Amendment 1

Amendment ID: H4664-1

Amendment 1

Equitable cost sharing for addiction treatment services

Mr. Keenan moves to amend the bill by inserting the following new sections:-

SECTION XX. Section 17N of chapter 32A of the General Laws, as appearing in the 2014 Official Edition, is hereby amended by inserting after the definition of “Clinical stabilization services” the following definition:-

“Transitional support services”, short-term, residential support services, as defined by the department of public health, usually following clinical stabilization services, that provide a safe and structured environment to support adults or adolescents through the addiction recovery process and the transition to outpatient or other step-down addiction recovery care.

SECTION XX. Said section 17N of said chapter 32A, as so appearing, is hereby further amended by striking out the second paragraph and inserting in place thereof the following paragraph:-

The commission shall provide for medically necessary acute treatment services, medically necessary clinical stabilization services and medically necessary transitional support services to an active or retired employee of the commonwealth who is insured under the group insurance commission coverage for up to 30 days and shall not require preauthorization prior to obtaining such acute treatment services, clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier with notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided however that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; and provided further, that the commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for, without preauthorization, substance abuse evaluations ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION XX. Section 10H of chapter 118E of the General Laws, inserted by section 19 of chapter 258 of the acts of 2014, is hereby repealed.

SECTION XX. Said chapter 118E is hereby further amended by inserting after section 10I the following section:-

Section 10J. For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:

“Acute treatment services”, 24-hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility, as defined by the department of public health, that provides evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychoeducational groups and discharge planning.

“Clinical stabilization services”, 24-hour clinically managed post detoxification treatment for adults or adolescents, as defined by the department of public health, usually following acute treatment services for substance abuse for individuals beginning to engage in recovery from addiction, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others and aftercare planning.

The division and its 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 primary care clinician plan shall cover the cost of medically necessary clinical stabilization services and medically necessary transitional support services for up to 30 days and shall not require preauthorization prior to obtaining clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided, however, that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; and provided further, that the division and its 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 primary care clinician plan shall cover, without preauthorization, substance abuse evaluations ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION XX. Section 47GG of chapter 175 of the General Laws, as appearing in the 2014 Official Edition, is hereby amended by inserting after the definition of “Clinical stabilization services” the following definition:-

SECTION XX. Said section 47GG of said chapter 175, as so appearing, is hereby further amended by striking out the second paragraph and inserting in place thereof the following paragraph:-

Any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth, which is considered creditable coverage under section 1 of chapter 111M, shall provide coverage for medically necessary acute treatment services, medically necessary clinical stabilization services and medically necessary transitional support services for up to 30 days and shall not require preauthorization prior to obtaining acute treatment services, clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided however that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; provided further, any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth, which is considered creditable coverage pursuant to section 1 of chapter 111M, shall cover, without preauthorization, a substance abuse evaluation ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION XX. Section 8II of chapter 176A of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Clinical stabilization services” the following definition:-

SECTION XX. Said section 8II of said chapter 176A, as so appearing, is hereby further amended by striking out the second paragraph and inserting in place thereof the following paragraph:-

Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary acute treatment services, medically necessary clinical stabilization services and medically necessary transitional support services for up to 30 days and shall not require preauthorization prior to obtaining acute treatment services, clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided however that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; provided further, any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth, shall cover, without preauthorization, a substance abuse evaluation ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION XX. Section 4II of chapter 176B of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Clinical stabilization services” the following definition:-

SECTION XX. Said section 4II of said chapter 176B, as so appearing, is hereby further amended by striking out the second paragraph and inserting in place thereof the following paragraph:-

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary acute treatment services, medically necessary clinical stabilization services and medically necessary transitional support services for up to 30 days and shall not require preauthorization prior to obtaining acute treatment services, clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided however that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; provided further, any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for, without preauthorization, a substance abuse evaluation ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION XX. Section 4AA of chapter 176G of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Clinical stabilization services” the following definition:-

SECTION XX. Said section 4AA of said chapter 176G, as so appearing, is hereby further amended by striking out the second paragraph and inserting in place thereof the following paragraph:-

An individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary acute treatment services, medically necessary clinical stabilization services and medically necessary transitional support services for up to 30 days and shall not require preauthorization prior to obtaining acute treatment services, clinical stabilization services or transitional support services. The facility providing such services shall provide the carrier notification of admission and the initial treatment plan within 48 hours of admission and within a reasonable time thereafter shall provide the carrier with a projected discharge plan for the member. The carrier’s utilization review procedures may be initiated on day 14; provided however that a carrier shall not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment, clinical stabilization, or transitional support services unless a patient has received at least 30 consecutive days of said services; provided further, an individual or group health maintenance contract that is issued or renewed shall provide coverage for, without preauthorization, a substance abuse evaluation ordered pursuant to section 51½ of chapter 111. Upon receipt of notification by the admitting facility and receipt of the discharge plan, the carrier may provide outreach to the treating clinician and member to offer care management and support services.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION YY. The center for health information and analysis, in consultation with the division of insurance, the department of public health, the office of Medicaid and the health policy commission, shall conduct reviews on the 14 day mandated coverage of acute treatment services, clinical stabilization services and the long-term effects of the increase in covered days from 14 days to 30 days related to the mandated benefits for acute treatment services, clinical stabilization services and transitional support services on the following areas: (i) the continuum of care for substance use disorder treatment; (ii) access to the continuum of care for patients eligible for MassHealth and department of public health programs; (iii) access to the continuum of care for commercially insured patients; and (iv) any changes in costs to MassHealth, the department of public health and health insurance carriers. The center shall provide an initial report not later than October 1, 2017 on the effects of the 14 day mandated coverage of acute treatment services and clinical stabilization services to the areas listed above and a final report not later than October 1, 2019 on the effects of the 30 day mandated coverage of acute treatment services, clinical stabilization services and transitional support services to the areas listed above.

The initial report and final report shall be posted on the center’s website and shall be filed with the clerks of the house of representatives and senate, the house and senate chairs of the committee on financial services, the house and senate chairs of the committee on health care financing, the house and senate chairs of the committee on public health, and the house and senate committees on ways and means not later than October 1, 2017 and October 1, 2019, respectively.

SECTION ZZ. Sections XX through XX, inclusive, shall take effect October 1, 2017.