Applicability of E2SHB1688 to Commercial Carriers: The 1688 mobile crisis response coverage requirement applies to fully insured plans and self-funded plans that have elected to participate in the Balance Billing Protection Act. RCW provisions for self-funded groups that opt into the Balance Bill Protection Act identifies the specific provisions that apply to self-funded plans that elect to participate.
Phased implementation of the consensus recommendation:
The following BH-ASOs will be implementing the Consensus Recommendation by the 1st Quarter of 2024. Commercial Carriers will seek contracting arrangements with these BH-ASOs for MCR services in their associated Region(s).
See bottom of page for ‘Situations where the above defined “Path for Plan Year 2024” cannot be achieved‘
| BH-ASO Region | Planned Implementation Date | Considerations |
|---|---|---|
| Carelon – Pierce | Jan 1 2024 | Dependent upon timely contract negotiation with commercial carriers so that systems can be configured before implementation date |
| Carelon – Southwest | Jan 1 2024 | |
| Carelon – North Central | Jan 1 2024 | |
| King County | Jan 1 2024 | Goal is to have all the contracts executed and be on our way to submitting claims by Jan 1. |
| Thurston Mason | Jan 1 2024 – March 1, 2024 | The implementation timeframe takes into account start-up/testing, etc. |
As yet, there are no implementation timeframes for the other BH-ASO Regions. In these Regions, a commercial carrier will seek contracting arrangements directly with MCR Agencies / Providers.
General Implementation Approach: This approach applies to BH-ASOs that are implementing the Consensus Recommendation or MCR Agencies / Providers in those Regions where the BH-ASO is no implementing the Consensus Recommendation.
Effective immediately, the necessary work will be undertaken so that no later than plan year January 1, 2024, Fee-for-Service bills will be submitted to, and be reimbursed by, Commercial Carriers for Mobile Crisis Response services provided to their members. (The Fee-for-Service billing methodology will be followed unless the BH-ASO or MCR Agency/Provider and the commercial carrier both agree upon a fixed-cost or alternative methodology.)
Between January 1, 2023 and the completion of commercial carrier contracting with the BH-ASO in each applicable region or MCR Agencies / Providers, agencies that are licensed by the Washington state Department of Health that provide Mobile Crisis Services may submit claims for these services to the responsible commercial carrier as an “out-of-network” or “nonparticipating” provider. The carrier will accept and adjudicate these claims. If the carrier does not meet network access requirement (i.e., an AADR is in place), the member responsibility amount that is determined by the carrier can be no more than if the service were received in network. If the carrier does meet network access requirements (i.e., no AADR is in place, payment will be consistent with the Fee-for-Service methodology outlined in RCW 48.49.020. (Note: Regional differences in out-of-network billing practices by agencies should be expected.)
| Process / Function | Path for Plan Year 2024 |
|---|---|
| Contracting | Commercial Carriers will contract with the BH-ASOs. RCW 71.24.045 gives BH-ASOs the statutory authority to contract with commercial carriers for Behavioral Health Crisis Services within their designated Region. RCW 71.24 would not give authority to a BH-ASO to contract outside of their designated region. However, one BH-ASO could contract with another BH-ASO to provide services for them in their region. The BH-ASO can act as a provider network in their designated Region assuming that the BH-ASO has contracts with a sufficient number of behavioral health emergency services providers. The BH-ASO would not be considered a Health Care Benefits Manager (HCBM) and as such are not subject to specific HCBM regulatory requirements. When a BH-ASO negotiates with carriers, the negotiated rates should include their administrative costs. As part of the contracting arrangement with commercial carrier, the carriers are likely to ask BH-ASO to provide them with the information about Mobile Crisis Response providers (initial set of information and updates) so that the carriers can communicate this to the OIC on Form A. |
| Commercial Carrier Network Access Reporting | Based upon recent rulemaking WAC 284-170-210(2)(b), which addresses the submission of alternate access delivery requests (AADR) by carriers to the Office of the Insurance Commissioner (OIC), has been updated as follows: “Documentation of good faith efforts to contract may include, but is not limited to:” This change permits a carrier to submit certain information to the Office of the Insurance Commissioner to show good faith efforts to contract. In recognition of the work that the carriers and the BHES Workgroup are currently engaged in, OIC confirmed to the carriers that for PY2023 they could submit the following types of information to show “good faith efforts” in addition to outreach to providers/facilities to demonstrate to the OIC that they are working towards obtaining a contract for PY2024: a. Participation dates/level with working group (for example – X person attends the meetings for Carrier) b. Project plan for PY2022 that includes work to date and any items that are resolved c. Project plan for PY2023 to get to contract (could involve contracts with providers directly or via BH-ASO) d. List of individuals, both internal and external, that they are working with (identify BHASOs, Providers, etc). The AADR must follow standard requirements to waive coinsurance and must ensure the member incurs no greater cost then if a contract were executed. This could mean paying billed charges. OIC Commentary: The carriers did request clarification as to whether these principles applied to both mobile crisis response providers and facilities. The carriers may already have contracts or are in a better position to obtain contracts with the facilities at this point. The rule applies to both situations. The carrier can make a business decision as to whether they want to file one AADR to address BH Emergency Services as a whole or submit separate AADRs to address the unique challenges specific to each service in the BH Emergency delivery system (meaning Mobile Crisis Response Team and Facility). |
