HB 1432 — Improving access to appropriate mental health and substance use disorder services.

Quantitative treatment limitations and nonquantitative treatment p.

7 SHB 1432 limitations, including any referral and prescription requirements, for mental health or substance use disorder care shall comply with the requirements of the mental health parity and addiction equity act, state law, and any implementing regulations.

(b)p. "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW.

8 HB 1432 (b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW.

RCW 48.43.41048.43.091 and 20191999 c 17187 s 21 are each amended to read as follows:

For(1) Every health planscarrier delivered,that issuedprovides coverage for delivery,any or((outpatient)) renewedmental onhealth or((service)) afterservices, Januaryas 1,defined 2021,in clinicalsection review2 criteriaof usedthis toact, establishshall acomply p.with the following requirements:

8(((1))) SHB(a) 1432In prescriptionperforming druga utilization managementreview protocolof mustmental behealth evidence-services basedfor anda updatedspecific onenrollee, athe regularutilization basisreview throughis reviewlimited ofto newaccessing evidence,only research,the andspecific newlyhealth developedcare treatments.information contained in the enrollee's record.

For(((2))) prescription(b) drugsIn prescribedperforming toan treataudit of a provider that has furnished mental health orservices substanceto usea disordercarrier's conditions,enrollees, clinicalthe reviewaudit criteriais mustlimited meetto accessing only the requirementsrecords of sectionenrollees 2covered ofby thisthe act.specific health carrier for which the audit is being performed, except as otherwise permitted by RCW 70.02.050 ((and 71.05.630)).

(c) A health carrier shall approve coverage of mental health services that are the subject of a prescription drug exception request, an enrollee grievance, or appeal, or a prior authorization request if the health carrier does not respond to the request, grievance, or appeal within the time frames applicable under RCW 48.43.420, 48.43.530, or 48.43.830.

(2) A health carrier may not request a refund of amounts paid to a provider from that provider for mental health services more than 180 days after the date of payment, except in cases of fraud.

RCW 48.43.410 and 2019 c 171 s 2 are each amended to read as follows:

For health plans delivered, issued for delivery, or renewed on or after January 1, 2021, clinical review criteria used to establish a prescription drug utilization management protocol must be evidence- based and updated on a regular basis through review of new evidence, research, and newly developed treatments.

For prescription drugs prescribed to treat mental health or substance use disorder conditions, clinical review criteria must meet the requirements of section 2 of this act.

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9 HB 1432 Sec.

6.

(1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review and clinical review criteria based on reasonable medical evidence.

For mental health services, as defined in section 2 of this act, clinical review criteria must meet the requirements of section 2 of this act.

Carriers shall make clinical protocols, medical management standards, clinical review criteria as defined in section 2 of this act, and other review criteria available upon request to participating providers.

For mental health services, as defined in section 2 of this act, clinical review criteria must meet the requirements of section 2 of this act.

6.

RCW 48.43.530 and 2019 c 56 s 6 are each amended to read as follows:

(1) Each carrier and health plan must have fully operational, comprehensive grievance and appeal processes, and for plans that are not grandfathered, fully operational, comprehensive, and effective grievance and review of adverse benefit determination processes that comply with the requirements of this section and any rules adopted by the commissioner to implement this section.

For the purposes of this section, the commissioner must consider applicable grievance and appeal or review of adverse benefit determination process standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services, and for health plans that are not grandfathered health plans as approved by p.

9 SHB 1432 the United States department of health and human services or the United States department of labor.

In the case of coverage offered in connection with a group health plan, if either the carrier or the health plan complies with the requirements of this section and RCW 48.43.535, then the obligation to comply is satisfied for both the carrier and the plan with respect to the health insurance coverage.

(2) Each carrier and health plan must process as a grievance an enrollee's expression of dissatisfaction about customer service or the quality or availability of a health service.

Each carrier must implement procedures for registering and responding to oral and written grievances in a timely and thorough manner.

(3) Each carrier and health plan must provide written notice to an enrollee or the enrollee's designated representative, and the enrollee's provider, of its decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits, including the admission to or continued stay in a health care facility.

Such notice must be sent directly to a protected individual receiving care when accessing sensitive health care services or when a protected individual has requested confidential communication pursuant to RCW 48.43.505(5).

