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Removing health coverage barriers to accessing substance use disorder treatment services (Cody, Macri, Jinkins)

AN ACT Relating to removing health coverage barriers to accessing substance use disorder treatment services; adding a new section to chapter 41.05 RCW; adding a new section to chapter 48.43 RCW; adding a new section to chapter 71.24 RCW; and creating a new section.

SUMMARY OF 1ST SUBSTITUTE BILL COMPARED TO ORIGINAL BILL
The substitute bill removes the underlying provisions of the bill, except for the legislative findings. Common requirements for the Public Employees Benefits Board, private health insurers, and behavioral health organizations (payors) are established related to substance use disorder coverage.
The substitute bill requires payors to cover, without utilization management review limitations, the first 24 hours of the following services: (1) inpatient hospital detoxification; (2) residential subacute detoxification; (3) inpatient hospital substance use disorder treatment; (4) residential substance use disorder treatment; (5) partial hospitalization substance use disorder treatment; and (6) intensive outpatient substance use disorder treatment. Treatment facilities and programs must provide notice of admission to the enrollees as soon as practicable, but no later than 24 hours following admission.
The substitute bill requires treatment facilities and programs to confirm and document that enrollees and clients who present without a referral from a hospital or provider were not induced by a third party.
The substitute bill requires payors to inform enrollees or clients and the attending physician if a treatment facility or program is out-of-network. Payors must pay for a transfer to an innetwork facility without payment or cost-sharing from enrollees or clients.
The substitute bill allows a payor, upon finding that admission to inpatient substance use disorder treatment was not medically necessary or clinically appropriate, to not pay the facility or program for services offered after the first 24 hours. If the utilization review finds that services other than those at the inpatient substance use disorder treatment facility or program are needed, the payor and the facility or program must coordinate arrangements to assure that the enrollee obtains the proper medically necessary or clinically appropriate.

EFFECT OF 2ND SUBSTITUTE (Appropriations)
(1) Limits the substance use disorder coverage that is initially exempt from utilization management review to only the listed services to the extent covered by the Public Employees Benefits Board (PEBB), a private insurer, or a behavioral health organization. (2) Includes all health plans offered by the PEBB, not only those as defined in RCW 48.43.005 (a definition that would have excluded the Uniform Medical Plan).

SENATE COMMITTEE (Human Services & Corrections) STRIKER AMENDMENT
(1) Adds the treatment facility or program as entities that must also confirm and document that they 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, in chapter 48.43 RCW. (2) Changes that if the health plan as defined in RCW 48.43.005 does not cover 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. (3) Clarifies that if a health plan as defined in RCW 48.43.005 determines that the admission to inpatient hospital detoxification, residential subacute detoxification, inpatient hospital substance use disorder treatment, residential substance use disorder treatment, partial hospitalization substance use disorder treatment, or intensive outpatient substance use disorder treatment was not medically necessary or 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, not only inpatient substance use disorder treatment.

SENATE COMMITTEE (Ways & Means) STRIKER AMENDMENT
(1) Requires health plans and/or behavioral health organizations (BHOs) to cover the first 48 hours of certain substance use disorder (SUD) treatments, without prior authorization or utilization management review, to the extent that the treatment services are covered benefits. (2) Adds the treatment facility or program as entities that must also confirm and document that they 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, in chapter 48.43 RCW. (3) Changes that if the health plan as defined in RCW 48.43.005 does not cover 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. (4) Clarifies that if a health plan as defined in RCW 48.43.005 determines that the admission to inpatient hospital detoxification, residential subacute detoxification, inpatient hospital substance use disorder treatment, residential substance use disorder treatment, partial hospitalization substance use disorder treatment, or intensive outpatient substance use disorder treatment was not medically necessary or clinically appropriate, the health plan is not required to pay the facility or program for the services delivered after the initial forty-eight hour admission period, not only inpatient substance use disorder treatment.

Hearing Date: Thursday, February 22, 2018 -- 6:00 pm

WA State Legislature Link:
http://app.leg.wa.gov/billsummary?BillNumber=2572&Year=2017    (opens a new browser tab)