Source: http://register.dls.virginia.gov/details.aspx?id=6490
Timestamp: 2019-08-18 19:19:41
Document Index: 552836632

Matched Legal Cases: ['§ 32', '§ 1902', '§ 1396', '§ 1905', '§ 6403', '§ 1905', '§ 1905', 'art 440', '§ 1915']

Vol. 33 Iss. 24 (Proposed Regulation) 12VAC30-120, Waivered Services July 24, 2017
12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-61).
12VAC30-80. Methods and Standards for Establishing Payment Rates; Other Types of Care (adding 12VAC30-80-97).
12VAC30-120. Waivered Services (amending 12VAC30-120-380).
Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance and to make, adopt, promulgate, and enforce regulations to implement the state plan, and § 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by § 1902(a) of the Social Security Act (42 USC § 1396a) provides governing authority for payments for services.
Section 1905 of the Social Security Act requires state Medicaid programs to provide early and periodic screening, diagnosis, and treatment (EPSDT) services for individuals who are eligible under the plan and are younger than the age of 21 years, to include "Such other necessary health care, diagnostic services, treatment, and other measures described in § 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan." If an individual is determined through an EPSDT screening to need a medical service that is not otherwise covered in Virginia's State Plan, then this provision in federal law requires the Commonwealth to cover that service. Behavioral therapy services are an EPSDT service.
Purpose: The proposed regulatory action is intended to promote an improved quality of Medicaid-covered behavioral therapy services provided to children and adolescents. The proposed regulation will differentiate Medicaid's coverage of behavioral therapy and applied behavior analysis services from coverage of community mental health and other developmental services. This regulatory action is essential to protect the health, safety, and welfare of these affected individuals and to ensure the quality of services rendered to children and adolescents who demonstrate the medical need for EPSDT behavioral therapy services. Regulations are needed to establish clear criteria for Medicaid payment of these services. Regulatory action is needed to ensure that Medicaid individuals and their families and service providers are well informed about service specifications prior to receiving or providing these services. These services will allow children receiving services to improve interactions with their schools, families, communities, future employers, and jobs and thus benefit a broad range of citizens. These regulations are not expected to negatively affect the health, safety, or welfare of citizens of the Commonwealth.
Substance: Currently, Medicaid payment for behavioral therapy services is being authorized on an individual case basis under the authority provided by the basic EPSDT definition found in 12VAC30-50-130 B. The absence of consistently applied definitions, service requirements, required provider qualifications, and quality assurance standards might result in arbitrary decisions that cannot be sustained in an appeal. With increasing numbers of children being diagnosed with autism and autism spectrum disorders in need of such services, the individual-case-basis method of covering these services is no longer satisfactory or appropriate.
DMAS proposes to initiate uniform coverage of behavioral therapy services for individuals under the age of 21 years who meet the medical necessity criteria. Trained professionals rendering early intensive treatment, including applied behavior analysis techniques, has been shown to be effective in ameliorating impairments in major life functions arising from autism spectrum disorders and other diagnosed conditions. Coverage of EPSDT behavioral therapy services will not cause more individuals to be eligible for this service but will ensure appropriate treatment of eligible children who are already in the care delivery system as well as those initiating behavioral therapy services.
Prior to treatment, an appropriate health care practitioner conducts an intake documenting the child's medical and psychiatric diagnosis and describing how service needs can best be met through behavioral therapy interventions. The assessment includes a description of the behavior or behaviors targeted for treatment, including data on the frequency, duration, and intensity of the behavior or behaviors. An individualized service plan (ISP) is developed based on the assessment. The ISP describes each targeted behavior, the behavioral modification strategy to be used to manage each targeted behavior, and the measurement and data collection methods to be used for each targeted behavior in the plan.
Behavioral analysis treatment strategies are systematic interventions that are primarily provided in the family home. Family training and counseling related to the implementation of the behavioral therapy shall be included as part of the behavioral therapy service. Behavioral therapy may be intermittently provided in community settings when approved settings are deemed by DMAS or its contractor as medically necessary treatment. These services are designed to enhance communication skills and decrease maladaptive patterns of behavior that, if left untreated, could lead to more complex problems and the need for a greater or a more restrictive level of care, such as institutionalization. Successful implementation of behavioral therapy services requires the participation of a parent or guardian.
