WA Senate Bill 6228 Brings New Rules for 2025

In 2024, the Washington state legislature passed a law that establishes new standards for authorizing inpatient or residential substance use disorder (SUD) treatment and withdrawal management (detox) and includes requirements for unbundled reimbursement of opioid overdose reversal medication and long-acting injectable buprenorphine at certain outpatient facilities. The rules are effective beginning January 1, 2025, and apply to care delivered in Washington state to members of fully insured health plans regulated by Washington state.

Prior authorization requirements

When a health plan conducts a utilization management review to authorize inpatient or residential SUD treatment (doesn’t apply to inpatient or residential detoxification except as noted below), the health plan must comply with the following:

• Can’t require prior authorization during the first 2 business days of inpatient or residential SUD treatment and/or first 3 calendar days of withdrawal management (detox).
• Must authorize SUD treatment for a minimum 14-day period from the start of treatment (includes the 2-day mandatory authorization noted above). Any subsequent SUD authorization must be for a minimum of 7 days of treatment.
• May not consider the person’s length of stay in treatment at a behavioral health agency when authorizing continuing care at the behavioral health agency.
• May not determine that a person does not meet medical necessity criteria based primarily on the person’s length of abstinence from substance use. If abstinence was due to incarceration, inpatient treatment, or hospitalization, it may not be considered (effective immediately).
• Must use the American Society of Addition Medicine (ASAM) criteria fourth edition to determine medical necessity in place of the 3rd edition no later than January 1, 2026, unless the Health Care Authority (HCA) and the Office of the Insurance Commissioner (OIC) jointly determine that the 4th edition should not be used.
  • For subsequent updates to the ASAM Criteria, the HCA and the OIC will jointly determine whether to use the updated version in place of the previous version, and, if so, the date when the updated version must begin to be used.

Reimbursement requirements

Health carriers must reimburse hospitals and psychiatric hospitals for the outpatient services of dispensing opioid overdose reversal medication and administering long-acting injectable buprenorphine, separate from any bundled payment arrangements. For these services, Premera will reimburse 100% of billed charges.

This requirement applies when both of the following criteria are met:

• The services are provided in an outpatient hospital (medical or behavioral health) or emergency room setting, and,
• The provider is reimbursed using a bundled rate.

To ensure accurate and timely reimbursement in compliance with the new law, impacted facilities are required to bill using complete and accurate coding, which may include the following best practices:

• Use revenue codes 0636 or 0253 to bill drugs impacted by the new law.
• Each drug should be billed as a separate line.
• Provide the current/correct:
  • NDC number
  • HCPCS code
• Include the number of units

Premera provider contracts contain clauses about compliance with laws. As a result, we don’t expect any updates to existing contracts because of SB 6228.