AB713: Bill Text

LRB-2837/1

TJD:kjf

2015 - 2016 LEGISLATURE

2015 Assembly BILL 713

January 13, 2016 - Introduced by Representatives VanderMeer, Tittl, Ballweg, Horlacher, Knodl, Kremer, Murphy, A. Ott, Quinn, Rohrkaste, Sanfelippo, Zepnick, Novak and Kitchens, cosponsored by Senator Harsdorf. Referred to Committee on Health.

AB713,1,3 An Act to create 49.45 (29w) (a) 3. to 7., 49.45 (29w) (c) and 49.45 (29w) (d) of the statutes; relating to: access to and prior authorization for mental health services under the Medical Assistance program.

Analysis by the Legislative Reference Bureau

This bill sets limitations on what is required for prior authorizations for mental health treatment under the Medical Assistance (MA) program. Specifically, the bill limits the information that may be collected on a prior authorization form, requires the Department of Health Services (DHS) to allow 24 mental health therapy visits before requiring prior authorization for additional visits, requires DHS to allow 15 days of adolescent day treatment services before requiring prior authorization for additional days, and creates a preferred provider status for purposes of processing prior authorization requests. The bill also requires a health maintenance organization that provides mental health services under the MA program to use uniform application, provider recertification, and prior authorization forms and processes prescribed by DHS and to allow mental health agencies to replace a departing mental health professional on the provider panel with another mental health professional of similar qualifications who agrees to abide by the health maintenance organization's policies.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB713,1 Section 1. 49.45 (29w) (a) 3. to 7. of the statutes are created to read:

AB713,2,3 49.45 (29w) (a) 3. Allow 24 mental health therapy visits before requiring prior authorization for additional mental health visits.

AB713,2,5 4. Allow 15 days of adolescent day treatment services before requiring prior authorization for additional days of adolescent day treatment services.

AB713,2,7 5. Limit the collection of information on the prior authorization form for mental health services to the following elements:

AB713,2,8 a. Diagnostic criteria and symptoms.

AB713,2,9 b. Patient and mental health services provider identification.

AB713,2,11 c. Modality and frequency of treatment for which prior authorization is requested.

AB713,2,13 d. Goals and discharge criteria for treatment for which prior authorization is requested.

AB713,2,17 6. Limit the collection of information on prior authorization forms and by reviewers for prior authorization of mental health services to the information that is within the scope of practice of the mental health service provider requesting prior authorization to provide treatment.

AB713,2,20 7. Limit the collection of information for prior authorization renewals to measures of progress on treatment goals and to new information on the individual's condition for which prior authorization for treatment is being requested.

AB713,2 Section 2. 49.45 (29w) (c) of the statutes is created to read:

AB713,3,4 49.45 (29w) (c) 1. For purposes of reviewing requests for prior authorization for mental health services provided under this subchapter, the department shall recognize a preferred provider status which is a mental health service provider that meets all of the following criteria:

AB713,3,6 a. The mental health service provider has a minimum of 5 years of experience as a certified provider under the Medical Assistance program under this subchapter.

AB713,3,8 b. The mental health service provider has had no instances of substantiated fraud in the 5 years previous to requesting preferred provider status.

AB713,3,12 c. The mental health service provider has a history of having 90 percent of prior authorization requests approved, regardless of whether the department requested additional information before approval, for the 3 years previous to requesting preferred provider status.

AB713,3,16 2. In providing mental health benefits under this subchapter, the department shall process prior authorization requests from a mental health service provider with preferred provider status under subd. 1. automatically, without delay, in a manner similar to claims for services that do not require prior authorization.

AB713,3,18 3. A mental health service provider may appeal denial of or termination of preferred provider status under subd. 1. under ch. 227.

AB713,3 Section 3. 49.45 (29w) (d) of the statutes is created to read:

AB713,3,21 49.45 (29w) (d) A health maintenance organization that provides mental health services under this subchapter shall do all of the following:

AB713,3,24 1. Use uniform application, provider recertification, and prior authorization forms and processes prescribed by the department for use by all health maintenance organizations providing mental health services under this subchapter.

AB713,4,5 2. Allow a mental health agency that is certified to provide mental health service under the Medical Assistance program under this subchapter to replace a departing mental health professional on the health maintenance organization's provider panel with another mental health professional of similar qualifications who agrees to abide by the policies of the health maintenance organization.

AB713,4,6 (End)