(4) An enrollee's written or oral request that a carrier reconsider its decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits, including the admission to, or continued stay in, a health care facility must be processed as follows:

(a) When the request is made under a grandfathered health plan, the plan and the carrier must process it as an appeal;

(b) When the request is made under a health plan that is not grandfathered, the plan and the carrier must process it as a review of an adverse benefit determination;

and (c) Neither a carrier nor a health plan, whether grandfathered or not, may require that an enrollee file a complaint or grievance prior to seeking appeal of a decision or review of an adverse benefit determination under this subsection.

(5) To process an appeal, each plan that is not grandfathered and each carrier offering that plan must:

(a) Provide written notice to the enrollee when the appeal is received;

(b) Assist the enrollee with the appeal process;

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10 SHB 1432 (c) Make its decision regarding the appeal within thirty days of the date the appeal is received.

An appeal must be expedited if the enrollee's provider or the carrier's medical director reasonably determines that following the appeal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

The decision regarding an expedited appeal must be made within seventy-two hours of the date the appeal is received;

(d) Cooperate with a representative authorized in writing by the enrollee;

(e) Consider information submitted by the enrollee;

(f) Investigate and resolve the appeal;

and (g) Provide written notice of its resolution of the appeal to the enrollee and, with the permission of the enrollee, to the enrollee's providers.

The written notice must explain the carrier's and health plan's decision and the supporting coverage or clinical reasons and the enrollee's right to request independent review of the carrier's decision under RCW 48.43.535.

(6) Written notice required by subsection (3) of this section must explain:

(a) The carrier's and health plan's decision and the supporting coverage or clinical reasons;

and (b) The carrier's and grandfathered plan's appeal or for plans that are not grandfathered, adverse benefit determination review process, including information, as appropriate, about how to exercise the enrollee's rights to obtain a second opinion, and how to continue receiving services as provided in this section.

(7) When an enrollee requests that the carrier or health plan reconsider its decision to modify, reduce, or terminate an otherwise covered health service that an enrollee is receiving through the health plan and the carrier's or health plan's decision is based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the carrier and health plan must continue to provide that health service until the appeal, or for health plans that are not grandfathered, the review of an adverse benefit determination, is resolved.

If the resolution of the appeal, review of an adverse benefit determination, or any review sought by the enrollee under RCW 48.43.535 affirms the carrier's or health plan's decision, the enrollee may be responsible for the cost of this continued health service.

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11 SHB 1432 (8) Each carrier and health plan must provide a clear explanation of the grievance and appeal, or for plans that are not grandfathered, the process for review of an adverse benefit determination process upon request, upon enrollment to new enrollees, and annually to enrollees and subcontractors.

(9) Each carrier and health plan must ensure that each grievance, appeal, and for plans that are not grandfathered, grievance and review of adverse benefit determinations, process is accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance, appeal or review of an adverse benefit determination.

(10)(a) Each plan that is not grandfathered and the carrier that offers it must:

Track each appeal until final resolution;

maintain, and make accessible to the commissioner for a period of three years, a log of all appeals;

and identify and evaluate trends in appeals.

(b) Each grandfathered plan and the carrier that offers it must:

Track each review of an adverse benefit determination until final resolution;

maintain and make accessible to the commissioner, for a period of six years, a log of all such determinations;

and identify and evaluate trends in requests for and resolution of review of adverse benefit determinations.

(11) In complying with this section, plans that are not grandfathered and the carriers offering them must treat a rescission of coverage, whether or not the rescission has an adverse effect on any particular benefit at that time, and any decision to deny coverage in an initial eligibility determination as an adverse benefit determination.

(12) A health carrier shall approve coverage of the mental health services that are the subject of the grievance, appeal, or adverse benefit determination if the health carrier does not respond to the grievance, appeal, or adverse benefit determination within the time frames required in this section.

Sec.

For purposes of this section, p."carrier" also applies to a health plan if the health plan administers the appeal process directly or through a third party.

12 SHB 1432 "carrier" also applies to a health plan if the health plan administers the appeal process directly or through a third party.

(3) The commissioner must establish and use a rotational registry system for the assignment of a certified independent review organizationp. to each dispute.

10 HB 1432 organization to each dispute.

(5) Enrollees must be provided with at least five business days to submit to the independent review organization in writing additional information that the independent review organization must p.consider when conducting the external review.

