Mental health services

AN ACT Relating to improving access to appropriate mental health 1
and substance use disorder services by updating Washington's mental 2
health parity law and ensuring coverage of medically necessary care; 3
amending RCW 48.43.016, 48.43.091, 48.43.410, 48.43.520, 48.43.535, 4
48.43.761, and 48.43.830; adding a new section to chapter 48.43 RCW; 5
creating new sections; repealing RCW 48.20.580, 48.21.241, 48.41.220, 6
48.44.341, and 48.46.291; and providing effective dates.7
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:8
NEW SECTION. Sec. 1. (1) The legislature finds that:9
(a) Access to mental health and substance use disorder treatment 10
is critical to the health and well-being of individuals with these 11
conditions and that access to appropriate care is important to 12
reducing preventable emergency department visits, hospitalizations, 13
and physical health care costs associated with significant 14
comorbidities; 15
(b) Health insurance coverage is essential to ensuring that 16
individuals can access needed mental health and substance use 17
disorder treatment and that health carriers should make medical 18
necessity determinations based on the objective needs of the patient; 19
and 20
H-0502.2
HOUSE BILL 1432
State of Washington 69th Legislature 2025 Regular Session
By Representatives Simmons, Eslick, Rule, Davis, Macri, Stearns,
Reed, Goodman, Salahuddin, Pollet, Timmons, and Santos
Read first time 01/20/25. Referred to Committee on Health Care &
Wellness.
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(c) The mental health and substance use disorder workforce faces 1
a number of administrative barriers and undue financial risks with 2
respect to participation in health carriers' provider networks that 3
should be alleviated. 4
(2) Therefore, it is the intent of the legislature to increase 5
access to mental health and substance use disorder treatment by 6
updating Washington's mental health parity requirements, requiring 7
that medical necessity determinations be consistent with generally 8
accepted standards of care and recommendations from nonprofit health 9
care provider associations, requiring consistent rules for both 10
mental health and substance use disorders, and eliminating harmful 11
barriers to care. 12
NEW SECTION. Sec. 2. A new section is added to chapter 48.43 13
RCW to read as follows: 14
(1) For the purposes of this section: 15
(a) "Clinical review criteria" means any criteria, standards, 16
protocols, or guidelines used by a health carrier to conduct 17
utilization review. 18
(b) "Core treatment" means a standard treatment or course of 19
treatment, therapy, service, or intervention indicated by generally 20
accepted standards of mental health and substance use disorder care 21
for a condition or disorder. 22
(c) "Generally accepted standards of mental health and substance 23
use disorder care" means standards of care and clinical practice that 24
are generally recognized by health care providers practicing in 25
relevant clinical specialties such as psychiatry, psychology, 26
clinical sociology, social work, addiction medicine and counseling, 27
and behavioral health treatment. Valid, evidence-based sources 28
establishing generally accepted standards of care include peer-29
reviewed scientific studies and medical literature, and 30
recommendations of nonprofit professional associations including, but 31
not limited to, patient placement criteria and clinical practice 32
guidelines, recommendations of federal government agencies, and drug 33
labeling approved by the United States food and drug administration.34
(d) "Medically necessary" means a service or product addressing 35
the specific needs of a patient, for the purpose of screening, 36
preventing, diagnosing, managing, or treating an illness, injury, 37
condition, or its symptoms, including minimizing the progression of 38
an illness, injury, condition, or its symptoms, in a manner that is:39
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(i) In accordance with generally accepted standards of mental 1
health and substance use disorder care; 2
(ii) Clinically appropriate in terms of type, frequency, extent, 3
site, and duration of a service or product; and 4
(iii) Not primarily for the economic benefit of the insurer or 5
purchaser or for the convenience of the patient, treating physician, 6
or other health care provider. 7
(e) "Mental health services" means: 8
(i) For health benefit plans issued or renewed before January 1, 9
2021, medically necessary outpatient and inpatient services provided 10
to treat mental disorders covered by the diagnostic categories listed 11
in the most current version of the diagnostic and statistical manual 12
of mental disorders, published by the American psychiatric 13
association, on June 11, 2020, or such subsequent date as may be 14
provided by the insurance commissioner by rule, consistent with the 15
purposes of chapter 6, Laws of 2005, with the exception of the 16
following categories, codes, and services: (A) Substance related 17
disorders; (B) life transition problems, currently referred to as "V" 18
codes, and diagnostic codes 302 through 302.9 as found in the 19
diagnostic and statistical manual of mental disorders, 4th edition, 20
published by the American psychiatric association; (C) skilled 21
nursing facility services, home health care, residential treatment, 22
and custodial care; and (D) court-ordered treatment, unless the 23
insurer's medical director or designee determines the treatment to be 24
medically necessary; 25
(ii) For a health benefit plan or a plan deemed by the 26
commissioner to have a short-term limited purpose or duration, or to 27
be a student-only health plan that is guaranteed renewable while the 28
covered person is enrolled as a regular, full-time undergraduate 29
student at an accredited higher education institution, issued or 30
renewed on or after January 1, 2021, medically necessary outpatient 31
services, residential care, partial hospitalization services, and 32
inpatient services provided to treat mental health and substance use 33
disorders covered by the diagnostic categories listed in the most 34
current version of the diagnostic and statistical manual of mental 35
disorders, published by the American psychiatric association, on June 36
11, 2020, or such subsequent date as may be provided by the insurance 37
commissioner by rule, consistent with the purposes of chapter 6, Laws 38