The service goal is to ensure that the member's family is trained to successfully manage clinically designed behavioral modification strategies in the home setting. The family involvement in therapy is meant to increase the child's adaptive functioning by training the family in effective methods of behavioral modification strategies. Family members do not have to be present during all hours of therapy. Family members must be present and participate with their treatment plan objectives in an effective manner as documented by the clinical supervisor.
EPSDT behavioral therapy services are intended to improve the functional behaviors of the member by integrating multidisciplinary clinical and medical services with the behavioral therapy protocol to increase the member's adaptive functioning and communicative abilities. Treatment results must be documented to indicate a generalization of behaviors across different settings to maintain the targeted functioning outside of the treatment setting in the patient's residence and the larger community within which the individual resides.
Behavioral therapy services are currently excluded from Medicaid managed care contracts and reimbursed by the behavioral health services administrator (currently, Magellan) on a fee-for-service basis. Technical corrections are made to the catchlines of several existing services in 12VAC30-60-61 to create consistency in regulatory text and improve readability.
Issues: The proposed regulation is advantageous to individuals and their families by ensuring that Medicaid funded behavioral therapy services are provided by licensed practitioners with the education, experience, and clinical training necessary to effectively correct or ameliorate problematic behaviors through the use of evidence based behavior modification principles. Regulatory action will ensure that individuals, their families, and service providers are well informed about Medicaid service requirements prior to receiving or providing these services, thereby avoiding DMAS recovery of provider payments made for inappropriate or inadequate services. This regulatory action will also support the efforts of DMAS and its contractors to provide effective care coordination and administrative oversight of service delivery by clarifying provider requirements and service delivery requirements in the Virginia Administrative Code. The primary advantage to the Commonwealth, in the setting of these criteria and standards, will be the statewide uniform application of policies that should result in fewer costly provider appeals and reduced risks for fraud, waste, and abuse. There are no disadvantages to the Commonwealth for this action.
Summary of the Proposed Amendments to Regulation. The proposed regulation establishes in the Virginia Administrative Code uniform and specific standards for diagnosis and provision of behavioral therapy services under Medicaid for young people from birth through the age of 21.
Estimated Economic Impact. The proposed regulation establishes in the Virginia Administrative Code Medicaid coverage for behavioral therapy services for young people from birth through the age of 21 under the authority of the Early and Periodic Screening, Diagnosis and Treatment program. To be covered for this service, children and adolescents must have autism or autism spectrum disorders, or other similar developmental delays as demonstrated by their lack of communication skills or lack of interaction with their environments.
Prior to 2012 these services were already covered by Medicaid, but there were no uniform standards. The coverage decisions were made on a case-by-case basis. In 2012, the Department of Medical Assistance Services (DMAS) adopted a service manual setting out uniform rules for coverage and provision of behavioral therapy services (e.g., rules for provider enrollment, eligibility criteria, limitations, service authorization requirements, etc.). In December 2013, DMAS contracted Magellan Health to administer the provision of behavioral therapy services. Selection of a behavioral services administrator to run the program marked the beginning of a significant increase in provision of these services. In fiscal year 2013, 524 individuals received these services at a cost of approximately $12.2 million. In calendar year 2014, $28.2 million was spent on services provided to 1,831 individuals. In calendar year 2015, the expenditures and recipients increased to $41.6 million and 2,313, respectively. In calendar year 2016, expenditures stood at $60.6 million and the number of recipients was 2,996.
While the provision of behavioral therapy services has grown significantly in the recent past, the impact of the proposed regulation on utilization is expected to be neutral. These services have been provided according to the uniform standards set out in the service manual since 2012. Consistent with the service manual, this action specifies in the regulation the behavioral service requirements, medical necessity criteria, provider clinical assessment and intake procedures, service planning and progress measurement requirements, care coordination, clinical supervision, and other standards.
