Insurer Holding Company Act (R 2024-04)

The NAIC revised these models in 2020 and adopted the updated versions as accreditation requirements for state insurance regulators effective Jan. 1, 2026.  

This rulemaking will fully implement the new law and update NAIC model laws. It will also provide administrative guidance and regulatory clarification for the group capital calculation requirements, including insurance holding company exemptions. Additionally, this rulemaking is designed to adopt the complete group capital calculation framework recommended by the NAIC.

Consolidated Health Care Rulemaking (R 2023-07)

These rules will ensure all affected healthcare and insurance entities understand their legal rights and obligations under the new legal framework. The rulemaking includes but is not limited to updating emergency medical conditions, prior authorizations, and telemedicine timeframes. The rule will also attempt to clarify hearing instrument coverage requirements and cost-sharing for abortion and breast exams.

Policy and operational recommendations

Background

In the late summer of 2022, the OIC and HCA called for participation in a multi-stakeholder workgroup (PDF 147.02KB) with the objective to recommend policy and operational changes to enable Commercial Insurance Coverage for Behavioral Health Crisis Service as emergency services per E2SHB1688.

In addition to the OIC and HCA, the following organizations  are represented and participating in the workgroup:

  • Behavioral Health – Administrative Services Organizations (BH-ASOs)
  • Behavioral Health Providers; Mobile Crisis Response providers and behavioral health crisis facilities
  • Commercial carriers

On November 8, 2022, the workgroup reached consensus on a set of recommendations to achieve the following goal:

“To the extent possible, maintain the Behavioral Health Crisis System as it currently exists so that 1) the inclusion of Commercial Coverage is seamless from the perspective of the patient and ideally of the provider and 2) and new/additional administrative burden and/or cost to the provider is minimized.“

Between November 8th and the present, the Policy and Operational Recommendations continue to be refined for each of the services below

Links to Related Documents (for History and Audit Trail of Changes)

Mobile crisis response: policy and operations

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 .

Covered services and billing

Covered services

Under E2HB1688, covered emergency services include mental health and substance use disorder services that are provided by Mobile Crisis Response Teams and/or by qualified staff in the following Crisis Facilities; 

a)   Hospital Based Emergency Room with stabilization/post stabilization in an Inpatient Unit

b)   Evaluation and Treatment Facility (including Secure Withdrawal Management Services)

c)   Crisis Stabilization Unit,

d)   Crisis Triage Facility,

e)   Withdrawal Management Facility

The above 5 facilities are all considered Behavioral Health Crisis Facilities and any/all of the SERI specified services (procedure / revenue codes) provided in any of those facilities are considered covered Behavioral Health Crisis Services.

The specific Behavioral Health Crisis Services are a subset of those services defined in HCA’s SERI Guide. That subset of services and related coding guidance is defined in the spreadsheet ‘Crisis Code Guide for Private Insurance Plans’, which is also posted at the above link.

For the scope Behavioral Health Emergency Services, coding requirements for commercial carriers would mirror Medicaid SERI guidance  and would be reflected as such on any updates to the SERI spreadsheet.  Changes to Medicaid can be triggered by legislation, but also may be triggered by state plan amendments, CMS rule changes, 988 crisis system changes, etc.

The SERI Guide is typically updated once a year by HCA and with a 90-day implementation timeframe.  However, not all SERI Guide updates will be applicable to Behavioral Health Crisis Services and, as such, will not appear on the SERI spreadsheet.

Commercial Carriers can sign up to receive updates on the Service Encounter Reporting Instructions (SERI) guide. (An account would need to be created if one does not already exist.)  When signing up, select “Service Encounter Reporting Instructions (SERI) updates”, under the “Behavioral Health and Recovery” heading.  Once signed up, carriers will receive an email notification any time there are changes to the SERI guide, as well as any changes to the services coding grid related to E2SHB 1688 legislation.

The material in the documents in the table below is an extract from the January 1, 2023 version of the SERI Guide and from the October 2, 2023 version of the Crisis Code Guide for Private Insurance Plans. (The documents posted here below may not be kept current with any future SERI changes. To ensure  accuracy over time, the SERI Guide should be referenced via this link https://www.hca.wa.gov/billers-providers-partners/program-information-providers/service-encounter-reporting-instructions-seri so that any/all future changes are not missed.)

January 1, 2023 version of the SERI Guide and from the October 2, 2023 version of the Crisis Code Guide for Private Insurance Plans.
Material Document
This link contains a subset of the January 1, 2023 SERI Guide, which are the Behavioral Health Crisis Services (BHCS) along with conditions under which they are covered.

SERI-Defined BHCS (PDF 235.76KB)

This link provides additional detail about BHCS crisis codes, such as the “included” services, that will be used on the 837P or 837I .