of 2005; and 39
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(iii) For a health benefit plan or a plan deemed by the 1
commissioner to have a short-term limited purpose or duration, or to 2
be a student-only health plan that is guaranteed renewable while the 3
covered person is enrolled as a regular, full-time undergraduate 4
student at an accredited higher education institution, issued or 5
renewed on or after January 1, 2026, medically necessary outpatient 6
services, residential care, partial hospitalization services, 7
inpatient services, and prescription drugs provided to treat mental 8
health or substance use disorders covered by: 9
(A) The diagnostic categories listed in the most current version 10
of the diagnostic and statistical manual of mental disorders, 11
published by the American psychiatric association, on June 11, 2020, 12
or such subsequent date as may be provided by the insurance 13
commissioner by rule, consistent with the purposes of chapter 6, Laws 14
of 2005; or 15
(B) The diagnostic categories listed in the mental, behavioral, 16
and neurodevelopmental chapters of the version available on January 17
13, 2025, of the international classification of diseases adopted by 18
the federal department of health and human services through 42 C.F.R. 19
Sec. 162.002 or any subsequent version as determined by the insurance 20
commissioner in rule consistent with this section and the goals 21
listed in section 1 of this act. 22
(f) "Nonprofit professional association" means a not-for-profit 23
health care provider professional association or specialty society 24
that is generally recognized by clinicians practicing in the relevant 25
clinical specialty and issues peer-reviewed guidelines, criteria, or 26
other clinical recommendations developed through a transparent 27
process. 28
(g) "Utilization review" means the prospective, concurrent, or 29
retrospective assessment of the medical necessity and appropriateness 30
of the allocation of health care resources and services of a provider 31
or facility, given or proposed to be given to an enrollee or group of 32
enrollees. 33
(2) Each health plan providing coverage for medical and surgical 34
services shall provide coverage for: 35
(a) Mental health services. The copayment or coinsurance for 36
mental health services may be no more than the copayment or 37
coinsurance for medical and surgical services otherwise provided 38
under the health plan. Wellness and preventive services that are 39
provided or reimbursed at a lesser copayment, coinsurance, or other 40
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cost sharing than other medical and surgical services are excluded 1
from this comparison. If the health plan imposes a maximum 2
out-of-pocket limit or stop loss, it shall be a single limit or stop 3
loss for medical, surgical, and mental health services. If the health 4
plan imposes any deductible, mental health services shall be included 5
with medical and surgical services for the purpose of meeting the 6
deductible requirement. Treatment limitations or any other financial 7
requirements on coverage for mental health services are only allowed 8
if the same limitations or requirements are imposed on coverage for 9
medical and surgical services; and 10
(b) Prescription drugs intended to treat any of the disorders 11
covered in this section to the same extent, and under the same terms 12
and conditions, as other prescription drugs covered by the health 13
plan. 14
(3) Utilization review and clinical review criteria must be 15
consistent with generally accepted standards of mental health and 16
substance use disorder care. 17
(4) In conducting utilization reviews relating to service 18
intensity or level of care placement, continued stay, or transfer or 19
discharge, the health carrier shall apply relevant age-appropriate 20
patient placement criteria from nonprofit professional associations 21
and shall authorize placement at the service intensity and level of 22
care consistent with that criteria. The health carrier may not apply 23
different, additional, conflicting, or more restrictive criteria. If 24
the assessed level of placement is not available, the health carrier 25
shall authorize the next higher level of care. In the event of 26
disagreement with the provider, as part of the adverse benefit 27
determination, the health carrier shall provide full detail of its 28
assessment to the provider and the covered person.29
(5) A health carrier may not limit benefits or coverage for 30
medically necessary mental health services on the basis that those 31
services should or could be covered by a public entitlement program 32
including, but not limited to, special education or an individualized 33
education program, medicaid, medicare, supplemental security income, 34
or social security disability insurance, and may not include or 35
enforce a contract term that excludes otherwise covered benefits on 36
the basis that those services should or could be covered by a public 37
entitlement program. 38
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(6) This section applies to any health care benefit manager, as 1
defined in RCW 48.200.020 or contracted provider that performs 2
utilization review functions on a health carrier's behalf.3
(7) A health carrier may not adopt, impose, or enforce terms in 4
its policies or provider agreements, in writing or in operation, in a 5
manner that undermines, alters, or conflicts with the requirements of 6
this section. 7
(8) If a health carrier provides any benefits for a mental health 8
condition or substance use disorder in any classification of 9
benefits, it shall provide meaningful benefits for that mental health 10
condition or substance use disorder in every classification in which 11
medical or surgical benefits are provided. For purposes of this 12
subsection, whether the benefits provided are considered "meaningful 13
benefits" is determined in comparison to the benefits provided for 14
medical conditions and surgical procedures in the classification and 15
requires, at a minimum, coverage of benefits for that condition or 16
disorder in each classification in which the health carrier provides 17
benefits for one or more medical conditions or surgical procedures. A 18
health carrier does not provide meaningful benefits under this 19
subsection unless it provides benefits for a core treatment for that 20
condition or disorder in each classification in which the health 21
