wa-law.org > bill > 2023-24 > SB 6228 > Original Bill
The single standard set of criteria to define medical necessity for substance use disorder treatment and define substance use disorder levels of care in Washington is the most recent version of the ASAM Criteria as published by the American society of addiction medicine.
No health carrier or licensed or certified behavioral health agency may deny substance use disorder treatment to a person who meets the ASAM Criteria for the requested course of substance use disorder treatment on the grounds that the person has not recently used a substance that is connected to the person's substance use disorder.
A managed care organization may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment services in a behavioral health agency licensed or certified under RCW 71.24.037.
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A managed care organization must:
Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance use disorder treatment prior to conducting a utilization review; and
Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.
The managed care organization 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. Once the times specified in (a) of this subsection have passed, the managed care organization 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. When the managed care organization authorizes inpatient substance use disorder treatment, the minimum initial authorization period is for 29 days from the start of treatment.
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The behavioral health agency under (a) of this subsection must notify an enrollee's managed care organization as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admitting the enrollee. The time of notification does not reduce the requirements established in (a) of this subsection.
The behavioral health agency under (a) of this subsection must provide the managed care organization with its initial assessment and initial treatment plan for the enrollee within two business days of admission, excluding weekends and holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
After the time period in (a) of this subsection and receipt of the material provided under (c)(ii) of this subsection, the managed care organization may initiate a medical necessity review process. Medical necessity review must be based on the ASAM Criteria as published by the American society of addiction medicine. If the health plan determines within one business day from the start of the medical 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. If the managed care organization's medical necessity review is completed more than one business day after the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection, the managed care organization must pay for the services delivered from the time of admission until the time at which the medical necessity review is completed and the agency is advised of the decision in writing.
The behavioral health agency shall document to the managed care organization the patient's need for continuing care and justification for level of care placement following the current treatment period, based on the ASAM Criteria as published by the American society of addiction medicine, with documentation recorded in the patient's medical record. The behavioral health agency may not be required to document the need for continuing care for inpatient substance use disorder treatment until the end of the initial authorization period.
Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
If the behavioral health agency under subsection (2)(a) of this section is not in the enrollee's network:
The managed care organization is not responsible for reimbursing the behavioral health agency at a greater rate than would be paid had the agency been in the enrollee's network; and
The behavioral health agency may not balance bill, as defined in RCW 48.43.005.
When the treatment plan approved by the managed care organization involves transfer of the enrollee to a different facility or to a lower level of care, the care coordination unit of the managed care organization shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care. The managed care organization shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete. A seamless transfer to a lower level of care may include same day or next day appointments for outpatient care, and does not include payment for nontreatment services, such as housing services. If placement with an agency in the managed care organization's network is not available, the managed care organization shall pay the current agency at the service level until a seamless transfer arrangement is made.
The requirements of this section do not apply to treatment provided in out-of-state facilities.
For the purposes of this section "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.
For health plans issued or renewed on or after January 1, 2025, a health carrier shall provide:
Coverage for ground ambulance transports to behavioral health emergency services providers for enrollees who are experiencing an emergency medical condition as defined in RCW 48.43.005. A health carrier may not require prior authorization of ground ambulance services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed; and
Coverage for transportation from the behavioral health emergency services provider upon discharge to the enrollee's next level of care when a prudent layperson acting reasonably would believe that such transportation is necessary to protect the enrollee from a relapse or other discontinuity in care that would jeopardize the health and safety of the enrollee, which must be accomplished by means which a prudent layperson acting reasonably would deem appropriate to the present circumstances of the enrollee including, but not limited to, ground ambulance transportation, escorted transportation in a private vehicle, or use of a taxi service.
Coverage of ground ambulance transports to behavioral health emergency services providers and transportation from the behavioral health emergency services provider upon discharge may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter 48.49 RCW.
Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, section 3 of this act, and chapter 48.49 RCW.
Beginning January 1, 2025, a managed care organization must:
Provide coverage for ground ambulance transports to behavioral health emergency services providers for enrollees who are experiencing an emergency medical condition as defined in RCW 48.43.005. A managed care plan may not require prior authorization of ground ambulance services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed; and
Provide coverage for transportation from the behavioral health emergency services provider upon discharge to the enrollee's next level of care when a prudent layperson acting reasonably would believe that such transportation is necessary to protect the enrollee from a relapse or other discontinuity in care that would jeopardize the health and safety of the enrollee, which must be accomplished by means which a prudent layperson acting reasonably would deem appropriate to the present circumstances of the enrollee including, but not limited to, ground ambulance transportation, escorted transportation in a private vehicle, or use of a taxi service.
