Federal and state rules dictate how to provide and pay for crisis services and involuntary treatment associated with mental health and substance use disorder for Medicare/Medicaid clients.
Involuntary Treatment Act (ITA)
Washington State’s Involuntary Treatment Act (ITA) provides the legal framework that allows individuals to be detained by Designated Crisis Responders (DCRs) and/or committed by a court order to a mental hospital or institution against their will following due process as required by the 14th amendment. Involuntary civil commitments are meant to provide for the evaluation and treatment of individuals with a mental disorder who may be either gravely disabled or pose a danger to themselves or others, danger to property and who refuse or are unable to enter treatment on their own.
In April 2018, the ITA was extended to individuals with SUD under E3SHB 1713. The law is known as the “Ricky Garcia Act” or “Ricky’s Law.” The 2018 law applies to the following hospital settings: Emergency Departments; Inpatient units; and any other location, such as an outpatient clinic, where staff may assess or refer a patient to a DCR for an evaluation for a substance use disorder. Involuntary treatment can also be initiated in a community setting by DCRs.
What is a DCR authorized to do?
A DCR will determine if the person presents a harm to self/others/property, or is gravely disabled and is at imminent risk, or if there is a non-emergent risk due to a substance use disorder or mental disorder, or is in need of assisted outpatient behavioral health treatment.
The DCR will conduct an evaluation and investigation:
- Interviewing all reasonably available family, friends, or others.
- Interview the person after informing them of their involuntary treatment rights.
- Consider all available less restrictive treatment options.
- Determine if the person meets criteria for involuntary treatment.
- If the DCR finds the person meets the criteria for involuntary treatment, the DCR will work to find an available treatment bed.
- If there is no available involuntary treatment bed, then the DCR will not detain the person and send in a no bed report to the state.
Involuntary Treatment for Medicare/Medicaid Individuals
Two conditions must be met in order for Medicare to pay for Involuntary Treatment for mental health and substance abuse disorder for dual eligibles.
- The services are provided by a Medicare approved provider or facility;
- The service is covered by Medicare.
If the conditions are not met, then either the Behavioral Health – Administrative Service Organization (BH-ASO) or the Integrated Managed Care Organization (MCO) may be responsible for payment.
Providers must bill Medicare first if the BH service is covered, and the individual has a Medicare benefit—even if an individual is on court-ordered involuntary treatment. The provider will receive an Explanation of Benefits (EOB) which will show which services are denied and which services are paid for.