substance use disorder residential treatment facility prior to conducting a utilization review;

and(ii) Provide coverage for no less than threefive days inof state-licensed withdrawal management programsservices, priorincluding an extension to conductingallow for any intervening weekend days or holidays, in a utilizationstate-licensed review.(b)withdrawal management program.(b) The health plan may not require an enrollee to obtain prior authorization for withdrawal management services or residential substance use disorder treatment as a condition for payment of services, prior to the times specified in (a) of this subsection.

Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the program providing services requests continuing substance use disorder treatment services.(c)(i) The substancefacility useproviding disorderthe residentialservices treatmentshall facilityprovide or the withdrawalhealth managementplan programwith mustnotification provideof anadmission, enrollee'sinitial healthassessment, and the initial treatment plan withwithin noticetwo business days of admissionadmission, asincluding soonan asextension practicableto afterallow admittingfor any intervening weekend days or holidays.(ii) Upon receipt of the enrollee,materials butin not(c)(i) laterof thanthis twenty-foursubsection, hoursthe afterplan admittingmay initiate the enrollee.medical necessity review process.

TheIf timea notificationhealth doesplan notdetermines, reducewithin thetwenty-four requirementshours established in (a) of thisreceiving subsection.(ii)the Thematerials, facilitythat providing the servicesadmission shallto provide the healthfacility planwas withnot notificationmedically ofnecessary admission,or initialclinically assessment,appropriate, and the initialhealth treatment plan withinis twonot businessrequired daysto ofpay admission,the includingfacility an extension to allow for anythe interveningservices weekenddelivered daysafter orthe holidays.(iii)initial Uponadmission receiptperiods ofspecified the materials in (c)(ii)(a) of this subsection, thesubject planto may initiate the medicalconclusion necessityof reviewany processfiled basedappeals onof the Americanadverse societybenefit ofdetermination. addiction medicine criteria.

If athe health planplan's determines,medical withinnecessity onereview businessis daycompleted more than twenty-four hours after the receipt of receivingthe materials and the materials,review determines that the admission to the facility was not medically necessary or clinically appropriate, the health plan ismust not required to pay the facility for the services delivered afterfollowing the initialhealth admissionplan's periodsreceipt specifiedof the materials in (a)(c)(i) of this subsection,subsection subjectuntil tothe time at which the conclusionreview ofhas anybeen filedcompleted.(iii) appealsThe enrollee's use of stimulants may not be the adversesole benefitgrounds determination.for determining that an admission to a withdrawal management facility is not medically necessary or clinically appropriate.

IfThe theenrollee's healthdecision plan'sto medicalbegin necessitymedication reviewassisted istreatment completedfor moreopioid thanuse onedisorder businessmay daynot afterbe the receiptsole ofgrounds thefor materialsdetermining and the review determines that thean admission to thea withdrawal management facility wasis not medically necessary or clinically appropriate,appropriate.(3) theThe healthtreating planprovider mustshall paydetermine for the servicespatient's deliveredneed followingfor thecontinuing healthcare plan'sand receiptjustification of thetreatment materialsplacement inafter (c)(ii)stabilization, based on American society of thisaddiction subsectionmedicine untilcriteria thefor timedetermining atmedical whichnecessity with documentation recorded in the reviewpatient's hasmedical beenrecord.(4) completed.(3)(a)When Thea treatingpatient provideris shallat documentan toaddiction stabilization facility and the healthrecommended plan theof patient'streatment needinvolves forplacement continuingin a different facility or at a lower level of care, the care andcoordination justificationunit of treatmentthe placementhealth afterplan stabilization,shall basedwork onwith Americanthe societycurrent ofprovider addictionto medicinemake criteriaarrangements for determininga medicalseamless necessitytransfer withas documentationsoon recordedas inpossible theto patient'san medicalappropriate record.and available facility.

(b)The Nothing in this section prevents a health carrierplan fromshall denyingcontinue coverageto basedcover on insurance fraud.(c) If the healthcost planof coverscare out-of-networkat services, and the enrolleecurrent is admitted to an out-of-network facility oruntil program located in Washington, the healthseamless plan must pay for a covered mode of transfer tois ancomplete. in-network facility or program without requiring payment or cost sharing from the enrollee.

