If an out of state BH crisis services facility is in a state (other than Washington) that has determined that these are “emergency services” under the NSA by licensing BH crisis facilities as freestanding emergency departments, then a carrier in Washington state be required to cover these out-of-state BH crisis services in compliance with the NSA’s emergency service protections if:
- The services meet the definition of “emergency services;”
- The services are provided are provided with respect to a visit to a facility that meets the definition of an “emergency department of a hospital” or an “independent freestanding emergency department; (facility separately licensed to provide emergency services)”, and
- The plan or issuer issuer provides or covers any benefits for services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department.
In plan year 2023, depending on the Region, commercial carriers may have 2 options to contract for crisis facility-based services. In some regions, the only option will be for carriers to contract directly with a behavioral health crisis facility. In other regions, the carrier may have the option of contracting with a BH-ASO on behalf of facilities and/or contracting directly with the facilities. Under both options, Fee-for-Service bills for Crisis Facility Services will be submitted to and reimbursed by the commercial carrier. (The Fee-for-Service billing methodology will be followed unless the BH-ASO/Facility and the Commercial Carrier agree upon a fixed-cost or alternative methodology.)
Current options by Region, which is subject to change:
- In the King County Region, Commercial Carriers will contract either with King BH-ASO and/or directly with Facilities.
- In other Regions, Commercial Carriers will contract directly with Facilities.
Non-contracted DOH licensed Facilities may submit claims for Crisis Facility services, as an “out-of-network” or “ nonparticipating” provider to the responsible commercial carrier In situations where a contract for administrative services is in place between a Crisis Facility and a BH-ASO AND the Crisis Facility or the BH-ASO does not have a contract with the commercial carrier that provides coverage to the person in crisis, that BH-ASO may submit claims for that facility, “out-of-network” or “nonparticipating” provider, to the responsible commercial carrier.
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 2023 |
| Contracting | Depending upon the Region, commercial carriers will contract either with the BH-ASO and/or directly with behavioral health crisis facilities in order to meet Network Access Requirements.
In a Region where a BH-ASO contracts with a Carrier, 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 the 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 crisis facilities. 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. |
| 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 OIC to show good faith efforts to contract. In recognition of the work in which the carriers and the BHES Workgroup are currently engaged, 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 theOIC 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) 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 1 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 | Depending upon Region, Commercial Carriers will either credential the Facility or will delegate credentialing of the Facility to the BH-ASO.
Facilities will be credentialed at the facility level, per their DOH licensure. |
| Determining Commercial Carrier Eligibility and Coverage | Facilities will be responsible for determining eligibility at time-of-service. If a BH-ASO is providing administrative services for that Facility, the BH-ASO will also confirm eligibility and coverage prior to notifying Carrier about a facility admission and submitting a claim to the Carrier.
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 / Facility and the commercial carrier mutually agree on a different approach in a Region, e.g., BH-ASO repository. |
| Notifying about Admission | Depending upon the Region and the contract terms, the BH-ASO / Facility will notify the Commercial Carrier about Facility admission. |
| Billing / Reimbursement / Collection | a) The SERI Guide will define the codes and conditions that will be used to bill Commercial Carriers for Facility Crisis Services.
b) A fee-for-service billing methodology will be followed, unless the BH-ASO/Facility and the Commercial Carrier agree upon a fixed-cost or alternative methodology. Rates will be negotiated between the BH-ASO and the Commercial Carrier. c) In Regions where the BH-ASO is providing administrative services to the Crisis Facility, Claims (837) will be submitted to the Commercial Carrier by the BH-ASO on behalf of the facility and any reimbursement (835) will be made to the BH-ASO. Claims would be submitted by the BH-ASO as the ‘Billing Provider’ and the Facility would be reported as the ‘Rendering Provider’. The fee paid to the Facility by the BH-ASO is negotiated between the Facility and the BH-ASO. Otherwise the facility will submit claims directly to the Commercial Carrier and reimbursement (835) will be made to the facility. d) HCA’s allocation of General Fund Dollars to the BH-ASOs will remain the same e) For those Facilities that are currently capacity funded, HCA/BH-ASOs and Facilities will discuss if/how any financial shortfalls that may result from Fee-for-Service billing will be addressed. |
| Collecting Member’s Cost Share | The decision about whether or not to collect the patient’s/enrollee’s cost share from the patient / enrollee will be left to the BH-ASO/Facility. 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/Facility for deductible, co-pay, coinsurance or any other 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 from the patient/enrollee before the Carrier’s is responsible for any payment. For non-HDHP, on average the deductible amount in Washington State for single coverage is $1,740. Per HCA (07-31-2023 Meeting Synopsis) Funds from a BH-ASO are allowed to cover all costs related to a stay at a Crisis Facility. Since most facilities bill on a per diem basis, the costs would all be inclusive for the stay. Any deductible or copay could be covered by the BH-ASO funds. Some facilities are instructed to wait for a denial by the primary insurance carrier and then pay for the stay. It depends upon the contract that the BH-ASO has with the facility. |
| Making Next Day Appointments (NDA) (E2SHB1477) | 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 with a provider that can deliver services outside of the Behavioral Health Crisis System. This process and contact list is also available to crisis facilities within the Behavioral Health Crisis System for making HB1477 – NDA.
Crisis facilities 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. |
| Care Coordination | Facilities and Commercial Carriers will set up Care Coordination / Discharge Planning processes as appropriate.
Any expectation about a BH-ASO’s involvement in Care Coordination, to include NDA’s , will be agreed upon between the Carrier and the BH-ASO. |
| The ‘Future’ of BH-ASO Administrative Services | In Regions other than King County, HCA, BH-ASOs and Facilities will work collaboratively and in good faith to consider if/how BH-ASOs might provide an administrative function for facilities. Discussions will include whether the billing methodology would be fee-for-service, capacity-fixed rate or an alternative methodology. If / as a process is viable, the Commercial Carrier will be brought into the discussion. |
| Enhancing System Capabilities to support Fee-For-Service Billing and Eligibility Determination | Per HCA (07-31-2023 Meeting Synopsis), the BH-ASO is a per diem rate paid to the facility for services. There is not a contract requirement that the per diem covers only stay related costs. The facility is allowed to utilize the funding as necessary to provide services for the individual. If the facility has a budget specific to systems implementation or administration or however they might label it within their financial statements, it would be part of the overall costs. If the facility has excess and it is considered profit or retained earnings or additional cash flow, they could utilize that as they see fit. The contracts limiting the ability to fund certain items would be highly unusual as a business practice, |