Community-Based Emergency Behavioral Health Care; Issued June 22, 2023

MAURA HEALEY GOVERNOR KIM DRISCOLL LIEUTENANT GOVERNOR COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi GARY D. ANDERSON COMMISSIONER OF INSURANCE # BULLETIN 2023-11 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary D. Anderson, Commissioner of Insurance Date: June 22, 2023 Re: Community-Based Emergency Behavioral Health Care Gary D. Anderson The Division of Insurance (“Division”) issues this Bulletin 2023-11 to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations (“Carriers”) to identify the Division’s expectations regarding Carriers’ requirements to provide community-based emergency behavioral health care. The Division issues this Bulletin pursuant to Sections 51, 55, 58, and 61 of Chapter 177 of the Acts of 2022, which add M.G.L. c. 175, §47RR; M.G.L. c. 176A, §8TT; M.G.L. c. 176B, §4TT; and M.G.L. c. 176G, §4LL (“Statutes”), effective as of November 8, 2022. ## Roadmap for Behavioral Health Reform The Executive Office of Health and Human Services, in collaboration with the Department of Public Health and the Department of Mental Health, is expanding and strengthening the delivery of community behavioral health services across the Commonwealth through the Roadmap for Behavioral Health Reform (“Roadmap”). Key components of the Roadmap include ensuring access to community-based alternatives to emergency departments for behavioral health crisis intervention services, as well as expanding access to urgent and outpatient behavioral health treatment. As of January 2023, there is a new Behavioral Health Help Line and designated Community Behavioral Health Centers (“CBHCs”), serving all areas of the Commonwealth. The Behavioral Health Help Line will act as an accessible “front door” to treatment, enabling residents to more easily find available providers and services that meet their needs. The Behavioral Health Help Line’s phone and chat line will offer real-time clinical triage, de-escalation, and service navigation to help individuals and families access the range of treatment for mental health and addiction offered in the Commonwealth, including outpatient and urgent care and immediate crisis intervention. Any Massachusetts resident in need of a clinical assessment and support is able to access the Help Line 24/7 via phone and text at 833-773-BHHL, as well as online at masshelpline.com. Bulletin 2023-11 June 22, 2023 CBHCs will serve as regional hubs of coordinated and integrated mental health and substance use disorder treatment and will provide routine and urgent outpatient services, crisis services for adults and youth, and community crisis stabilization services for adults and youth. CBHCs will provide Adult Community-Based Mobile Crisis Intervention (“AMCI”) services, formerly known as the Emergency Services Program, and Youth Community-Based Mobile Crisis Intervention (“YMCI”), formerly known as Mobile Crisis Intervention. AMCI and YMCI will be available to all residents of the Commonwealth, regardless of insurance status. AMCI and YMCI services will be provided at community-based sites and through mobile response. The objective of AMCI and YMCI services (collectively, “MCI services”) is to respond rapidly, assess effectively, and deliver a course of treatment intended to promote recovery, ensure safety, and stabilize the crisis. For individuals who do not require inpatient services or another 24-hour level of care, AMCI provides up to three days of daily post-stabilization follow-up. YMCI provides crisis assessment and crisis stabilization intervention to youth under the age of 21. Each YMCI encounter, including ongoing coordination following the crisis assessment and stabilization intervention, may last up to seven days. CBHCs also will provide Adult Community Crisis Stabilization (“Adult CCS”) services and access to Youth Community Crisis Stabilization (“YCCS”) services. Adult CCS provides short-term, staff-secure, safe, and structured crisis stabilization and treatment services 24/7/365. Similarly, YCCS will provide youth up to age 18 with short-term crisis stabilization, therapeutic intervention, and specialized programming in a staff-secure environment with a high degree of supervision and structure. In addition to the services above provided through the statewide network of CBHCs, existing Community Mental Health Centers across the Commonwealth may qualify to be designated by MassHealth as Behavioral Health Urgent Care providers if they offer timely access to treatment for urgent behavioral health needs, including offering same- or next-day appointments and night and weekend hours. The Behavioral Health Help Line will provide “warm handoffs” between Behavioral Health Urgent Care