No. SB 1648
Filed under Healthcare.
Access to Applied Behavior Analysis Services; Requiring the Agency for Health Care Administration to consider certain factors when evaluating network adequacy for applied behavior analysis services under the Medicaid program; requiring Medicaid managed care plans to take reasonable steps to support workforce retention and recruitment; requiring managed care plans to notify providers of credentialing deficiencies in a specified manner and timeframe; prohibiting managed care plans from imposing a moratorium on applied behavior analysis services providers unless such providers can demonstrate specified criteria to the agency, etc.
Plain English Summary
AI-GENERATEDMedicaid managed care plans may no longer impose a moratorium on new applied behavior analysis providers unless the plan proves to the state that its network already meets adequacy standards and the freeze is narrowly tailored and time-limited.
Plans must credential new providers within 60 days of a complete application and flag every deficiency in one notice within 15 days, instead of trickling out problems one at a time.
New enrollees and patients switching providers get at least 120 days of guaranteed coverage without losing authorized services to paperwork delays. Coverage decisions must be based on each patient's own needs, not a fixed hour limit tied to age.
Plans must pay valid claims promptly, explain any denial in specific terms, and cannot recoup payments for their own administrative mistakes. The state must update its managed care contracts to enforce all of this.
AIA managed care plan cannot impose a moratorium on applied behavior analysis providers unless it first shows the agency, in writing, that network adequacy is fully met and the freeze is narrowly tailored, time-limited, and necessary.
AIManaged care plans must flag every credentialing deficiency in a single notice within 15 calendar days of an application, and must complete initial credentialing and activation within 60 calendar days of a clean application.
AIA recipient who is newly enrolled in a plan or switching providers must get at least 120 days of continued, authorized applied behavior analysis services, and those services cannot be cut off due to administrative or credentialing delays.
AIDecisions about how many hours of applied behavior analysis a patient receives must be based on that patient's own medical necessity. Age-based hour targets or incentive benchmarks cannot be used as fixed caps, minimums, or substitutes for that determination.
AIAuthorization and utilization review decisions must be made by reviewers with demonstrated training and experience in applied behavior analysis, and plans cannot require a new authorization cycle sooner than every 90 days absent a documented material change in the patient's condition.
AIManaged care plans cannot demand repayment of a claim already paid, or treat it as an overpayment, based only on an administrative or system error, unless the provider was actually at fault and that fault is documented.
AIThe agency must amend its existing managed care plan contracts as needed to enforce this new section, using tools such as corrective action plans, liquidated damages, or sanctions against noncompliant plans.