Budget Amendment ID: FY2023-S4-481
EHS 481
Ensuring Resources for Psychiatric Patients While They Board in Acute Care Settings
Ms. Lovely, Messrs. Collins and Timilty, Ms. Gobi, Ms. Chang-Diaz, Ms. Rausch and Messrs. Gomez, O'Connor and Hinds moved that the proposed new text be amended by inserting after section XX the following sections:-
SECTION XX. Section 22 of chapter 32A of the general laws is hereby amended by inserting after paragraph (g) the following new paragraph:-
(g ½) The commission’s health benefit plans shall be required to reimburse an acute care hospital for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor, to be contracted between the insurer and acute care hospital, for each day the insured is waiting in an acute care hospital for admission for behavioral health treatment. The contractual rate required to board and care for the patient may be no less than the facility’s contracted inpatient psychiatric rate with the insurer if the facility has an inpatient psychiatric unit. If the facility does not have an inpatient psychiatric unit, the contractual rate required to board and care for the patient shall be no less than the prevailing MassHealth inpatient psychiatric per diem rate. If a plan reimburses for behavioral health patients boarding in an observation unit or if a behavioral health patient is considered in observation status, reimbursement cannot be limited to 48 hours and must be continued until the patient can be safely discharged home or to an appropriate facility. This does not preclude a hospital from billing for other medically necessary services. The insurer shall reimburse medically necessary services in addition to payment for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor. Any qualified behavioral health worker employed by or contracted with the hospital, community behavioral health center, community-based behavioral health provider, or affiliate providing behavioral health services and supports to a patient while the insured is boarding in any acute care hospital service areas while they are waiting for an inpatient or other behavioral health admission shall be reimbursed for those behavioral health services including diagnostic and treatment services by the insurer at the negotiated rate, including services that are delivered via telemedicine, electronic or telephonic consultation. Behavioral health services provided in this setting under this section shall be deemed medically necessary and shall not require prior authorization by an insurer.
SECTION XX. Chapter 118E of the General Laws is hereby amended by inserting after Section 10Q the following new section:-
Section 10R. 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 be required to reimburse an acute care hospital for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor, for each day the member is waiting in an acute care hospital for admission for behavioral health treatment. The contractual rate required to board and care for the patient may be no less than the facility’s contracted inpatient psychiatric rate with the division or 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 payer if the facility has an inpatient psychiatric unit. If the facility does not have an inpatient psychiatric unit, the contractual rate required to board and care for the patient shall be no less than the prevailing MassHealth inpatient psychiatric per diem rate.
This does not preclude a hospital from billing for other medically necessary services. 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 reimburse medically necessary services in addition to payment for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor. Any qualified behavioral health worker employed by or contracted with the hospital, community behavioral health center, community-based behavioral health provider, or affiliate providing behavioral health services and supports to a member while the member is boarding in any acute care hospital service areas while they are waiting for an inpatient or other behavioral health admission shall be reimbursed for those behavioral health services including diagnostic and treatment services by the insurer at the negotiated rate, including services that are delivered via telemedicine, electronic or telephonic consultation. Behavioral health services provided in this setting under this section shall be deemed medically necessary and shall not require prior authorization by the division or 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.
SECTION XX. Chapter 176O of the General Laws is hereby amended by inserting after section 5C the followings new section:-
Section 5D. A carrier shall be required to reimburse an acute care hospital for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor, to be contracted between the insurer and acute care hospital, for each day the insured is waiting in an acute care hospital for admission for behavioral health treatment. The contractual rate required to board and care for the patient may be no less than the facility’s contracted inpatient psychiatric rate with the carrier if the facility has an inpatient psychiatric unit. If the facility does not have an inpatient psychiatric unit, the contractual rate required to board and care for the patient shall be no less than the prevailing MassHealth inpatient psychiatric per diem rate. If a plan reimburses for behavioral health patients boarding in an observation unit or if a behavioral health patient is considered in observation status, reimbursement cannot be limited to 48 hours and must be continued until the patient can be safely discharged home or to an appropriate facility. This does not preclude a hospital from billing for other medically necessary services. The carrier shall reimburse medically necessary services in addition to payment for health care services required to board and care for a behavioral health patient in the emergency department, observation unit, or inpatient floor. Any qualified behavioral health worker employed by or contracted with the hospital, community behavioral health center, community-based behavioral health provider, or affiliate providing behavioral health services and supports to an insured while the insured is boarding in any acute care hospital service areas while they are waiting for an inpatient or other behavioral health admission shall be reimbursed for those behavioral health services including diagnostic and treatment services by the insurer at the negotiated rate, including services that are delivered via telemedicine, electronic or telephonic consultation. Behavioral health services provided in this setting under this section shall be deemed medically necessary and shall not require prior authorization by an insurer.
With respect to an insured enrolled in a health benefit plan under which the carrier or utilization review organization only provides administrative services, the obligations of a carrier or utilization review organization created by this section and related to payment shall be limited to recommending to the third party payor that coverage should be authorized.
The division shall promulgate regulations to implement this section.