providers and CBHCs, including for immediate deployment of crisis intervention teams, AMCI, and YMCI. ### Coverage for Behavioral Health Care Carriers offering fully-insured health plans in Massachusetts are mandated to include coverage for medically necessary emergency services programs, according to the relevant requirements of the Statutes. In Section 49 of Chapter 177, the term “emergency services programs” is defined as “all programs subject to contract between the Massachusetts Behavioral Health Partnership (“MBHP”) and nonprofit organizations for the provision of community-based emergency psychiatric services, including, but not limited to, behavioral health crisis assessment, intervention and stabilization services 24 hours per day, 7 days per week, through: (i) mobile crisis intervention services for youth; (ii) mobile crisis intervention services for adults; (iii) emergency service provider community-based locations; and (iv) adult community crisis stabilization services.” Changes that are occurring under the Roadmap for Behavioral Health Reform include that the designated CBHC network will deliver renamed A/YMCI Services; thus the Statutes require that Carriers cover those emergency behavioral health services that are provided by the new CBHCs that are contracting with MBHP for such care. Carriers are expected to reimburse providers for all MCI and CCS care that is provided by a CBHC and will provide necessary information to CBHCs about the appropriate way to bill for medically Bulletin 2023-11 June 22, 2023 necessary services. Each Carrier is expected to have identified staff or departments that will be responsible to coordinate communications between the Carrier and the CBHCs for the coordination of claims for required services. Carriers will maintain lists for use by the CBHCs of these identified staff or departments and the best methods to contact these persons. ## Medical Necessity in Relation to Community-Based Emergency Behavioral Health Care Pursuant to M.G.L. c. 176O, §16(b), Massachusetts-issued insured health plans are required to provide coverage for health care services if: (1) the services are a covered benefit under the insured's health benefit plan; and (2) the services are medically necessary. Carriers that are accredited by the Division as managed care companies under M.G.L. c. 176O may employ utilization review systems for insured health plans in making decisions about whether services are medically necessary. Utilization review is defined in M.G.L. c. 176O as "a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings." In establishing its utilization review criteria, the Carrier is expected to base the criteria on the following provisions of M.G.L. c. 176O, §16(b): A carrier may develop guidelines to be used in applying the standard of medical necessity, as defined in this subsection. Any such medical necessity guidelines utilized by a carrier in making coverage determinations shall be: (i) developed with input from practicing physicians and participating providers in the carrier's or utilization review organization's service area; (ii) developed under the standards adopted by national accreditation organizations; (iii) updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice; and (iv) evidence-based, if practicable. In applying such guidelines, a carrier shall consider the individual health care needs of the insured. Any such medical necessity guidelines criteria shall be applied consistently by a carrier or a utilization review organization and made easily accessible and up-to-date on a carrier or utilization review organization's website to insureds, prospective insureds and health care providers consistent with [M.G.L. c. 176O, §12(a)]. Carriers are expected to establish appropriate criteria that do not cause inappropriate delays, interruptions, or denials of care for covered members with acute behavioral and substance use disorder needs. Carriers shall not apply prior authorization or other procedures that could lead to delays in approval of crisis intervention or stabilization care. Notification of an admission at the Community Crisis Stabilization Service within the CBHC must occur within 72 hours of the admission. Utilization management practices may be implemented for non-urgent behavioral health services that are provided in the normal course of services at a CBHC. ## Carriers Acting As Administrators When Carriers are acting as administrators for employment-sponsored non-insured health benefit plans, the Division expects Carriers to encourage plan sponsors to take steps that are consistent with the provisions of this Bulletin 2023-11. If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner for the Health Care Access Bureau, at (617) 521-7323.