December 17, 2020
Starting January 1, 2021, the “No Wrong Door” Substance Use Treatment Accessibility Act goes into effect in Washington state. The law removes important health coverage barriers to care for people seeking detoxification and substance use disorder (SUD) treatment services. And it comes with updated guidelines and new responsibilities for health plans and providers.
Here are key things providers should know about the new law:
- This law applies to members on fully insured plans purchased in Washington—fully insured group, individual, School Employees Benefits Board (SEBB), and Public Employees Benefits Board (PEBB)—and for care provided in Washington, with the exception of certain student-only plans. It does not apply to your clients on a self-funded plan, nor if care is provided outside of Washington.
- Treatment facilities and providers can admit patients for detoxification, SUD residential treatment, and SUD inpatient rehabilitation without prior authorization, which cannot be required by health plans. Health plans are required to provide coverage for detoxification for no less than two business days and inpatient/residential SUD treatment for no less than three days prior to conducting a utilization or medical necessity review.
- Providers must now notify a patient’s health plan as soon as practical after, but no later than 24 hours after admitting them. Then, the initial assessment and plan for SUD treatment must be done within 2 business days of admission, excluding weekends and holidays, or within 3 days for detoxification services.
- After receiving a provider’s assessment and plan, Premera will complete the medical necessity review within one business day. If your patient’s plan includes transition to a different facility or lower level of care, we’re required to pay the provider until the seamless transfer to the different facility or lower level of care is complete.
- The HCA and OIC are required to adopt a single set of criteria for health plans and behavioral health service agencies to use for SUD treatment, utilization or medical necessity reviews, and to determine levels of care.; they will use the ASAM (American Society of Addiction Medicine Medicine) criteria. Additionally, the HCA is developing an action plan to improve the transition of substance use disorder treatment clients between levels of care. Details of these are yet to be determined by the government.
- Out-of-network providers can’t balance bill Premera members. Out-of-network providers will be paid no more than the rate that would have been paid if they were in-network.
To learn more, House Bill 2642 is available on the Washington state legislature website.
To learn if a Premera member is covered by this law, you can use your OneHealthPort account to sign in and check their eligibility and benefits.