carrier provides benefits for a core treatment for one or more 22
medical conditions or surgical procedures. If there is no core 23
treatment for a covered mental health condition or substance use 24
disorder with respect to a classification, the health carrier is not 25
required to provide benefits for a core treatment for such condition 26
or disorder in that classification, but shall provide benefits for 27
such condition or disorder in every classification in which medical 28
or surgical benefits are provided. 29
(9) The requirements related to the mental health parity and 30
addiction equity act, 89 Fed. Reg. 77586 (September 23, 2024), are 31
incorporated in this section in their entirety. 32
(10) If a health care provider or a current or prospective 33
covered person requests one or more nonquantitative treatment 34
limitation parity compliance analyses that the health carrier is 35
required to have completed by 29 U.S.C. Sec. 1185a or 42 U.S.C. Sec. 36
300gg–26, the health carrier shall provide the requested analyses 37
free of charge. The health carrier shall include in each of their 38
health plan policies and mental health and substance use disorder 39
provider contracts a notification of the right to request 40
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nonquantitative treatment limitation analyses free of charge. The 1
notification must include information on how to request the analyses. 2
In addition to any other action authorized under RCW 48.02.080, 3
48.05.185, 48.44.166, and 48.46.135, failure by a health carrier to 4
provide the full requested analyses shall result in a penalty of $100 5
per day, which shall be collected by the commissioner and remitted to 6
the requestor. 7
(11) If the commissioner determines that a health carrier has 8
violated this section, the commissioner may, after appropriate notice 9
and opportunity for hearing as required under chapters 48.04 and 10
34.05 RCW, by order, assess a civil monetary penalty not to exceed 11
$5,000 for each violation, or, if a violation was willful, a civil 12
monetary penalty not to exceed $10,000 for each violation. The civil 13
monetary penalties available to the commissioner pursuant to this 14
section are not exclusive and may be sought and employed in 15
combination with any other remedies available to the commissioner 16
under RCW 48.02.080. Beginning January 1, 2031, and every five years 17
thereafter, the penalty amounts specified in this section must be 18
adjusted based on the weighted cumulative average rate of change in 19
premium rates for the individual, small, and large group markets for 20
the previous five years. 21
(12) A violation of this section shall also be considered a 22
violation of RCW 48.43.0128. 23
(13) This section does not prohibit a requirement that mental 24
health services be medically necessary, if a comparable requirement 25
is applicable to medical and surgical services. 26
Sec. 3. RCW 48.43.016 and 2020 c 193 s 2 are each amended to 27
read as follows: 28
(1) A health carrier or its contracted entity that imposes 29
different prior authorization standards and criteria for a covered 30
service among tiers of contracting providers of the same licensed 31
profession in the same health plan shall inform an enrollee which 32
tier an individual provider or group of providers is in by posting 33
the information on its website in a manner accessible to both 34
enrollees and providers. 35
(2)(a) A health carrier or its contracted entity may not require 36
utilization management or review of any kind including, but not 37
limited to, prior, concurrent, or postservice authorization for an 38
initial evaluation and management visit and up to six treatment 39
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visits with a contracting provider in a new episode of care for each 1
of the following: Chiropractic, physical therapy, occupational 2
therapy, acupuncture and Eastern medicine, massage therapy, 3
outpatient mental health care, outpatient substance use disorder 4
care, or speech and hearing therapies. Visits for which utilization 5
management or review is prohibited under this section are subject to 6
quantitative treatment limits of the health plan. Notwithstanding RCW 7
48.43.515(5) this section may not be interpreted to limit the ability 8
of a health plan to require a referral or prescription for the 9
therapies listed in this section. 10
(b) For visits for which utilization management or review is 11
prohibited under this section, a health carrier or its contracted 12
entity may not: 13
(i) Deny or limit coverage on the basis of medical necessity or 14
appropriateness; or 15
(ii) Retroactively deny care or refuse payment for the visits.16
(3) A health carrier shall post on its website and provide upon 17
the request of a covered person or contracting provider any prior 18
authorization standards, criteria, or information the carrier uses 19
for medical necessity decisions. 20
(4) A health care provider with whom a health carrier consults 21
regarding a decision to deny, limit, or terminate a person's covered 22
health care services must hold a license, certification, or 23
registration, in good standing and must be in the same or related 24
health field as the health care provider being reviewed or of a 25
specialty whose practice entails the same or similar covered health 26
care service. 27
(5) A health carrier may not require a provider to provide a 28
discount from usual and customary rates for health care services not 29
covered under a health plan, policy, or other agreement, to which the 30
provider is a party. 31
(6) Nothing in this section prevents a health carrier from 32
denying coverage based on insurance fraud. 33
(7) For purposes of this section: 34
(a) "New episode of care" means treatment for a new condition or 35
diagnosis for which the enrollee has not been treated by a provider 36
of the same licensed profession within the previous ninety days and 37
is not currently undergoing any active treatment. 38
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(b) "Contracting provider" does not include providers employed 1
within an integrated delivery system operated by a carrier licensed 2
under chapter 48.44 or 48.46 RCW. 3
Sec. 4. RCW 48.43.091 and 1999 c 87 s 1 are each amended to read 4
as follows: 5
(1) Every health carrier that provides coverage for any 6
((outpatient)) mental health ((service)) services, as defined in 7