The main effect of the proposed changes is establishing clear criteria for Medicaid payment of these services in the Virginia Administrative Code and consequently providing legal basis for the programs administration. Having clear criteria in regulations is also expected to help protect the health, safety, and welfare of the affected children by improving the uniformity of service quality across providers.
Businesses and Entities Affected. As of August 2016, 348 behavioral therapy providers were credentialed with Magellan (only 89 of which actively provided services in 2016) and there were 488 licensed behavioral analysts and 103 licensed assistant behavioral analysts in the Commonwealth. In 2016, 2,996 individuals received these services.
Localities Particularly Affected. The proposed regulation does not disproportionally affect particular localities.
Costs and Other Effects. The Department of Medical Assistance Services estimates that 90% of the current providers are small businesses. The proposed amendments are not anticipated to create significant costs or other effects on small businesses.
Alternative Method that Minimizes Adverse Impact. The proposed amendments are not anticipated to have an adverse impact on small businesses.
Businesses. DMAS estimates that 10% of the current providers are non-small businesses. The proposed amendments are not anticipated to create significant costs or other effects on non-small businesses.
The proposed amendments establish Medicaid coverage for behavioral therapy services for children under the authority of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. EPSDT is a mandatory Medicaid-covered service that offers preventive, diagnostic, and treatment health care services to young people from birth through the age of 21 years. To be covered for this service, a child must have a psychiatric diagnosis relevant to the need for behavioral therapy services, including autism, autism spectrum disorders, or other similar developmental delays and must meet the medical necessity criteria. The proposed regulations define the behavioral therapy service requirements, medical necessity criteria, provider clinical assessment and intake procedures, service planning and progress measurement requirements, care coordination, clinical supervision, and other standards to assure quality. The behavioral therapy service will be reimbursed by DMAS outside of the Medallion 3 managed care contracts.
A. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.
4. Consistent with the Omnibus Budget Reconciliation Act of 1989 § 6403, early and periodic screening, diagnostic, and treatment services means the following services: screening services, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in Social Security Act § 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services and which are medically necessary, whether or not such services are covered under the State Plan and notwithstanding the limitations, applicable to recipients ages 21 and over, provided for by § 1905(a) of the Social Security Act.
"Licensed mental health professional" or "LMHP" means a licensed physician, licensed clinical psychologist, licensed psychiatric nurse practitioner, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, or certified psychiatric clinical nurse specialist.
(1) Such services must be therapeutic services rendered in a residential setting that provide structure for daily activities, psychoeducation, therapeutic supervision, care coordination, and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual® Criteria, or an equivalent standard authorized in advance by DMAS shall be required for this service.
6. Inpatient psychiatric services shall be covered for individuals younger than age 21 for medically necessary stays in inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the purpose of diagnosis and treatment of mental health and behavioral disorders identified under EPSDT when such services are rendered by (i) a psychiatric hospital or an inpatient psychiatric program in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations or (ii) a psychiatric facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the Commission on Accreditation of Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general acute care hospitals and freestanding psychiatric hospitals shall also be subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25. Inpatient psychiatric admissions to residential treatment facilities shall also be subject to the requirements of Part XIV (12VAC30-130-850 et seq.) of 12VAC30-130.
8. Behavioral therapy services shall be covered for individuals under the age of 21 years.
"Behavioral therapy" means systematic interventions provided by licensed practitioners acting within the scope of practice defined under a Virginia Health Professions Regulatory Board and covered as remedial care under 42 CFR 440.130(d) within the home to individuals under 21 years of age. Behavioral therapy includes applied behavioral analysis and is primarily provided in the family home. Family counseling and training related to the implementation of the behavioral therapy shall be included as part of the behavioral therapy service. Behavioral therapy services shall be subject to clinical reviews and determined as medically necessary. Behavioral therapy may be intermittently provided in community settings when approved settings are deemed by DMAS or its contractor as medically necessary treatment.
