The purpose of this bulletin is to provide information about the Second Substitute Senate Bill (2SSB) 5120, which establishes a new license type for 23-hour behavioral health crisis relief centers. The new law took effect in July 2023, however, rulemaking is still ongoing and details around funding are still being sorted out.
- Review this bulletin and 2SSB 5120 to understand the new behavioral health facility licensure type;
- Consider how your hospital may be impacted by these 23-hour crisis relief centers, how patients may be able to utilize these facilities, and consider if you may want to develop and open a 23-hour facility;
- Engage in the rulemaking process by participating in weekly Department of Health (DOH) stakeholder meetings and providing feedback to WSHA. More information on the rulemaking process can be found on the DOH website.
2SSB 5120, establishes behavioral health facility licensing for 23-hour crisis relief centers based on the national model developed by Crisis Now and the Substance Abuse and Mental Health Services Administration (SAMHSA). Crisis Relief Centers (CRCs) are a key component of the best practices model developed by SAMHSA for handling mental health crisis services. The three elements of the toolkit are: someone to talk to (which is the 988 line), someone to respond (mobile crisis teams), and somewhere to go (includes CRCs).
WSHA worked closely with legislators to draft this bill. In drafting, both WSHA and legislators attempted to remain as faithful to the SAMHSA model as possible while making accommodations for those things that are unique to Washington State, such as Designated Crisis Responders (DCRs).
23-hour facilities provide crisis response services where patients are treated or observed for fewer than 24 hours in recliner chairs as opposed to beds or stretchers. They are designed to be an alternative to hospital emergency departments, accepting all referrals and serving as a “no wrong door” option for people experiencing behavioral health crises that don’t require emergency care. Under this new license, hospitals and other behavioral health organizations will have the opportunity to open state licensed 23-hour facilities and bill for patient care under appropriate Health Care Authority designated billing codes for Medicaid/Apple Health. Under this new license, hospitals and other behavioral health organizations will have the opportunity to open state licensed 23-hour facilities and bill for patient care under appropriate Health Care Authority designated billing codes for Medicaid/Apple Health. There is also work underway with the Office of the Insurance Commissioner to require regulated insurers to pay using these same billing codes.
23-Hour Facility Requirements
CRCs are designed to offer “no wrong door” community access for mental health and substance use crises. These facilities are required to be open 24 hours a day, 7 days a week, accepting patients on a voluntary walk-in basis, and from law-enforcement and EMS drop-offs. The facilities will meet the needs of patients experiencing all levels of behavioral health crisis including acute crisis, pre-empting crisis, and connecting people to outpatient services.
Under 2SSB 5120 minimum requirements for the 23-hour facilities include:
- Open 24 hours a day, 7 days a week with access to a prescriber and the ability to dispense medications appropriate for individuals in behavioral health crisis;
- Maintain an open-door policy, with no medical clearance, and the ability to accept admissions at least 90% of the time when the facility is not at full capacity, with a no-refusal policy for law enforcement. All declined admissions must be documented, tracked, and available for DOH review;
- Ability to screen for physical health needs with an identified pathway to transfer to an emergency department if necessary;
- Ability to provide minor medical and wound care;
- Screen all patients with comprehensive suicide and violence risk assessments;
- Limit patient stays to a maximum of 23 hours and 59 minutes except for patients waiting on a designated crisis responder evaluation or making an imminent transition to another setting as part of an established aftercare plan;
- Any person held involuntarily should be evaluated by a DCR within 12 hours of notice for the need for evaluation. If a DCR is unable to respond within 12 hours, facilities may have to transfer the patient to an emergency department.
- Maintain relationships with entities capable of providing for the ongoing service needs of clients; and
- Coordinate connection to post-discharge care.
The goal of the CRCs is to limit the number of patients brought to the Emergency Department in behavioral health crisis. Ideally, CRCs will allow for safe de-escalation from behavioral health crisis, fewer behavioral health admissions, and a lower cost of care.
The Department of Health (DOH) has initiated rulemaking as directed by 2SSB5120. Rulemaking will determine physical environment standards including the number of recliners allowed at CRCs. The intention is to make these facilities less burdensome to open and operate than Evaluation and Treatment Centers, since patients will stay for shorter periods of time, remain outpatients, and if the need for involuntary commitment occurs, patients will be transferred.
Rulemaking will also establish medical stability criteria for EMS drop-offs, to help ensure that patients sent to 23-hour facilities by EMS transport are in fact experiencing a behavioral health crisis, as opposed to medical crisis. The criteria will not apply to walk-ins or law enforcement drop-offs. Facilities will be expected to have the ability to perform a stability screening and facilitate a transfer to a higher level of care, if necessary.
The Health Care Authority is similarly engaged to ensure that CRC services are billable to Medicaid, and the Office of the Insurance Commissioner is looking at requirements for regulated insurers using these same billing codes.
WSHA will actively engage and represent hospital interests throughout the rulemaking process. Rules are expected to be completed in early 2024. More information may be found on the DOH rulemaking webpage.
During the 2023 legislative session WSHA actively engaged with legislators to support and draft 2SSB 5120, establishing a new 23-hour behavioral health facility license. The 23-hour facility type did not previously exist in Washington law, and facilities attempting to provide crisis services struggled to shoehorn their services into previously existing license types and billing codes. Ultimately, this new licensure type will also allow facilities to work with the Health Care Authority (HCA) to bill appropriately for these crisis outpatient services. Little information is available on billing or billing codes at this point, however, the expectation is that the HCA will use the billing codes as recommended by SAMHSA.
The HCA has been charged with establishing a model for funding the centers as well as making crisis relief center services eligible for Medicaid billing to the maximum extent allowed by federal law.
WSHA’s 2023 New Law Implementation Guide
Please visit WSHA’s New Law Implementation Guide online. The Government Affairs team is hard at work preparing resources and information on the high priority bills that passed in 2023 to help members implement the new laws, as well as links to resources such as this bulletin. In addition, you will find the Government Affairs team’s schedule for release of upcoming resources on other laws and additional resources for implementation.