WA Senate Bill 6228 Treatment of Substance Use Disorders

The December newsletter included an article about Premera Blue Cross compliance with WA SB 6228. We’ve updated the article to provide further clarity around the prior authorization requirements and reimbursement for opioid reversal medication and long-acting injectable buprenorphine, including both the administration and medication.

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.

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

• Cannot require prior authorization.
  
• Must authorize the first 2 business days of non-withdrawal management inpatient or residential SUD treatment and the first 3 calendar days of inpatient or residential withdrawal management (detox). For non-withdrawal management inpatient or residential SUD treatment, if medical necessity is determined to be present, the health plan must authorize a minimum 14-day period from the start of treatment (includes the 2-day mandatory authorization noted above). If medical necessity is determined to be present, any subsequent authorizations must be for a minimum of 7 days.
• 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. This requirement is effective immediately.
• Must use the ASAM Criteria 4th 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 allow 100% of billed charges and apply any appropriate member cost shares on claims when all the following criteria are met:

• Premera member is covered by a fully insured health plan regulated by Washington state and the care is delivered in Washington state
• The contract between Premera and the provider utilizes a bundled rate methodology like APCs or per diems for outpatient hospital or ER services
• The claim must be billed using complete and accurate coding and include a diagnosis code related to substance use disorder

If all of the above criteria are not met, Premera will continue to process claims using the fee schedule described in your existing contract with Premera.

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:

• Utilize revenue code 636 or 253 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’s provider contracts contain clauses about compliance with laws. As a result, we do not expect any updates to existing contracts as a result of SB 6228.