"Individual" means the child or adolescent under the age of 21 who is receiving behavioral therapy services.
b. Behavioral therapy services shall be designed to enhance communication skills and decrease maladaptive patterns of behavior, which if left untreated, could lead to more complex problems and the need for a greater or a more intensive level of care. The service goal shall be to ensure the individual's family or caregiver is trained to effectively manage the individual's behavior in the home using modification strategies. The services shall be provided in accordance with the individual service plan and clinical assessment summary.
c. Behavioral therapy services shall be covered when recommended by the individual's primary care provider or other licensed physician, licensed physician assistant, or licensed nurse practitioner and determined by DMAS or its contractor to be medically necessary to correct or ameliorate significant impairments in major life activities that have resulted from either developmental, behavioral, or mental disabilities. Criteria for medical necessity are set out in 12VAC30-60-61 H. Service-specific provider intakes shall be required at the onset of these services in order to receive authorization for reimbursement. Individual service plans (ISPs) shall be required throughout the entire duration of services. The services shall be provided in accordance with the individual service plan and clinical assessment summary. These services shall be provided in settings that are natural or normal for a child or adolescent without a disability, such as his home, unless there is justification in the ISP, which has been authorized for reimbursement, to include service settings that promote a generalization of behaviors across different settings to maintain the targeted functioning outside of the treatment setting in the patient's residence and the larger community within which the individual resides. Covered behavioral therapy services shall include:
(5) Training a family member in behavioral modification methods;
8. 9. Addiction and recovery treatment services shall be covered under EPSDT consistent with 12VAC30-130-5000 et seq.
3. Service providers Providers shall be licensed under the applicable state practice act or comparable licensing criteria by the Virginia Department of Education, and shall meet applicable qualifications under 42 CFR Part 440. Identification of defects, illnesses or conditions and services necessary to correct or ameliorate them shall be performed by practitioners qualified to make those determinations within their licensed scope of practice, either as a member of the IEP team or by a qualified practitioner outside the IEP team.
12VAC30-60-61. Services related to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT); community mental health services for children; behavioral therapy services for children.
"Failed services" or "unsuccessful services" means, as measured by ongoing behavioral, mental, or physical distress, that the service or services did not treat or resolve the individual's mental health or behavioral issues.
2. Individuals qualifying for this service shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis to be authorized for these services:
The service-specific provider intake shall describe how the individual meets either subdivision a or b of this subdivision.
7. Individuals qualifying for this service shall demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals shall meet at least two of the following criteria on a continuing or intermittent basis:
15. The provider shall determine who the primary care provider is and, upon receiving written consent from the individual or parent/legal guardian, shall inform him of the child's receipt of community mental health rehabilitative services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted. The parent/legal guardian shall be required to give written consent that this provider has permission to inform the primary care provider of the child's or adolescent's receipt of community mental health rehabilitative services.
E. Community-based Utilization review of community-based services for children and adolescents under 21 years of age (Level A).
1. The staff ratio must be at least 1 to 6 during the day and at least 1 to 10 between 11 p.m. and 7 a.m. The program director supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E (as defined in 12VAC35-105-20). The program director must be employed full time.
3. Authorization is required for Medicaid reimbursement. All community-based services for children and adolescents under 21 (Level A) require authorization prior to reimbursement for these services. Reimbursement shall not be made for this service when other less intensive services may achieve stabilization.
7. If an individual receiving community-based services for children and adolescents under 21 (Level A) is also receiving case management services, the provider shall collaborate with the case manager by notifying the case manager of the provision of Level A services and shall send monthly updates on the individual's progress. When the individual is discharged from Level A services, a discharge summary shall be sent to the case manager within 30 days of the service discontinuation date. Service providers Providers and case managers who are using the same electronic health record for the individual shall meet requirements for the delivery of the notification, monthly updates, and discharge summary upon entry of this documentation into the electronic health record.
F. Therapeutic Utilization review of therapeutic behavioral services for children and adolescents under 21 years of age (Level B).
