Budget Amendment ID: FY2015-S4-708-R1

Redraft EHS 708

Barriers to Behavioral Healthcare

Mr. Keenan, Ms. Candaras, Messrs. Humason, DiDomenico and Eldridge moved that the proposed new text be amended by inserting at the end the following two new sections:

SECTION __. Notwithstanding any general or special law, rule or regulation to the contrary, no carrier as defined under section 1 of chapter 176O nor their respective contractors, nor any Medicaid or other public or private health insurer or contracted health insurers, managed care organizations, health plans, health maintenance organizations, behavioral health management firms or third party administrators under contract to a Medicaid managed care organization or a primary care clinician plan, shall require on or after January 1, 2105 a prior authorization or a prior approval requirement related to the coverage of inpatient level mental health and substance abuse services of a patient with a mental health condition or a substance abuse disorder where the patient is determined to have an emergency medical condition by the treating healthcare provider, as emergency medical condition is defined under Chapter 141 of the Acts of 2000. Any such prior authorization or prior approval requirements shall be prohibited and shall be considered violations of the requirements for coverage of emergency services as provided in Chapter 141 of the Acts of 2000, and of the mental health parity provisions required in chapter 224 of the Acts of 2012; provided, however, that Emergency Service Program teams, so-called, as contracted through MassHealth to conduct behavioral health assessments, shall not be considered a prior authorization or prior approval requirement under this section. Nothing in this provision shall be construed to prevent notifying such entities named above that a given patient has been deemed to require and is seeking such care by a given provider or organization.

SECTION __. Notwithstanding any general or special law, rule or regulation to the contrary, a Carrier, as defined under Section 1 of Chapter 176O and their contractors, and Medicaid contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or a primary care clinician plan shall implement all Current Procedural Terminology, or CPT, as well as evaluation and management codes for behavioral health services in accordance with the new CPT evaluation and management codes as most recently adopted by the American Medical Association and the Centers for Medicare and Medicaid Services, or CMS; provided further, that if a code is covered under a Carrier or Medicaid fee schedule and paid on the medical surgical benefit, then the code shall reimburse providers the same rate as provided in facility and non-facility settings on the behavioral health and substance abuse benefit; provided further, that the Carrier and office of Medicaid shall work with its actuary to ensure that capitation rates appropriately account for changes in provider rates for all rate changes associated with incremental increases for behavioral health services; provided further, that any integrated care organization, managed care entity or behavioral health carve-out entity that manages behavioral health services on behalf of the Carrier or Medicaid shall implement all CPT evaluation and management codes for behavioral health services in accordance with the new CPT codes for evaluation and management services as well as psychopharmacological services and neuropsychological assessment services as most recently adopted by the American Medical Association and CMS; provided further, that any integrated care organization, managed care entity or behavioral health carve-out entity that manages behavioral health services on behalf of a Carrier or Medicaid shall be required to pay, at a minimum, the Carrier’s or Medicaid’s rates of payment for all CPT evaluation and management codes for behavioral health services by January 1, 2015; and provided further, that the Carrier and Medicaid shall review and adjust all rates of payment accordingly for mental health services provided in hospitals, hospital clinics, outpatient clinics, private practice offices, community health centers and mental health centers by January 1, 2015; provided, however, that nothing in this section shall be construed to supersede, reverse, or otherwise affect rates promulgated pursuant to Section 32 of Chapter 118 of the Acts of 2013.