section 2 of this act, shall comply with the following requirements:8
(((1))) (a) In performing a utilization review of mental health 9
services for a specific enrollee, the utilization review is limited 10
to accessing only the specific health care information contained in 11
the enrollee's record. 12
(((2))) (b) In performing an audit of a provider that has 13
furnished mental health services to a carrier's enrollees, the audit 14
is limited to accessing only the records of enrollees covered by the 15
specific health carrier for which the audit is being performed, 16
except as otherwise permitted by RCW 70.02.050 ((and 71.05.630)).17
(c) A health carrier shall approve coverage of mental health 18
services that are the subject of a prescription drug exception 19
request, an enrollee grievance, or appeal, or a prior authorization 20
request if the health carrier does not respond to the request, 21
grievance, or appeal within the time frames applicable under RCW 22
48.43.420, 48.43.530, or 48.43.830.23
(2) A health carrier may not request a refund of amounts paid to 24
a provider from that provider for mental health services more than 25
180 days after the date of payment, except in cases of fraud.26
Sec. 5. RCW 48.43.410 and 2019 c 171 s 2 are each amended to 27
read as follows: 28
For health plans delivered, issued for delivery, or renewed on or 29
after January 1, 2021, clinical review criteria used to establish a 30
prescription drug utilization management protocol must be evidence-31
based and updated on a regular basis through review of new evidence, 32
research, and newly developed treatments. For prescription drugs 33
prescribed to treat mental health or substance use disorder 34
conditions, clinical review criteria must meet the requirements of 35
section 2 of this act.36
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Sec. 6. RCW 48.43.520 and 2000 c 5 s 8 are each amended to read 1
as follows: 2
(1) Carriers that offer a health plan shall maintain a documented 3
utilization review program description and written utilization review 4
criteria based on reasonable medical evidence. The program must 5
include a method for reviewing and updating criteria. Carriers shall 6
make clinical protocols, medical management standards, and other 7
review criteria available upon request to participating providers. 8
For mental health services, as defined in section 2 of this act, 9
clinical review criteria must meet the requirements of section 2 of 10
this act.11
(2) The commissioner shall adopt, in rule, standards for this 12
section after considering relevant standards adopted by national 13
managed care accreditation organizations and state agencies that 14
purchase managed health care services. 15
(3) A carrier shall not be required to use medical evidence or 16
standards in its utilization review of religious nonmedical treatment 17
or religious nonmedical nursing care. 18
Sec. 7. RCW 48.43.535 and 2022 c 263 s 4 are each amended to 19
read as follows: 20
(1) There is a need for a process for the fair consideration of 21
disputes relating to decisions by carriers that offer a health plan 22
to deny, modify, reduce, or terminate coverage of or payment for 23
health care services for an enrollee. For purposes of this section, 24
"carrier" also applies to a health plan if the health plan 25
administers the appeal process directly or through a third party.26
(2) An enrollee may seek review by a certified independent review 27
organization of a carrier's decision to deny, modify, reduce, or 28
terminate coverage of or payment for a health care service or of any 29
adverse determination made by a carrier under RCW 48.49.020, 30
48.49.030, or sections 2799A-1 or 2799A-2 of the public health 31
service act (42 U.S.C. Secs. 300gg-111 or 300gg-112) and implementing 32
federal regulations in effect as of March 31, 2022, after exhausting 33
the carrier's grievance process and receiving a decision that is 34
unfavorable to the enrollee, or after the carrier has exceeded the 35
timelines for grievances provided in RCW 48.43.530, without good 36
cause and without reaching a decision. 37
(3) The commissioner must establish and use a rotational registry 38
system for the assignment of a certified independent review 39
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organization to each dispute. The system should be flexible enough to 1
ensure that an independent review organization has the expertise 2
necessary to review the particular medical condition or service at 3
issue in the dispute, and that any approved independent review 4
organization does not have a conflict of interest that will influence 5
its independence. 6
(4) Carriers must provide to the appropriate certified 7
independent review organization, not later than the third business 8
day after the date the carrier receives a request for review, a copy 9
of: 10
(a) Any medical records of the enrollee that are relevant to the 11
review; 12
(b) Any documents used by the carrier in making the determination 13
to be reviewed by the certified independent review organization;14
(c) Any documentation and written information submitted to the 15
carrier in support of the appeal; and 16
(d) A list of each physician or health care provider who has 17
provided care to the enrollee and who may have medical records 18
relevant to the appeal. Health information or other confidential or 19
proprietary information in the custody of a carrier may be provided 20
to an independent review organization, subject to rules adopted by 21
the commissioner. 22
(5) Enrollees must be provided with at least five business days 23
to submit to the independent review organization in writing 24
additional information that the independent review organization must 25
consider when conducting the external review. The independent review 26
organization must forward any additional information submitted by an 27
enrollee to the plan or carrier within one business day of receipt by 28
the independent review organization. 29
(6) The medical reviewers from a certified independent review 30
organization will make determinations regarding the medical necessity 31
or appropriateness of, and the application of health plan coverage 32
provisions to, health care services for an enrollee. The medical 33
reviewers' determinations must be based upon their expert medical 34
judgment, after consideration of relevant medical, scientific, and 35
cost-effectiveness evidence, and medical standards of practice in the 36
