SB 231 — Relating to value-based payment requirements

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  AdoptedRejectedin effect 90 days from passage (June 12, 2026)] Enr CS for CS for SB 231 AN ACT to amend the Code of West Virginia, 1931, as amended, by adding a new article, designated §9-11-1, §9-11-2, §9-11-3, §9-11-4, §9-11-5, and §9-11-6, relating to value- based payment requirements;

providing legislative intent;

defining terms;

establishing value-based measures;

creating timelines for implementation;

setting out authority;

and making provision inoperable without approval.

Be it enacted by the Legislature of West Virginia:

ARTICLE 11.

ADDICTION CARE RECOVERY OUTCOMES.

§9-11-1.

Legislative findings and purpose.

The Legislature finds that West Virginia continues to be severely impacted by substance use disorder and overdose deaths.

While the state has made substantial investments in treatment, recovery, and prevention, the current addiction care system is fragmented and not aligned to measurable long-term recovery outcomes.

The purpose of this article is to reorganize the state’s addiction care system into a value-based continuum of care and incentivize coordination, integration, and accountability for recovery success.

§9-11-2.

Definitions.

As used in this article:

“Baseline year” means the designated time period during which performance data, including, but not limited to, cost, quality, utilization, and outcome-based performance measures is collected to establish benchmarks.

"Continuum of care" means a coordinated system of services that includes prevention, early intervention, treatment (including withdrawal management and medication-assisted treatment), recovery support, supportive housing, vocational and educational support, and peer services.

The continuum shall address the needs of individuals at all stages of substance use disorder and recovery.

"Value-based payment" means a payment model that incentivizes providers for quality and cost-effective care and reduces payments to providers who fail to meet specified metrics, Enr CS for CS for SB 231 shifting from paying for volume (fee-for-service) to paying for patient health outcomes and experiences.

This payment model shall include performance-based payments tied to specific outcomes identified in this article.

§9-11-3.

Establishment of value-based measures.

(a) On or before October 1, 2026, the Bureau for Medical Services, in conjunction with their managed care organizations, shall establish standard billing codes for all substance use disorder services to be used by providers in the continuum of care on or before January 15, 2027.

(b) The Bureau for Medical Services shall collect data from all providers in the continuum of care regarding billing codes and other measures to be collected by providers as set forth in this article for analysis purposes to determine utilization trends, costs, and outcomes by provider.

(c) The Bureau for Medical Services shall analyze the data for utilization and costs trends.

After the outcome measures are determined as set forth in this article, the Bureau for Medical Services shall collect and analyze the measures to improve quality in the Medicaid program and determine how to establish value-based payments to incentivize quality substance use disorder outcomes.

Any trends indicating overutilization or overbilling shall be referred to the Medicaid Fraud Control Unit.

(d) The Bureau for Medical Services shall submit a report to the Legislative Oversight Commission on Health and Human Resources Accountability on before January 1, 2028, and annually thereafter, regarding substance use disorder utilization trends and costs by provider and provider type.

All providers shall be given an anonymized synthetic identifier in the report to allow trends to be followed in multiple years.

Once the outcome measures are developed, this report shall further include outcomes by provider and provider type.

The outcome portion of this report shall first be included on July 1, 2028, and be reported annually thereafter.

All reports shall contain a comparison of state utilization, cost, and outcomes to the previous fiscal year’s data to also include, but not be limited to, the rate for neonatal abstinence syndrome and statewide adult Enr CS for CS for SB 231 deaths.

This analysis shall also include a comparison of utilization, cost, outcomes, the rate of neonatal abstinence, and adult death rates to a national rate.

(e) On or before July 1, 2026, the Bureau for Medical Services, in consultation with the Bureau for Behavioral Health, relevant state agencies, Marshall University, Joan C.

Edwards School of Medicine, West Virginia University School of Medicine Behavioral Health Faculty, individuals in recovery, providers, law enforcement, and other relevant stakeholders, shall develop a set of outcome-based performance measures for each level of care within the addiction treatment and recovery services care continuum.

§9-11-4.