Coverage of ground ambulance transports to behavioral health emergency services providers and transportation from the behavioral health emergency services provider upon discharge may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter 48.49 RCW.
Nothing in this section prevents a managed care plan from denying coverage based on insurance fraud.
If the behavioral health emergency services provider, ground ambulance transport, or behavioral health emergency services provider referenced in subsection (1) of this section are not in the enrollee's network, the managed care organization is not responsible for reimbursing these entities at a greater rate than they would be paid if the entity had been in the enrollee's network. The entities described in this subsection (4) may not balance bill, as defined in RCW 48.43.005.
The health care authority shall pursue a medicaid state plan amendment or take other steps necessary to obtain federal match for the coverage expansion described in section 5 of this act by January 1, 2025, or as soon thereafter as may be practicable.
(1) The secretary shall issue a trainee certificate to any applicant who demonstrates to the satisfaction of the secretary that he or she is working toward the education and experience requirements in RCW 18.205.090.
The secretary shall issue an associate license to any applicant who demonstrates to the satisfaction of the secretary that the applicant meets the following requirements for the applicant's practice area and submits a declaration that the applicant is working toward full licensure in that category:
Licensed social worker associateadvanced or licensed social worker associateindependent clinical: Graduation from a master's degree or doctoral degree educational program in social work accredited by the council on social work education and approved by the secretary based upon nationally recognized standards.
Licensed mental health counselor associate: Graduation from a master's degree or doctoral degree educational program in mental health counseling or a related discipline from a college or university approved by the secretary based upon nationally recognized standards.
Licensed marriage and family therapist associate: Graduation from a master's degree or doctoral degree educational program in marriage and family therapy or graduation from an educational program in an allied field equivalent to a master's degree or doctoral degree in marriage and family therapy approved by the secretary based upon nationally recognized standards.
Associates may not provide independent social work, mental health counseling, or marriage and family therapy for a fee, monetary or otherwise. Associates must work under the supervision of an approved supervisor.
Associates shall provide each client or patient, during the first professional contact, with a disclosure form according to RCW 18.225.100, disclosing that he or she is an associate under the supervision of an approved supervisor.
The department shall adopt by rule what constitutes adequate proof of compliance with the requirements of this section.
Applicants are subject to the denial of a license or issuance of a conditional license for the reasons set forth in chapter 18.130 RCW.
6.An associate license may be renewed if the applicant for renewal has successfully completed eighteen hours of continuing education in the preceding year. Beginning with the second renewal, at least six of the continuing education hours in the preceding two years must be in professional ethics.
It shall be the policy of the state of Washington that the cost of each professional, occupational, or business licensing program be fully borne by the members of that profession, occupation, or business.
The secretary shall from time to time establish the amount of all application fees, license fees, registration fees, examination fees, permit fees, renewal fees, and any other fee associated with licensing or regulation of professions, occupations, or businesses administered by the department. Any and all fees or assessments, or both, levied on the state to cover the costs of the operations and activities of the interstate health professions licensure compacts with participating authorities listed under chapter 18.130 RCW shall be borne by the persons who hold licenses issued pursuant to the authority and procedures established under the compacts. In fixing said fees, the secretary shall set the fees for each program at a sufficient level to defray the costs of administering that program and the cost of regulating licensed volunteer medical workers in accordance with RCW 18.130.360, except as provided in RCW 18.79.202. In no case may the secretary impose any certification, examination, or renewal fee upon a person seeking certification as a certified peer specialist trainee under chapter 18.420 RCW or, between July 1, 2025, and July 1, 2030, impose a certification, examination, or renewal fee of more than $100 upon any person seeking certification as a certified peer specialist under chapter 18.420 RCW. Between July 1, 2024, and July 1, 2029, the secretary may not impose any certification or certification renewal fee on a person seeking certification as a substance use disorder professional or substance use disorder professional trainee under chapter 18.205 RCW of more than $100.
All such fees shall be fixed by rule adopted by the secretary in accordance with the provisions of the administrative procedure act, chapter 34.05 RCW.