state of Washington. Except as provided in this subsection, the 37
certified independent review organization must ensure that 38
determinations are consistent with the scope of covered benefits as 39
outlined in the medical coverage agreement. Medical reviewers may 40
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override the health plan's medical necessity or appropriateness 1
standards if the standards are determined upon review to be 2
unreasonable or inconsistent with sound, evidence-based medical 3
practice. For reviews of mental health services, as defined in 4
section 2 of this act, the medical reviewers must conduct reviews and 5
make determinations in a manner consistent with the requirements of 6
section 2 of this act.7
(7) Once a request for an independent review determination has 8
been made, the independent review organization must proceed to a 9
final determination, unless requested otherwise by both the carrier 10
and the enrollee or the enrollee's representative.11
(a) An enrollee or carrier may request an expedited external 12
review if the adverse benefit determination or internal adverse 13
benefit determination concerns an admission, availability of care, 14
continued stay, or health care service for which the claimant 15
received emergency services but has not been discharged from a 16
facility; or involves a medical condition for which the standard 17
external review time frame would seriously jeopardize the life or 18
health of the enrollee or jeopardize the enrollee's ability to regain 19
maximum function. The independent review organization must make its 20
decision to uphold or reverse the adverse benefit determination or 21
final internal adverse benefit determination and notify the enrollee 22
and the carrier or health plan of the determination as expeditiously 23
as possible but within not more than seventy-two hours after the 24
receipt of the request for expedited external review. If the notice 25
is not in writing, the independent review organization must provide 26
written confirmation of the decision within forty-eight hours after 27
the date of the notice of the decision. 28
(b) For claims involving experimental or investigational 29
treatments, the independent review organization must ensure that 30
adequate clinical and scientific experience and protocols are taken 31
into account as part of the external review process.32
(8) Carriers must timely implement the certified independent 33
review organization's determination, and must pay the certified 34
independent review organization's charges. 35
(9) When an enrollee requests independent review of a dispute 36
under this section, and the dispute involves a carrier's decision to 37
modify, reduce, or terminate an otherwise covered health service that 38
an enrollee is receiving at the time the request for review is 39
submitted and the carrier's decision is based upon a finding that the 40
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health service, or level of health service, is no longer medically 1
necessary or appropriate, the carrier must continue to provide the 2
health service if requested by the enrollee until a determination is 3
made under this section. If the determination affirms the carrier's 4
decision, the enrollee may be responsible for the cost of the 5
continued health service. 6
(10) Each certified independent review organization must maintain 7
written records and make them available upon request to the 8
commissioner. 9
(11) A certified independent review organization may notify the 10
office of the insurance commissioner if, based upon its review of 11
disputes under this section, it finds a pattern of substandard or 12
egregious conduct by a carrier. 13
(12)(a) The commissioner shall adopt rules to implement this 14
section after considering relevant standards adopted by national 15
managed care accreditation organizations and the national association 16
of insurance commissioners. 17
(b) This section is not intended to supplant any existing 18
authority of the office of the insurance commissioner under this 19
title to oversee and enforce carrier compliance with applicable 20
statutes and rules. 21
Sec. 8. RCW 48.43.761 and 2024 c 366 s 7 are each amended to 22
read as follows: 23
(1) Except as provided in subsection (2) of this section, a 24
health plan issued or renewed on or after January 1, ((2021)) 2026, 25
may not require an enrollee to obtain prior authorization for 26
withdrawal management services or inpatient or residential substance 27
use disorder or mental health treatment services in a behavioral 28
health agency licensed or certified under RCW 71.24.037.29
(2)(a) A health plan issued or renewed on or after January 1, 30
((2021)) 2026, must: 31
(i) Provide coverage for no less than two business days, 32
excluding weekends and holidays, in a behavioral health agency that 33
provides inpatient or residential mental health or substance use 34
disorder treatment prior to conducting a utilization review; and35
(ii) Provide coverage for no less than three days in a behavioral 36
health agency that provides withdrawal management services prior to 37
conducting a utilization review. 38
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(b)(i) The health plan may not require an enrollee to obtain 1
prior authorization for the services specified in (a) of this 2
subsection as a condition for payment of services prior to the times 3
specified in (a) of this subsection. 4
(ii) Once the times specified in (a) of this subsection have 5
passed, the health plan may initiate utilization management review 6
procedures if the behavioral health agency continues to provide 7
services or is in the process of arranging for a seamless transfer to 8
an appropriate facility or lower level of care under subsection (6) 9
of this section. For a health plan issued or renewed on or after 10
January 1, ((2025)) 2026, if a health plan authorizes inpatient or 11
residential mental health or substance use disorder treatment 12
services pursuant to (a)(i) of this subsection following the initial 13
medical necessity review process under (c)(iii) of this subsection, 14
the length of the initial authorization may not be less than 14 days 15
from the date that the patient was admitted to the behavioral health 16
agency. Any subsequent reauthorization that the health plan approves 17
after the first 14 days must continue for no less than seven days 18
