ENGROSSED SUBSTITUTE SENATE BILL 6157 (PDF) Chapter 193, Laws of 2018 65th Legislature 2018 Regular Session
HEALTH CARRIER PRIOR AUTHORIZATION–PROVIDER VISITS
EFFECTIVE DATE: June 7, 2018
RCW 48.43.016 Prior authorization standards and criteria—Health carrier requirements—Definitions.
(2)A health carrier may not require prior authorization for an initial evaluation and management visit ((or an initial)) and up to six consecutive treatment visits with a contracting provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. (3)A health carrier shall post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. (4)A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person’s covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service. (5)A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party. (6)For purposes of this section: (a)”New episode of care” means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.20
From the OIC onMay 31, 2018
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The 2018 Washington Legislature passed two new laws, ESSB 6157 and ESB 5518, requiring action by all health plan carriers. Below you will find information from the Office of the Insurance Commissioner on implementation requirements.
1. Implementation of ESSB 6157 (Health Carrier Prior Authorization—Provider Visits)
In February 2018, the Washington State Legislature passed ESSB 6157, amending RCW 48.43.016, which prohibits a health carrier from requiring prior authorization for an initial evaluation and management visit, and up to six (6) consecutive treatment visits with a contracting provider in a new episode of care physical therapy, occupational therapy, east Asian medicine, massage therapy, and speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan.
Apart from the Washington requirements for direct access to participating chiropractors (RCW 48.43.515(5)), this amendment does not limit the health carrier’s ability to require a referral or prescription for the therapies listed. The law becomes effective on June 7, 2018. That means that all carriers and health plans must be in compliance as of that date.
All currently posted individual, small group and large group checklists (including the 2018/2019 School Year Higher Education Student Health Plan checklist) include this new requirement.
For health plan filings currently under review OIC will be using the following universal objection:
“Per RCW 48.43.016(2) a health plan issued or renewed on or after June 7, 2018 may not require prior authorization for an initial evaluation and management visit and up to six (6) consecutive treatment visits with a contracted provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Plans may require a referral or prescription for these therapies, other than chiropractic per RCW 48.43.515(5). A new episode of care has the same meaning as RCW 48.43.016(6)(a) which is “treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.” In response, please confirm that this plan complies with this new requirement and, if language is not included in the plan, how requests for these services will be handled for compliance purposes and how enrollees will be notified of this new prior authorization exemption. Thank you.”
In order to confirm that plans will comply with this law going forward, this objection will be sent with regard to 2 sets of form filings. It will be sent in carriers’ primary Individual and Small Group health plan filings for Plan Year 2019 and in all primary Large Group health plan filings not yet reviewed by OIC.
For plans currently in force which must comply with this law on June 7, 2018, OIC requests that each carrier respond to the following questions:
- With respect to health plans in effect on June 7, 2018, how will the carrier comply with the new prior authorization requirements in ESSB 6157? (This includes internal process changes, changes in processes affecting providers, and any other changes resulting from the new requirements.)
- How will the carrier notify enrollees of their rights under ESSB 6157?
- Are changes to the carrier’s health care plan forms necessary to change language inconsistent with ESSB 6157?
- If so, how and when does the carrier intend to make those changes?
- What plans will be affected? (This may be answered in a general way, e.g., “All Large Group Standard Masters”, “Approximately X Fully Negotiated filings”, “X Individual Plan filings and X Small Group filings”. The purpose of this question is to allow OIC to plan for filings to make these changes.)
Carriers should send their answers to the above questions about ESSB 6157 compliance to RFHealthPlan2019@oic.wa.gov by June 22, 2018.