13 SHB 1432 consider when conducting the external review.

Medical reviewers may overridep. the health plan's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.

11 HB 1432 override the health plan's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.

If the notice p.is not in writing, the independent review organization must provide written confirmation of the decision within forty-eight hours after the date of the notice of the decision.

14 SHB 1432 is not in writing, the independent review organization must provide written confirmation of the decision within forty-eight hours after the date of the notice of the decision.

(9) When an enrollee requests independent review of a dispute under this section, and the dispute involves a carrier's decision to modify, reduce, or terminate an otherwise covered health service that an enrollee is receiving at the time the request for review is submitted and the carrier's decision is based upon a finding that the healthp. service, or level of health service, is no longer medically necessary or appropriate, the carrier must continue to provide the health service if requested by the enrollee until a determination is made under this section.

12 HB 1432 health service, or level of health service, is no longer medically necessary or appropriate, the carrier must continue to provide the health service if requested by the enrollee until a determination is made under this section.

RCW 48.43.600 and 2005 c 278 s 1 are each amended to read as follows:

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15 SHB 1432 (1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not:

(a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made or, in the case of mental health services as defined in section 2 of this act, within six months after the date the payment was made;

or (b) request that a contested refund be paid any sooner than six months after receipt of the request.

Any such request must specify why the carrier believes the provider owes the refund.

If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.

(2) A carrier may not, if doing so for reasons related to coordination of benefits with another carrier or entity responsible for payment of a claim:

(a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within thirty months after the date that the payment was made or, in the case of mental health services as defined in section 2 of this act, within nine months after the date the payment was made;

or (b) request that a contested refund be paid any sooner than six months after receipt of the request.

Any such request must specify why the carrier believes the provider owes the refund, and include the name and mailing address of the entity that has primary responsibility for payment of the claim.

If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.

(3) A carrier may at any time request a refund from a health care provider of a payment previously made to satisfy a claim if:

(a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law, such as tort liability;

and (b) the carrier is unable to recover directly from the third party because the third party has either already paid or will pay the provider for the health services covered by the claim.

(4) If a contract between a carrier and a health care provider conflicts with this section, this section shall prevail.

However, nothing in this section prohibits a health care provider from choosing at any time to refund to a carrier any payment previously made to satisfy a claim.

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16 SHB 1432 (5) For purposes of this section, "refund" means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider.

(6) This section neither permits nor precludes a carrier from recovering from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy, or other benefit agreement.

(7) This section does not apply to claims for health care services provided through dental only health carriers, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter 48.66 RCW.

Sec.

9.

(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or after January 1, ((2021)) 2027,2026, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder or mental health treatment services in a behavioral health agency licensed or certified under RCW 71.24.037.

(2)(a) A health plan issued or renewed on or after January 1, ((2021)) 2027,2026, must:

(b)(i)p. The health plan may not require an enrollee to obtain prior authorization for the services specified in (a) of this subsection as a condition for payment of services prior to the times specified in (a) of this subsection.

(ii)13 OnceHB the1432 times(b)(i) specifiedThe inhealth (a)plan ofmay thisnot subsectionrequire havean passed,enrollee theto healthobtain planprior mayauthorization initiatefor utilizationthe managementservices reviewspecified proceduresin if(a) theof behavioralthis healthsubsection agencyas continuesa tocondition providefor servicespayment orof isservices inprior to the processtimes ofspecified arrangingin for(a) aof seamlessthis transfersubsection. to p.

17(ii) SHBOnce 1432the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the behavioral health agency continues to provide services or is in the process of arranging for a seamless transfer to an appropriate facility or lower level of care under subsection (6) of this section.

For a health plan issued or renewed on or after January 1, ((2025)) 2027,2026, if a health plan authorizes inpatient or residential mental health or substance use disorder treatment services pursuant to (a)(i) of this subsection following the initial medical necessity review process under (c)(iii) of this subsection, the length of the initial authorization may not be less than 14 days from the date that the patient was admitted to the behavioral health agency.

In a review forp. inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence.

14 HB 1432 for inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence.

If the health plan determines within one business day from the start of the medical p.necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination.

18 SHB 1432 necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination.

and (b)p. The behavioral health agency may not balance bill, as defined in RCW 48.43.005.