prior to requiring further reauthorization. Nothing prohibits a 19
health plan from requesting information to assist with a seamless 20
transfer under this subsection. 21
(c)(i) The behavioral health agency under (a) of this subsection 22
must notify an enrollee's health plan as soon as practicable after 23
admitting the enrollee, but not later than ((twenty-four)) 24 hours 24
after admitting the enrollee. The time of notification does not 25
reduce the requirements established in (a) of this subsection.26
(ii) The behavioral health agency under (a) of this subsection 27
must provide the health plan with its initial assessment and initial 28
treatment plan for the enrollee within two business days of 29
admission, excluding weekends and holidays, or within three days in 30
the case of a behavioral health agency that provides withdrawal 31
management services. 32
(iii) After the time period in (a) of this subsection and receipt 33
of the material provided under (c)(ii) of this subsection, the plan 34
may initiate a medical necessity review process. Medical necessity 35
((review)) reviews for a primary diagnosis of substance use disorder 36
must be based on the standard set of criteria established under RCW 37
41.05.528. Medical necessity reviews for a primary diagnosis of a 38
mental health disorder other than a substance use disorder must 39
comply with the requirements of section 2 of this act. In a review 40
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for inpatient or residential substance use disorder treatment 1
services, a health plan may not make a determination that a patient 2
does not meet medical necessity criteria based primarily on the 3
patient's length of abstinence. If the patient's abstinence from 4
substance use was due to incarceration, hospitalization, or inpatient 5
treatment, a health plan may not consider the patient's length of 6
abstinence in determining medical necessity. If the health plan 7
determines within one business day from the start of the medical 8
necessity review period and receipt of the material provided under 9
(c)(ii) of this subsection that the admission to the facility was not 10
medically necessary and advises the agency of the decision in 11
writing, the health plan is not required to pay the facility for 12
services delivered after the start of the medical necessity review 13
period, subject to the conclusion of a filed appeal of the adverse 14
benefit determination. If the health plan's medical necessity review 15
is completed more than one business day after the start of the 16
medical necessity review period and receipt of the material provided 17
under (c)(ii) of this subsection, the health plan must pay for the 18
services delivered from the time of admission until the time at which 19
the medical necessity review is completed and the agency is advised 20
of the decision in writing. 21
(3)(a) The behavioral health agency shall document to the health 22
plan the patient's need for continuing care and justification for 23
level of care placement following the current treatment period, based 24
on the standard set of criteria established under RCW 41.05.528, with 25
documentation recorded in the patient's medical record.26
(b) For a health plan issued or renewed on or after January 1, 27
2025, for inpatient or residential mental health or substance use 28
disorder treatment services, the health plan may not consider the 29
patient's length of stay at the behavioral health agency when making 30
decisions regarding the authorization to continue care at the 31
behavioral health agency. 32
(4) Nothing in this section prevents a health carrier from 33
denying coverage based on insurance fraud. 34
(5) If the behavioral health agency under subsection (2)(a) of 35
this section is not in the enrollee's network: 36
(a) The health plan is not responsible for reimbursing the 37
behavioral health agency at a greater rate than would be paid had the 38
agency been in the enrollee's network; and 39
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(b) The behavioral health agency may not balance bill, as defined 1
in RCW 48.43.005. 2
(6) When the treatment plan approved by the health plan involves 3
transfer of the enrollee to a different facility or to a lower level 4
of care, the care coordination unit of the health plan shall work 5
with the current agency to make arrangements for a seamless transfer 6
as soon as possible to an appropriate and available facility or level 7
of care. The health plan shall pay the agency for the cost of care at 8
the current facility until the seamless transfer to the different 9
facility or lower level of care is complete. A seamless transfer to a 10
lower level of care may include same day or next day appointments for 11
outpatient care, and does not include payment for nontreatment 12
services, such as housing services. If placement with an agency in 13
the health plan's network is not available, the health plan shall pay 14
the current agency until a seamless transfer arrangement is made.15
(7) The requirements of this section do not apply to treatment 16
provided in out-of-state facilities. 17
(8) For the purposes of this section "withdrawal management 18
services" means twenty-four hour medically managed or medically 19
monitored detoxification and assessment and treatment referral for 20
adults or adolescents withdrawing from alcohol or drugs, which may 21
include induction on medications for addiction recovery.22
Sec. 9. RCW 48.43.830 and 2023 c 382 s 1 are each amended to 23
read as follows: 24
(1) Each carrier offering a health plan issued or renewed on or 25
after January 1, 2024, shall comply with the following standards 26
related to prior authorization for health care services and 27
prescription drugs: 28
(a) The carrier shall meet the following time frames for prior 29
authorization determinations and notifications to a participating 30
provider or facility that submits the prior authorization request 31
through an electronic prior authorization process, as designated by 32
each carrier: 33
(i) For electronic standard prior authorization requests, the 34
carrier shall make a decision and notify the provider or facility of 35
the results of the decision within three calendar days, excluding 36
holidays, of submission of an electronic prior authorization request 37
by the provider or facility that contains the necessary information 38
to make a determination. If insufficient information has been 39
