HB 2572 — Removing health coverage barriers to accessing substance use disorder treatment services.

H-4618.1SECONDH-3619.1HOUSE SUBSTITUTE HOUSE BILL 2572State of Washington65th Legislature2018 Regular SessionBy House Appropriations (originally sponsored by Representatives Cody, Macri, Jinkins, Kagi, Wylie, Slatter, Tharinger, Ormsby, and Robinson)READRobinsonRead FIRSTfirst TIMEtime 02/06/18.AN01/10/18. ACT Relating to removing health coverage barriers to accessing substance use disorder treatment services;

Referred to Committee on Health Care & Wellness.AN ACT Relating to removing health coverage barriers to accessing substance use disorder treatment services;

and(c) When individuals are ready for treatment, they should be able to obtain it with minimal barriers relating to health care coverage.(2) The legislature therefore intends to ensure that there is no wrong door for individuals accessing substance use disorder treatment services by requiring coverage, and prohibiting prior authorization, for certain substance use disorder treatment services.NEW SECTION.  Sec. 2.  A new section is added to chapter 41.05 RCW to read as follows:(1) ToA thehealth extentplan thatoffered theto followingemployees servicesand aretheir covered benefits,dependents aunder healththis plan,chapter mustissued coveror inpatientrenewed hospitalon detoxification,or residentialafter subacutethe detoxification,effective inpatientdate hospitalof substancethis usesection disordermay treatment,not residentialrequire substancean useenrollee disorderto treatment,obtain partialprior hospitalizationauthorization substancefor use disorder treatment, and intensive outpatient substance use disorder treatment forif the firstprovider twenty-fouris hourslicensed afterunder anTitle enrollee18 presentsRCW forand anythe oftreatment theseis serviceswithin orthe isprovider's referredscope forof anypractice.(2) ofA thesehealth services,plan withoutoffered imposingto utilizationemployees managementand reviewtheir limitationscovered ondependents coverage,under includingthis priorchapter authorizationissued requirements.(a)or Ifrenewed locatedon inor Washington,after the treatmenteffective facilitydate orof programthis section must beprovide licensedcoverage orfor certified by the departmentfollowing ofservices healthfor up to delivera thetotal level of carefourteen beingdays: sought by the enrollee.

IfMedically locatednecessary inacute other states, the facility or program must be licensed or certified by the state agency with the authority to issue credentials for the level of care being sought by the enrollee.(b) If an enrollee presents without a referral from a hospital or provider, the treatment facilityservices or program must make a good faith effort to confirm and documentmedically thatnecessary aclinical thirdstabilization partyservices. did not induce the enrollee to seek treatment in exchange for payment of goods, nonmedical or mental health services, or moneys, provided either to the enrollee or the third party.(2) The treatment facility or program must provide an enrollee's health plan with notice of admission as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admission.

The time of notification does not reduce the requirements established in subsection (1) of this section.(a) The facility's initial assessment, basis for referral, and initial planned services must accompany the notice.(b) Upon receipt of notice of admission and the passage of the first twenty-four hours, as required under subsection (1) of this section, the health plan may initiatenot itsrequire utilizationan reviewenrollee of the member's need for services, and the remainder of the enrollee's services may be subject to utilizationobtain management, including prior authorization, as required by the enrollee's health coverage.(c) If the treatment facility or program is a contracted facility participating in the health plan's provider network, the health plan must conduct any prior authorization orfor othermedically utilization management review necessary toacute determine the covered length of stay and course of treatment, as permitted under the enrollee's health plan, on an urgent, expedited basis within twenty-four hours of receipt of all necessary documentation.(3) If the treatment facilityservices or programmedically isnecessary notclinical astabilization contractedservices. facility participating in the health plan's provider network, the health plan must inform the enrollee and the enrollee's attending physician that the facility is not in the health plan's provider network, and whether out-of-network coverage is available.

NothingThe infacility thisproviding sectionthe requiresservices ashall carrierprovide to include out-of-network coverage in a health plan.(a) If the health plan coversboth out-of-networknotification services,of admission and the enrolleeinitial istreatment admitted to an out-of-network facility or program located in Washington, the health plan mustwithin payforty-eight forhours a covered mode of transferadmission. to an in-network facility or program without requiring payment or cost sharing from the enrollee.