Note: For Professional Services (those that are reported on an 837P), the allowable Places of Service for each Behavioral Health Crisis Service will be negotiated between the Carrier and the BH-ASO / Facility at the time of contracting.  In the case of ‘out-of-network’ claims, the allowable Places of Service for Behavioral Health Crisis Service will be defined in the Crisis Code Guide for Private Insurance Plans spreadsheet.

Crisis code guide for private insurance plans (XLSX 19.13KB)

The ‘Crisis Code Guide for Private Insurance Plan’ spreadsheet along with the associated information in the SERI Guide will be used as the ‘Definitive Guidance’ for which codes will be used to identify covered emergency services.  Other than E&M codes, only the codes on the spreadsheet should appear on a claim and that code(s) should be considered the complete and exhaustive definition of the relevant covered emergency service.

The use of any different or additional codes may be negotiated between commercial carriers, BH-ASO and facilities, but that would be considered outside the scope of the ‘Definitive Guidance’.

Claims for any/all of the Behavioral Health Crisis Services, i.e., the subset of SERI Guide services specified in the Crisis Code Guide for Private Insurance Plan spreadsheet, that are provided by Agencies, Facilities and Providers who are appropriately certified/licensed by DOH will be processed as emergency services by commercial carriers in compliance with E2HB1688.

Billing Guidance

1)   Room and board “per diem” within a facility along with a SERI defined set of “included” clinical services would be included in the payment for the service code that is submitted on a claim, i.e., the “included” services would not be billed separately from the per diem. 

2)  Required clinical services that are in addition to SERI-defined “included” clinical services” may be provided in the facility by agency providers. 

These services, typically E&M codes, may be billed separately from the per diem on an 837P using the provider’s NPI, subject to any specific contract expectations.  (Depending upon the location,  the associated per diem would be billed on an 837I  using the agency’s NPI).

E&M codes on a claim along with a SERI defined covered emergency service are also considered covered emergency services.

These E&M services may be provided by an employee of the Crisis Facility, or a contractor of the Crisis Facility, or an “external” provider who has treatment privileges at the Crisis Facility.  For all three situations, AADR reporting requirements are analogous to those of a Hospital ER department, i.e.  the goal is that coverage of BH crisis facility services are comparable to those provided in a hospital ER department.

3) For Withdrawal Management Services, clinically managed or medically managed, claims will be submitted on an 837I unless otherwise contractually negotiated between the Carrier and the Facility.

Out-of-network Crisis Facilities for Withdrawal Management will submit claims on an 837I. Any 837P submissions will be denied.

4) Claims submitted by a BH-ASOs of behalf of an Agency or Facility would report the BH-ASO as the ‘Billing Provider’ and report the Agency / Facility as the ‘Rendering Provider’. 

5) For a compliant 837-claim transaction WHEN a carrier requires use of a Taxonomy Code:   In situations where a provider has a State Taxonomy Code, the BH-ASO will report a) either “101Y00000X” – Counselor or “390200000X” – Student in the Taxonomy Code field on the 837, and b) the state assigned Taxonomy Code in the NTE field on the 837, either at the claim level or line level whichever is most appropriate.  The message in the NTE field will be “Wash State Taxonomy Code #xxxxxxxxL”. (for more information – see 10-23-23 Meeting Synopsis (PDF 149.49KB)

 item B.1)

The following conditions must be met for using the National Taxonomy Code – “390200000X – Student” on an 837-claim . . . The 837-claim must be submitted:

  * For one or more of the procedure codes H2011, S9484, H2019, AND 

  * The rendering provider 

  • has a valid NPI, AND
  • has a National taxonomy code 390200000X – Student, AND 
  • is a Master Level Interns with the DOH certification; Registered Agency Affiliated Counselor or Certified Agency Affiliated Counselor,  AND

  *  The claim is otherwise coded as specified in the SERI Guide and the associated worksheet, 

THEN the claim will be considered a valid claim for a valid provider and will either be auto-adjudicated OR pended for manual processing.

6) The 835 – Remittance Advice transaction will be used to report the adjudication/ processing of claims by the Commercial Carrier.

7) Involuntary stays at crisis facilities are considered Behavioral Health Emergency Services and thus allowable codes to be covered by commercial carriers. The statutes at 48.43.005 and 48.43.093 require coverage of E&T facility services and make no distinction between voluntary and involuntary stays. 

About 1688 behavioral health crisis services

With the passage of the Engrossed 2nd Substitute House Bill – E2SHB 1688 by the Washington state legislature in 2022, commercial carriers, along with managed Medicaid organizations (MCOs), will now provide insurance coverage for behavioral health crisis services as emergency services:

  • Mobile Crisis Response Services
  • Crisis Facility Services; Hospital Emergency Room, Evaluation & Treatment (E&T), Crisis Stabilization, Crisis Triage and Withdrawal Management

The OIC and HCA pulled together a multi-stakeholder workgroup (PDF 147.02KB) to recommend how to build upon the current Behavioral Health Crisis System to implement the new law.

Subscribe to Insurers and regulated entities