TransportIf mustplacement bewith provideda byprovider anthat in-networkoffers transportationproper provider.(d)medically Anecessary healthor planclinically isappropriate notcare requiredin tothe coverhealth transportationplan's fromnetwork anis out-of-statenot treatmentavailable, programthe orhealth facilityplan ifshall thecontinue enrollee elects to transferpay tothe anaddiction in-state,stabilization in-networkfacility treatmentuntil programsuch oran facility.(4)alternate Ifarrangement theis facilitymade.(5) providingFor the servicespurposes isof notthis insection:(a) the"Addiction enrollee'sstabilization network:(a)services" Themeans healthintensive planservices isprovided notby responsiblea forresidential reimbursingtreatment the facility atlicensed ato greaterprovide ratewithdrawal thanmanagement wouldor beinpatient paidaddiction hadtreatment theand facilityinclude beentwenty-four inhour theobservation enrollee'sand network;supervision;

and(b) The facility may not balance bill, as defined in RCW 48.43.005.(5) When a patient is at an addiction stabilization facility and the treatment plan approved by the health plan involves placement in a different facility or at a lower level of care, the care coordination unit of the health plan shall work with the current provider to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility.

The health plan shall continue to cover the cost of care at the current facility until the seamless transfer to the appropriate facility or level of treatment is complete.

A seamless transfer to an appropriate level of care may include same day or next day appointments for outpatient care, but does not include nontreatment services, such as housing services.

If placement with a provider that offers proper medically necessary or clinically appropriate care in the health plan's network is not available, the health plan shall continue to pay the addiction stabilization facility until such an alternate arrangement is made.(6) Nothing in this section applies to a facility providing services outside of Washington state.(7) For the purposes of this section:(a) "Addiction stabilization services" means intensive services provided by a residential treatment facility licensed to provide withdrawal management or inpatient addiction treatment and include twenty-four hour observation and supervision;

and(ii) Provide coverage for no less than threefive days inof state-licensed withdrawal management programsservices, priorincluding an extension to conductingallow for any intervening weekend days or holidays, in a utilizationstate-licensed review.(b)withdrawal management program.(b) The managed care organization may not require an enrollee to obtain prior authorization for withdrawal management services or residential substance use disorder treatment as a condition for payment of services, prior to the times specified in (a) of this subsection.

Once the times specified in (a) of this subsection have passed, the managed care organization may initiate utilization management review procedures if the program providing services requests continuing substance use disorder treatment services.(c)(i) The substancefacility useproviding disorderthe residentialservices treatmentshall facilityprovide or the withdrawalmanaged managementcare programorganization mustwith providenotification anof enrollee'sadmission, managedinitial careassessment, organizationand withthe noticeinitial treatment plan within two business days of admissionadmission, asincluding soonan asextension practicableto afterallow admittingfor any intervening weekend days or holidays.(ii) Upon receipt of the enrollee,materials butin not(c)(i) laterof thanthis twenty-foursubsection, hoursthe aftermanaged admittingcare organization may initiate the enrollee.medical necessity review process.

TheIf timea notificationmanaged doescare notorganization reducedetermines, thewithin requirementstwenty-four establishedhours in (a) of thisreceiving subsection.(ii)the Thematerials, facilitythat providing the servicesadmission shallto provide the managedfacility carewas organizationnot withmedically notificationnecessary ofor admission,clinically initialappropriate, assessment, and the initialmanaged treatmentcare planorganization withinis twonot businessrequired daysto ofpay admission,the includingfacility an extension to allow for anythe interveningservices weekenddelivered daysafter orthe holidays.(iii)initial Uponadmission receiptperiods ofspecified the materials in (c)(ii)(a) of this subsection, thesubject managedto care organization may initiate the medicalconclusion necessityof reviewany processfiled basedappeals onof the Americanadverse societybenefit ofdetermination. addiction medicine criteria.