TransportThe must be provided by an in-network provider.(b) A health plan ismay notinitiate requiredutilization toreview coverprocedures transportationon from an out-of-state treatment program or facility if the enrolleeseventh electsday toafter transferadmission.(3) toFor anpurposes in-state,of in-networkthis treatmentsection, programmedical ornecessity facility.(4)(a)must Ifbe adetermined healthby plan determines that the admissiontreating toprovider inpatientin substanceconsultation usewith disorder treatment was not medically necessary or clinically appropriate, the healthpatient planand ismust notbe requirednoted toin pay the facilitypatient's ormedical programrecord.(4) forFor thepurposes services delivered after the initial twenty-four hour admission period, subject to the conclusion of any filed appeals of the adverse benefit determination.(b) If the patient evaluation and plan of care conducted at the facility under (a) of this subsectionsection:(a) and"Acute thetreatment healthservices" plan'smeans utilizationtwenty-four reviewhour processmedically identifysupervised aaddiction needtreatment for servicesadults otheror thanadolescents thoseprovided availablein ata themedically inpatientmanaged substance use disorder treatment facility or program,medically themonitored healthinpatient plan in collaboration with the facility must fully coordinate the arrangements for assuring that theprovides enrolleeevaluation obtainsand thewithdrawal propermanagement. medically necessary or clinically appropriate care.

To"Acute fullytreatment coordinateservices" theseincludes arrangements,biopsychosocial aassessment, healthindividual planand maygroup needcounseling, topsychoeducational identifygroups, and contactdischarge anplanning.(b) available"Clinical programstabilization orservices" facilitymeans thattwenty-four offershour the medically necessary or clinically appropriatemanaged care,post assistdetoxification withtreatment arranging the admission or initial appointment between the enrollee and the provider, assist with the transfer of health records including the initial evaluation and plan of care, and conduct other activities to facilitate a seamless transition for theadults enrollee into the appropriate care.(5) A health plan must use evidence-based criteria for assessing the medical necessity and clinical appropriateness of an enrollee's need for substance use disorder residential treatment.(6) This section does not restrict the right of enrollees to seek emergency medical care requiring stabilization or acuteadolescents, detoxificationusually services from any emergency room or urgent care center without prior authorization.NEW SECTION.  Sec. 3.  A new section is added to chapter 48.43 RCW to read as follows:(1) To the extent that the following servicesacute are covered benefits, a health plan, as defined in RCW 48.43.005, must cover inpatient hospital detoxification, residential subacute detoxification, inpatient hospital substance use disorder treatment, residential substance use disorder treatment, partial hospitalization substance use disorder treatment, and intensive outpatient substance use disorder treatment for the first twenty-four hours after an enrollee presents for any of these services or is referred for anysubstance ofabuse. these services, without imposing utilization management review limitations on coverage, including prior authorization requirements.(a) If located in Washington, the treatment facility or program must be licensed or certified by the department of health to deliver the level of care being sought by the enrollee.

If"Clinical locatedstabilization inservices" otherincludes states,intensive theeducation facilityand orcounseling programregarding must be licensed or certified by the statenature agency with the authority to issue credentials for the level of caresubstance beinguse soughtdisorder byand theits enrollee.(b)consequences, Ifrelapse anprevention, enrolleeoutreach presents without a referral from a hospital or provider, the treatment facility or program must make a good faith effort to confirmfamilies and documentsignificant thatothers, aand thirdaftercare partyplanning, didfor notindividuals inducebeginning the enrollee to seekengage treatment in exchangerecovery forfrom paymenta ofsubstance goods,use nonmedicaldisorder.(c) or"Substance mentaluse healthdisorder services,treatment" ormeans: moneys, provided either to the enrollee or the third party.(2) The treatment facility or program must provide an enrollee's health plan with notice of admission as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admission.

TheEarly timeintervention of notification does not reduce the requirements established in subsection (1) of this section.(a) The facility's initial assessment, basis for referral, and initial planned services must accompany the notice.(b) Upon receipt of notice of admission and the passage of the first twenty-four hours, as required under subsection (1) of this section, the health plan may initiate its utilization review of the member's need for services,substance anduse thedisorder remaindertreatment; of the enrollee's services may be subject to utilization management, including prior authorization, as required by the enrollee's health coverage.(c) If the treatment facility or program is a contracted facility participating in the health plan's provider network, the health plan must conduct any prior authorization or other utilization management review necessary to determine the covered length of stay and course of treatment, as permitted under the enrollee's health plan, on an urgent, expedited basis within twenty-four hours of receipt of all necessary documentation.(3) If the treatment facility or program is not a contracted facility participating in the health plan's provider network, the health plan must inform the enrollee and the enrollee's attending physician that the facility is not in the health plan's provider network, and whether out-of-network coverage is available.

Nothingsubstance inuse thisdisorder sectionevaluation; requires a carrier to include out-of-network coverage in a health plan.(a) 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 health plan must pay for a covered mode of transfer to an in-network facility or program without requiring payment or cost sharing from the enrollee.