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provided to the carrier to make a decision, the carrier shall request 1
any additional information from the provider or facility within one 2
calendar day of submission of the electronic prior authorization 3
request. 4
(ii) For electronic expedited prior authorization requests, the 5
carrier shall make a decision and notify the provider or facility of 6
the results of the decision within one calendar day of submission of 7
an electronic prior authorization request by the provider or facility 8
that contains the necessary information to make a determination. If 9
insufficient information has been provided to the carrier to make a 10
decision, the carrier shall request any additional information from 11
the provider or facility within one calendar day of submission of the 12
electronic prior authorization request. 13
(b) The carrier shall meet the following time frames for prior 14
authorization determinations and notifications to a participating 15
provider or facility that submits the prior authorization request 16
through a process other than an electronic prior authorization 17
process: 18
(i) For nonelectronic standard prior authorization requests, the 19
carrier shall make a decision and notify the provider or facility of 20
the results of the decision within five calendar days of submission 21
of a nonelectronic prior authorization request by the provider or 22
facility that contains the necessary information to make a 23
determination. If insufficient information has been provided to the 24
carrier to make a decision, the carrier shall request any additional 25
information from the provider or facility within five calendar days 26
of submission of the nonelectronic prior authorization request.27
(ii) For nonelectronic expedited prior authorization requests, 28
the carrier shall make a decision and notify the provider or facility 29
of the results of the decision within two calendar days of submission 30
of a nonelectronic prior authorization request by the provider or 31
facility that contains the necessary information to make a 32
determination. If insufficient information has been provided to the 33
carrier to make a decision, the carrier shall request any additional 34
information from the provider or facility within one calendar day of 35
submission of the nonelectronic prior authorization request.36
(c) In any instance in which a carrier has determined that a 37
provider or facility has not provided sufficient information for 38
making a determination under (a) and (b) of this subsection, a 39
carrier may establish a specific reasonable time frame for submission 40
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of the additional information. This time frame must be communicated 1
to the provider and enrollee with a carrier's request for additional 2
information. 3
(d) The carrier's prior authorization requirements must be 4
described in detail and written in easily understandable language. 5
The carrier shall make its most current prior authorization 6
requirements and restrictions, including the written clinical review 7
criteria, available to providers and facilities in an electronic 8
format upon request. The prior authorization requirements must be 9
based on peer-reviewed clinical review criteria. The clinical review 10
criteria must be evidence-based criteria and must accommodate new and 11
emerging information related to the appropriateness of clinical 12
criteria with respect to black and indigenous people, other people of 13
color, gender, and underserved populations. The clinical review 14
criteria must be evaluated and updated, if necessary, at least 15
annually. Clinical review criteria used for purposes of reviewing and 16
decided upon prior authorization requests related to mental health 17
services, as defined in section 2 of this act, must meet the 18
requirements of section 2 of this act.19
(2)(a) Each carrier shall build and maintain a prior 20
authorization application programming interface that automates the 21
process for in-network providers to determine whether a prior 22
authorization is required for health care services, identify prior 23
authorization information and documentation requirements, and 24
facilitate the exchange of prior authorization requests and 25
determinations from its electronic health records or practice 26
management system. The application programming interface must support 27
the exchange of prior authorization requests and determinations for 28
health care services beginning January 1, 2025, and must:29
(i) Use health level 7 fast health care interoperability 30
resources in accordance with standards and provisions defined in 45 31
C.F.R. Sec. 170.215 and 45 C.F.R. Sec. 156.22(3)(b);32
(ii) Automate the process to determine whether a prior 33
authorization is required for durable medical equipment or a health 34
care service; 35
(iii) Allow providers to query the carrier's prior authorization 36
documentation requirements; 37
(iv) Support an automated approach using nonproprietary open 38
workflows to compile and exchange the necessary data elements to 39
populate the prior authorization requirements that are compliant with 40
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the federal health insurance portability and accountability act of 1
1996 or have an exception from the federal centers for medicare and 2
medicaid services; and 3
(v) Indicate that a prior authorization denial or authorization 4
of a service less intensive than that included in the original 5
request is an adverse benefit determination and is subject to the 6
carrier's grievance and appeal process under RCW 48.43.535.7
(b) Each carrier shall establish and maintain an interoperable 8
electronic process or application programming interface that 9
automates the process for in-network providers to determine whether a 10
prior authorization is required for a covered prescription drug. The 11
application programming interface must support the exchange of prior 12
authorization requests and determinations for prescription drugs, 13
including information on covered alternative prescription drugs, 14
beginning January 1, 2027, and must: 15
(i) Allow providers to identify prior authorization information 16
and documentation requirements; 17
(ii) Facilitate the exchange of prior authorization requests and 18
determinations from its electronic health records or practice 19