15 HB 1432 (b) The behavioral health agency may not balance bill, as defined in RCW 48.43.005.

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

19 SHB 1432 facility or lower level of care is complete.

10.9.

If insufficient information has been providedp. to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

16 HB 1432 provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

If p.insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

20 SHB 1432 insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

(c) In any instance in which a carrier has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a carrier may establish a specific reasonable time frame for submission ofp. the additional information.

17 HB 1432 of the additional information.

The prior authorization requirements must be p.based on peer-reviewed clinical review criteria.

21 SHB 1432 based on peer-reviewed clinical review criteria.

(iv) Support an automated approach using nonproprietary open workflows to compile and exchange the necessary data elements to populate the prior authorization requirements that are compliant with thep. federal health insurance portability and accountability act of 1996 or have an exception from the federal centers for medicare and medicaid services;

18 HB 1432 the federal health insurance portability and accountability act of 1996 or have an exception from the federal centers for medicare and medicaid services;

(b) Each carrier shall establish and maintain an interoperable electronic process or application programming interface that p.automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug.

22 SHB 1432 automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug.

(A)p. The reasons that the carrier cannot reasonably satisfy the requirements;

19 HB 1432 (A) The reasons that the carrier cannot reasonably satisfy the requirements;

(ii) The commissioner may grant a one-year delay in enforcement of the requirements of (a) of this subsection (2) if the commissioner p.determines that the carrier has made a good faith effort to comply with the requirements.

23 SHB 1432 determines that the carrier has made a good faith effort to comply with the requirements.

(3) ANothing healthin carrierthis shallsection approveapplies coverageto of the mental health services that are the subject of the prior authorization requestdeterminations ifmade thepursuant health carrier does not respond to theRCW prior48.43.761. authorization request within the time frames required in this section.

(4) NothingFor inthe thispurposes sectionof appliesthis tosection: prior authorization determinations made pursuant to RCW 48.43.761.

(((4))) (5) For the purposes of this section:

(A)p. Could seriously jeopardize the life or health of the enrollee;

20 HB 1432 (A) Could seriously jeopardize the life or health of the enrollee;

or (C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to p.severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request;

24 SHB 1432 severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request;

11.10.

and (3) ToSpecifying ensurerequirements consistentrelating utilization review and application of clinical review criteria to meetincreases thein requirementsnetwork ofreimbursement thisrates act,for includingmental identificationhealth ofservices clinicalto reviewremedy criteriaa that are consistent with generally accepted standards of mental health andcarrier's substancenetwork useinadequacies; disorder care.

and (4) To ensure consistent utilization review and application of clinical review criteria to meet the requirements of this act, including identification of clinical review criteria that are consistent with generally accepted standards of mental health and substance use disorder care.

12.11.

Sections 1 through 109 of this act take effect January 1, 2027.2026.

NEWp. SECTION.

21 HB 1432 NEW SECTION.

13.12.

The following acts or parts of acts, as now existing or hereafter amended, are each repealed, effective January 1, 2027:2026:

(1) RCW 48.20.580 (Mental health servicesservices—Definition—Coverage — Definition— Coverage required, when) and 2020 c 228 s 2 & 2007 c 8 s 1;

(2) RCW 48.21.241 (Mental health servicesservices—Group — Group health plansplans— — Definition— Coverage required, when) and 2020 c 228 s 3, 2007 c 8 s 2, 2006 c 74 s 1, & 2005 c 6 s 3;

p.(4) RCW 48.44.341 (Mental health services— Health plans— Definition— Coverage required, when) and 2020 c 228 s 5, 2007 c 8 s 3, 2006 c 74 s 2, & 2005 c 6 s 4;

25and SHB(5) 1432 (4) RCW 48.44.34148.46.291 (Mental health services—Healthservices— Health plans— Definition—CoverageDefinition— Coverage required, when) and 2020 c 228 s 5,6, 2007 c 8 s 3,4, 2006 c 74 s 2,3, & 2005 c 6 s 4;5.

and (5) RCW 48.46.291 (Mental health services—Health plans— Definition—Coverage required, when) and 2020 c 228 s 6, 2007 c 8 s 4, 2006 c 74 s 3, & 2005 c 6 s 5.

2622 SHBHB 1432