Transportoutpatient mustservices, beincluding provided by an in-network provider.(b) A health plan is not required to cover transportation from an out-of-state treatment program or facility if the enrollee elects to transfer to an in-state, in-network treatment program or facility.(4)(a) If a health plan determines that the admission to inpatient substance use disorder treatment was not medically necessaryassisted ortherapies; clinically appropriate, the health plan is not required to pay the facility or program for the services delivered after the initial twenty-four hour admission period, subject to the conclusion of any filed appeals of the adverse benefit determination.(b) If the patient evaluation and plan of care conducted at the facility under (a) of this subsection and the health plan's utilization review process identify a need for services other than those available at the inpatient substance use disorder treatment facility or program, the health plan in collaboration with the facility must fully coordinate the arrangements for assuring that the enrollee obtains the proper medically necessary or clinically appropriate care.

Tointensive fullyoutpatient coordinate these arrangements, a health plan may need to identify and contact an available program or facility that offers the medically necessary or clinically appropriate care, assist with arranging the admission or initial appointment between the enrollee and the provider, assist with the transfer of health records including the initial evaluation and plan of care, and conduct other activities to facilitate a seamless transition for the enrollee into the appropriate care.(5) A health plan must use evidence-based criteria for assessing the medical necessity and clinical appropriateness of an enrollee's need for substance use disorder residential treatment.(6) This section does not restrict the right of enrollees to seek emergency medical care requiring stabilization or acute detoxification services from any emergency room or urgent care center without prior authorization.NEW SECTION.  Sec. 4.  A new section is added to chapter 71.24 RCW to read as follows:(1) To the extent that the following services are covered benefits, a behavioral health organization must cover inpatient hospital detoxification, residential subacute detoxification, inpatient hospital substance use disorder treatment, residential substance use disorder treatment, partial hospitalization substanceservices; use disorder treatment, and intensive outpatient substance use disorder treatment for the first twenty-four hours after a client presents for any of these services or is referred for any of these services, without imposing utilization management review limitations on coverage, including prior authorization requirements.(a) If located in Washington, the treatment facility or program must be licensed or certified by the department of health to deliver the level of care being sought by the client.

Ifresidential located in other states, the facility or programinpatient mustservices beother licensedthan oracute certified by the state agency with the authority to issue credentials for the level of care being sought by the client.(b) If a client presents without a referral from a hospital or provider, the treatment facilityservices or programclinical muststabilization makeservices; a good faith effort to confirm and document that a third party did not induce the client to seek treatment in exchange for payment of goods, nonmedical or mental health services, or moneys, provided either to the client or the third party.(2) The treatment facility or program must provide a client's behavioral health organization with notice of admission as soon as practicable after admitting the client, but not later than twenty-four hours after admission.

Theand timemedically ofmanaged notificationintensive doesinpatient notservices reduceother thethan requirementsacute establishedtreatment in subsection (1) of this section.(a) The facility's initial assessment, basis for referral, and initial planned services mustor accompanyclinical thestabilization notice.(b)services.NEW UponSECTION.  Sec. 3.  A receiptnew ofsection noticeis ofadded admissionto andchapter the48.43 passageRCW ofto theread first twenty-four hours, as requiredfollows:(1) underA subsection (1) of this section, the behavioral health organizationplan mayissued initiateor itsrenewed utilizationon reviewor ofafter the client'seffective needdate for services, and the remainder of thethis client'ssection services may benot subjectrequire toan utilizationenrollee management,to includingobtain prior authorization,authorization asfor requiredsubstance byuse thedisorder client's coverage through the behavioral health organization.(c) If the treatment facilityif or program is a contracted facility participating in the behavioral health organization provider network,is thelicensed behavioralunder healthTitle organization18 mustRCW conductand any prior authorization or other utilization management review necessary to determine the covered length of stay and course of treatment onis an urgent, expedited basis within twenty-fourthe hoursprovider's ofscope receipt of allpractice.(2) necessaryA documentation.(3)health Ifplan theissued treatment facility or programrenewed ison notor aafter contracted facility participating in the behavioraleffective healthdate organization'sof providerthis network,section the behavioral health organization must informprovide thecoverage clientfor and the client'sfollowing attendingservices physicianfor thatup theto facilitya ortotal programof isfourteen notdays: in the behavioral health organization's provider network, and whether out-of-network coverage is available.

NothingMedically innecessary thisacute sectiontreatment requiresservices a behavioral health organization to include out-of-network coverage.(a) If the behavioral health organization covers out-of-network services, and themedically clientnecessary isclinical admittedstabilization toservices. an out-of-network facility or program located in Washington, the behavioral health organization must pay for a covered mode of transfer to an in-network facility or program without requiring payment or cost sharing from the client.