| Credentialing | As part of the contracting process, commercial carriers will delegate credentialing of the agencies to the BH-ASOs. Agencies will be credentialed at the agency level, per their DOH licensure. |
| Determining Commercial Carrier Eligibility and Coverage | The BH-ASO will be responsible for identifying if/which commercial carrier provides coverage for the person in crisis. 270-271 transaction exchange / web portal queries, either directly with the carrier or via an eligibility clearinghouse service, will be the methodology used for determining eligibility, unless the BH-ASO and the commercial carrier mutually agree on a different approach in a Region, e.g., BH-ASO repository. |
| Billing / Reimbursement / Collection | a) The SERI Guide will define the codes and conditions that will be used to bill commercial carriers for Behavioral Health Crisis Services. b) A fee-for-service billing methodology will be followed unless the BH-ASO and the commercial carrier mutually agree upon a fixed-cost or alternative methodology. Rates (Fee-for-Service or otherwise ) will be negotiated between the BH-ASO and the commercial carrier. Claims (837) will be submitted to the commercial carrier by the BH-ASO on behalf of the agencies and any reimbursement (835) will be made to the BH-ASO. c) The BH-ASO will pay providers the current fixed cost amount regardless of the payment amount received from the commercial carrier. HCA’s allocation of General Fund Dollars to the BH-ASOs will remain the same d) Revenue Cycle Systems for BH-ASOs and secure infrastructure to send 837Ps to Commercial Carrier and receive 835s and payments will be required. Per HCA review of proviso language (05-31-2023 Meeting Synopsis), the BH-ASOs can use existing General Fund dollars to improve their system capabilities. This would be improving the crisis system to allow for other insurance to cover crisis services based on legislation. Up to 5% can be used on utilization and quality management, up to 10 % of administration. Improving system capabilities could be either bucket. |
| Collecting Member’s Cost Share | The decision about whether or not to collect the patient’s cost share from the patient / enrollee will be left to the BH-ASO/Agency. This includes IRS-defined High Deductible Health Plans (HDHP), with/without a Health Savings Account, as well as all other types of plans. When a claim is submitted to the commercial carrier, the carrier will adjudicate the claim based upon the patient’s/enrollee’s benefits and will reimburse the carrier’s contracted amount. The carrier’s payment amount will not include the amount due from the patient/enrollee to the BH-ASO/Agency for deductible, co-pay, coinsurance or any other applicable cost sharing. As an example, if the patient/enrollee has a HDHP and has not met their deductible, e.g., $6,500, then the deductible amount must be met before the Carrier’s is responsible for any payment to the BH-ASO/agency. For non-HDHP, the average deductible amount in Washington State for single coverage is $1,740. Per HCA (07-31-2023 Meeting Synopsis), BH-ASOs can use non-Medicaid funding to cover member cost share that is not paid by the commercial carriers, regardless of income. |
| Making Next Day Appointments (NDA) (E2HB1477) | The details pertaining to HB1477 – Next Day Appointments (NDA’s) are being addressed in a separate workgroup led by the Washington State Health Care Authority. As part of that work, HCA is developing a process and set of contacts for use by the Regional / 988 Crisis Lines to offer consumers a Next Day Appointment (NDA) with a provider that can deliver services outside of the Behavioral Health Crisis System. This process and contact list is also available to mobile crisis teams within the Behavioral Health Crisis System for making HB 1477 – NDA’s. Agencies within the Behavioral Health Crisis System will determine if subsequent appointments with the person presenting in crisis are needed. If a Behavioral Health Crisis System provider makes a determination that a person should be seen by a provider outside of the Behavioral Health Crisis System, then they will use the NDA process and contact list to make that appointment. |
| A ‘Future’ Fixed Rate Methodology | In recognition of the 24/7 nature of crisis services and the best practice use of capacity-based payment methodologies for these services, BH-ASOs and Commercial Carriers will work collaboratively and in good faith to capture the utilization & cost data necessary to determine if/how best to transition to a capacity-based payment model for crisis-related services rather than fee-for-service billing. |
| Enhancing System Capabilities to support Fee-For-Service billing and Eligibility Determination | Per HCA (07-31-2023 Meeting Synopsis), the BH-ASOs can use existing funds to improve their system capabilities. This would be improving the crisis system to allow for other insurance to cover crisis services based on legislation. Up to 5% can be used on utilization and quality management, up to 10 % of administration. Improving system capabilities could be either bucket. |
Situations where the above defined “Path for Plan Year 2024” cannot be achieved
OIC will assess implications for Network Access Requirements for those Regions where the BH-ASO / Agency either;
a.) Does not have the capability to implement the above consensus recommended “Path for Plan Year 2024”,
b.) Intends to implement the above consensus recommended “Path for Plan Year 2024”, but will not be ready to implement by January 1, 2024,
c.) Intends to and is ready to implement the above consensus recommended “Path for Plan Year 2024”, but cannot reach mutually agreeable contract terms with a commercial carrier and the carrier’s action is consistent with the conditions in their AADR.
In any of these situations, a commercial carrier should seek contracting arrangements directly with MCR Agencies / Providers in the associated Region.
AADRs for 2024 can be submitted through the portal starting October 1, 2023. The requirement for an AADR will be:
- Demonstrated good faith effort to contract with Mobile Crisis Response and behavioral health emergency services Agencies / Providers, as defined in RCW 48.43.005.
- Demonstrated good faith participation in the OHP Policy & Design Workgroup
- Demonstrated good faith participation in HCA’s Behavioral Health Crisis Services Financing workgroup through to submission of their final report to the legislature in 2024 .