management system, and may include the necessary data elements to 20
populate the prior authorization requirements that are compliant with 21
the federal health insurance portability and accountability act of 22
1996 or have an exception from the federal centers for medicare and 23
medicaid services; and 24
(iii) Indicate that a prior authorization denial or authorization 25
of a drug other than the one included in the original prior 26
authorization request is an adverse benefit determination and is 27
subject to the carrier's grievance and appeal process under RCW 28
48.43.535. 29
(c) If federal rules related to standards for using an 30
application programming interface to communicate prior authorization 31
status to providers are not finalized by the federal centers for 32
medicare and medicaid services by September 13, 2023, the 33
requirements of (a) of this subsection may not be enforced until 34
January 1, 2026. 35
(d)(i) If a carrier determines that it will not be able to 36
satisfy the requirements of (a) of this subsection by January 1, 37
2025, the carrier shall submit a narrative justification to the 38
commissioner on or before September 1, 2024, describing:39
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(A) The reasons that the carrier cannot reasonably satisfy the 1
requirements; 2
(B) The impact of noncompliance upon providers and enrollees;3
(C) The current or proposed means of providing health information 4
to the providers; and 5
(D) A timeline and implementation plan to achieve compliance with 6
the requirements. 7
(ii) The commissioner may grant a one-year delay in enforcement 8
of the requirements of (a) of this subsection (2) if the commissioner 9
determines that the carrier has made a good faith effort to comply 10
with the requirements. 11
(iii) This subsection (2)(d) shall not apply if the delay in 12
enforcement in (c) of this subsection takes effect because the 13
federal centers for medicare and medicaid services did not finalize 14
the applicable regulations by September 13, 2023. 15
(e) By September 13, 2023, and at least every six months 16
thereafter until September 13, 2026, the commissioner shall provide 17
an update to the health care policy committees of the legislature on 18
the development of rules and implementation guidance from the federal 19
centers for medicare and medicaid services regarding the standards 20
for development of application programming interfaces and 21
interoperable electronic processes related to prior authorization 22
functions. The updates should include recommendations, as 23
appropriate, on whether the status of the federal rule development 24
aligns with the provisions of chapter 382, Laws of 2023. The 25
commissioner also shall report on any actions by the federal centers 26
for medicare and medicaid services to exercise enforcement discretion 27
related to the implementation and maintenance of an application 28
programming interface for prior authorization functions. The 29
commissioner shall consult with the health care authority, carriers, 30
providers, and consumers on the development of these updates and any 31
recommendations. 32
(3) Nothing in this section applies to prior authorization 33
determinations made pursuant to RCW 48.43.761. 34
(4) For the purposes of this section: 35
(a) "Expedited prior authorization request" means a request by a 36
provider or facility for approval of a health care service or 37
prescription drug where: 38
(i) The passage of time: 39
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(A) Could seriously jeopardize the life or health of the 1
enrollee; 2
(B) Could seriously jeopardize the enrollee's ability to regain 3
maximum function; or 4
(C) In the opinion of a provider or facility with knowledge of 5
the enrollee's medical condition, would subject the enrollee to 6
severe pain that cannot be adequately managed without the health care 7
service or prescription drug that is the subject of the request; or8
(ii) The enrollee is undergoing a current course of treatment 9
using a nonformulary drug. 10
(b) "Standard prior authorization request" means a request by a 11
provider or facility for approval of a health care service or 12
prescription drug where the request is made in advance of the 13
enrollee obtaining a health care service or prescription drug that is 14
not required to be expedited. 15
NEW SECTION. Sec. 10. The insurance commissioner may adopt 16
rules:17
(1) Necessary to administer and implement this act;18
(2) Specifying data testing requirements to determine plan design 19
and in-operation parity compliance for quantitative and 20
nonquantitative treatment limitations, including but not limited to 21
prior authorization, concurrent review, retrospective review, 22
credentialing standards, and reimbursement rates. Such data testing 23
requirements may utilize independent generally recognized benchmarks 24
to determine parity compliance; 25
(3) Specifying requirements relating to increases in network 26
reimbursement rates for mental health services to remedy a health 27
carrier's network inadequacies; and 28
(4) To ensure consistent utilization review and application of 29
clinical review criteria to meet the requirements of this act, 30
including identification of clinical review criteria that are 31
consistent with generally accepted standards of mental health and 32
substance use disorder care. 33
NEW SECTION. Sec. 11. Sections 1 through 9 of this act take 34
effect January 1, 2026.35
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NEW SECTION. Sec. 12. The following acts or parts of acts, as 1
now existing or hereafter amended, are each repealed, effective 2
January 1, 2026:3
(1) RCW 48.20.580 (Mental health services — Definition— Coverage 4
required, when) and 2020 c 228 s 2 & 2007 c 8 s 1; 5
(2) RCW 48.21.241 (Mental health services — Group health plans — 6
Definition— Coverage required, when) and 2020 c 228 s 3, 2007 c 8 s 2, 7
2006 c 74 s 1, & 2005 c 6 s 3; 8
(3) RCW 48.41.220 (Mental health services — Definition— Coverage 9
required, when) and 2020 c 228 s 4 & 2007 c 8 s 6;10
(4) RCW 48.44.341 (Mental health services — Health plans — 11
Definition— Coverage required, when) and 2020 c 228 s 5, 2007 c 8 s 3, 12
2006 c 74 s 2, & 2005 c 6 s 4; and 13
(5) RCW 48.46.291 (Mental health services — Health plans — 14
Definition— Coverage required, when) and 2020 c 228 s 6, 2007 c 8 s 4, 15
2006 c 74 s 3, & 2005 c 6 s 5. 16
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