TransportThe must be provided by an in-network provider.(b) A behavioral health organizationplan ismay not requiredrequire to cover transportation from an out-of-stateenrollee treatment program or facility if the client elects to transferobtain toprior anauthorization in-state,for in-network treatment program or facility.(4)(a) If a behavioral health organization determines that the admission to inpatient substance use disorder treatment was not medically necessary oracute clinicallytreatment appropriate, the behavioral health organization is not required to pay the facility or program for the services delivered after the initial twenty-four hour admission period, subject to the conclusion of any filed appeals of the adverse benefit determination.(b) If the patient evaluation and plan of care conducted at the facility or program under (a) of this subsection and the behavioral health organization's utilization review process identify a need for services other than those available at the inpatient substance use disorder treatment facility or program, the behavioral health organization in collaboration with the facility or program must fully coordinate the arrangements for assuring that the client obtains the proper medically necessary orclinical clinicallystabilization appropriateservices. care.

ToThe fully coordinate these arrangements, a behavioral health organization may need to identify and contact an available program or facility thatproviding offers the medicallyservices necessaryshall orprovide clinicallythe appropriatehealth care,plan assistboth withnotification arrangingof the admission or initial appointment between the client and the provider, assist with the transfer of health records including the initial evaluationtreatment and plan ofwithin care,forty-eight andhours conduct other activities to facilitate a seamless transition for the client into the appropriate care.(5) A behavioral health organization must use evidence-based criteria for assessing the medical necessity and clinical appropriateness of aadmission. client's need for substance use disorder residential treatment.(6) This section does not restrict the right of clients to seek emergency medical care requiring stabilization or acute detoxification services from any emergency room or urgent care center without prior authorization.--- END ---

The health plan may initiate utilization review procedures on the seventh day after admission.(3) For purposes of this section, medical necessity must be determined by the treating provider in consultation with the patient and must be noted in the patient's medical record.(4) For purposes of this section:(a) "Acute treatment services" means twenty-four hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility that provides evaluation and withdrawal management.

"Acute treatment services" includes biopsychosocial assessment, individual and group counseling, psychoeducational groups, and discharge planning.(b) "Clinical stabilization services" means twenty-four hour clinically managed post detoxification treatment for adults or adolescents, usually following acute treatment services for substance abuse.

"Clinical stabilization services" includes intensive education and counseling regarding the nature of substance use disorder and its consequences, relapse prevention, outreach to families and significant others, and aftercare planning, for individuals beginning to engage in recovery from a substance use disorder.(c) "Substance use disorder treatment" means:

Early intervention services for substance use disorder treatment;

substance use disorder evaluation;

outpatient services, including medically assisted therapies;

intensive outpatient and partial hospitalization services;

residential or inpatient services other than acute treatment services or clinical stabilization services;

and medically managed intensive inpatient services other than acute treatment services or clinical stabilization services.NEW SECTION.  Sec. 4.  A new section is added to chapter 71.24 RCW to read as follows:(1) Beginning January 1, 2019, a behavioral health organization may not require an enrollee to obtain prior authorization for substance use disorder treatment if the provider is licensed under Title 18 RCW and the treatment is within the provider's scope of practice.(2) Beginning January 1, 2019, a behavioral health organization must provide coverage for the following services for up to a total of fourteen days:

Medically necessary acute treatment services and medically necessary clinical stabilization services.

The behavioral health organization may not require an enrollee to obtain prior authorization for medically necessary acute treatment services or medically necessary clinical stabilization services.

The facility providing the services shall provide the behavioral health organization both notification of admission and the initial treatment plan within forty-eight hours of admission.

The behavioral health organization may initiate utilization review procedures on the seventh day after admission.(3) For purposes of this section, medical necessity must be determined by the treating provider in consultation with the patient and must be noted in the patient's medical record.(4) For purposes of this section:(a) "Acute treatment services" means twenty-four hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility that provides evaluation and withdrawal management.

"Acute treatment services" includes biopsychosocial assessment, individual and group counseling, psychoeducational groups, and discharge planning.(b) "Clinical stabilization services" means twenty-four hour clinically managed post detoxification treatment for adults or adolescents, usually following acute treatment services for substance abuse.

"Clinical stabilization services" includes intensive education and counseling regarding the nature of substance use disorder and its consequences, relapse prevention, outreach to families and significant others, and aftercare planning, for individuals beginning to engage in recovery from a substance use disorder.(c) "Substance use disorder treatment" means:

Early intervention services for substance use disorder treatment;

substance use disorder evaluation;

outpatient services, including medically assisted therapies;

intensive outpatient and partial hospitalization services;

residential or inpatient services other than acute treatment services or clinical stabilization services;

and medically managed intensive inpatient services other than acute treatment services or clinical stabilization services.--- END ---