If athe managed care organizationorganization's determines,medical withinnecessity onereview businessis daycompleted more than twenty-four hours after the receipt of receivingthe materials and the materials,review determines that the admission to the facility was not medically necessary or clinically appropriate, the managed care organization ismust not required to pay the facility for the services delivered afterfollowing the initialmanaged admissioncare periodsorganization's specifiedreceipt of the materials in (a)(c)(i) of this subsection,subsection subjectuntil tothe time at which the conclusionreview ofhas anybeen filedcompleted.(iii) appealsThe enrollee's use of stimulants may not be the adversesole benefitgrounds determination.for determining that an admission to a withdrawal management facility is not medically necessary or clinically appropriate.

IfThe theenrollee's manageddecision careto organization'sbegin medicalmedication necessityassisted reviewtreatment isfor completedopioid moreuse thandisorder onemay businessnot daybe after the receiptsole ofgrounds thefor materialsdetermining and the review determines that thean admission to thea withdrawal management facility wasis not medically necessary or clinically appropriate,appropriate.(3) theThe managedtreating careprovider organizationshall mustdetermine paythe patient's need for thecontinuing servicescare deliveredand followingjustification theof managedtreatment careplacement organization'safter receiptstabilization, based on American society of theaddiction materialsmedicine incriteria (c)(ii)for ofdetermining thismedical subsectionnecessity untilwith documentation recorded in the timepatient's medical record.(4) When a patient is at whichan theaddiction reviewstabilization hasfacility beenand completed.(3)(a)the Therecommended treatingplan providerof shalltreatment documentinvolves toplacement thein manageda caredifferent organizationfacility theor patient'sat needa forlower continuinglevel of care, the care andcoordination justificationunit of treatmentthe placementmanaged aftercare stabilization,organization basedmust onwork Americanwith societythe ofcurrent addictionprovider medicineto criteriamake arrangements for determininga medicalseamless necessitytransfer withas documentationsoon recordedas inpossible theto patient'san medicalappropriate record.and available facility.

(b)The If the health plan covers out-of-network services, and the enrollee is admitted to an out-of-network facility or program located in Washington, the managed care organization must paycontinue forto acover coveredthe modecost of transfercare toat anthe in-networkcurrent facility oruntil programthe withoutseamless requiringtransfer paymentis orcomplete. cost sharing from the enrollee.

TransportIf mustplacement bewith provideda byprovider anthat in-networkoffers transportationproper provider.(c)medically Anecessary managedor careclinically organizationappropriate iscare notin requiredthe tomanaged covercare transportationorganization's fromnetwork anis out-of-statenot treatmentavailable, programthe ormanaged facilitycare iforganization themust enrolleecontinue elects to transferpay tothe anaddiction in-state,stabilization in-networkfacility treatmentuntil programsuch oran facility.(4)alternate Ifarrangement theis facilitymade.(5) providingFor the servicespurposes isof notthis insection:(a) the"Addiction enrollee'sstabilization network:(a)services" Themeans healthintensive planservices isprovided notby responsiblea forresidential reimbursingtreatment the facility atlicensed ato greaterprovide ratewithdrawal thanmanagement wouldor beinpatient paidaddiction hadtreatment theand facilityinclude beentwenty-four inhour theobservation enrollee'sand network;supervision;

and(b) The facility may not balance bill, as defined in RCW 48.43.005.(5) When a patient is at an addiction stabilization facility and the treatment plan approved by the managed care organization involves placement in a different facility or at a lower level of care, the care coordination unit of the managed care organization must work with the current provider to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility.

The managed care organization must continue to cover the cost of care at the current facility until the seamless transfer to the appropriate facility or level of treatment is complete.

A seamless transfer to an appropriate level of care may include same day or next day appointments for outpatient care, but does not include nontreatment services, such as housing services.

If placement with a provider that offers proper medically necessary or clinically appropriate care in the managed care organization's network is not available, the managed care organization must continue to pay the addiction stabilization facility until such an alternate arrangement is made.(6) Nothing in this section applies to a facility providing services outside of Washington state.(7) For the purposes of this section:(a) "Addiction stabilization services" means intensive services provided by a residential treatment facility licensed to provide withdrawal management or inpatient addiction treatment and include twenty-four hour observation and supervision;

intensive inpatient and long-term residential treatment.(c) "Withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from drugs, which may include induction on medications for addiction recovery.NEWrecovery.--- SECTION.  Sec.END ---

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