1. The staff ratio must be at least 1 to 4 during the day and at least 1 to 8 between 11 p.m. and 7 a.m. The clinical director must be a licensed mental health professional. The caseload of the clinical director must not exceed 16 individuals including all sites for which the same clinical director is responsible.
8. If an individual receiving therapeutic behavioral services for children and adolescents under 21 (Level B) is also receiving case management services, the therapeutic behavioral services provider must collaborate with the care coordinator/case manager by notifying him of the provision of Level B services and the Level B services provider shall send monthly updates on the individual's treatment status. When the individual is discharged from Level B services, a discharge summary shall be sent to the care coordinator/case manager within 30 days of the discontinuation date.
9. The provider shall determine who the primary care provider is and, upon receiving written consent from the individual or parent/legal guardian, shall inform him of the individual's receipt of these Level B services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted. If these individuals are children or adolescents, then the parent/legal guardian shall be required to give written consent that this provider has permission to inform the primary care provider of the individual's receipt of community mental health rehabilitative services.
G. Utilization review. Utilization reviews for community-based services for children and adolescents under 21 years of age (Level A) and therapeutic behavioral services for children and adolescents under 21 years of age (Level B) shall include determinations whether providers meet all DMAS requirements, including compliance with DMAS marketing requirements. Providers that DMAS determines have violated the DMAS marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000(E).
4. Prior to treatment, an appropriate service-specific provider intake shall be conducted, documented, signed, and dated by a licensed behavior analyst (LBA), licensed assistant behavior analyst (LABA), or LMHP, LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice, documenting the individual's diagnosis (including a description of the behavior or behaviors targeted for treatment with their frequency, duration, and intensity) and describing how service needs can best be met through behavioral therapy. The service-specific provider intake shall be conducted face-to-face in the individual's residence with the individual and parent or guardian. A new service-specific provider intake shall be conducted and documented every three months, or more often if needed, to observe the individual and family interaction, review clinical data, and revise the ISP as needed.
5. The ISP shall be developed upon admission to the service and reviewed within 30 days of admission to the service to ensure that all treatment goals are reflective of the individual's clinical needs and shall describe each treatment goal, targeted behavior, one or more measurable objectives for each targeted behavior, the behavioral modification strategy to be used to manage each targeted behavior, the plan for parent or caregiver training, care coordination, and the measurement and data collection methods to be used for each targeted behavior in the ISP. The ISP shall be fully completed, signed, and dated by an LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual and individual's parent or guardian. The ISP shall be reviewed every three months (at the same time the service-specific provider intake is conducted and documented) and updated as the individual progresses and his needs change, but at least annually, and shall be signed by either the parent or legal guardian and the individual. Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP.
7. Clinical supervision shall be required for Medicaid reimbursement of behavioral therapy services that are rendered by an LABA, LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of practice as described by the applicable Virginia Department of Health Professions regulatory board. Clinical supervision shall occur at least weekly and, as documented in the individual's medical record, shall include a review of progress notes and data and dialogue with supervised staff about the individual’s progress and the effectiveness of the ISP.
8. The following shall not be covered under this service:
g. Services that are provided in the absence of the individual and a parent or other authorized caregiver identified in the ISP with the exception of treatment review processes described in 12VAC30-60-61 H 11 e, care coordination, and clinical supervision.
9. Behavioral therapy services shall not be reimbursed concurrently with community mental health services described in 12VAC30-50-130 B 5 or 12VAC30-50-226, or behavioral, psychological, or psychiatric therapeutic consultation described in 12VAC30-120-756, 12VAC30-120-1000, or 12VAC30-135-320.
10. If the individual is receiving targeted case management services under the Medicaid state plan (defined in 12VAC30-50-410 through 12VAC30-50-491, the provider shall notify the case manager of the provision of behavioral therapy services unless the parent or guardian requests that the information not be released. In addition, the provider shall send monthly updates to the case manager on the individual's status pursuant to a valid release of information. A discharge summary shall be sent to the case manager within 30 days of the service discontinuation date. A refusal of the parent or guardian to release information shall be documented in the medical record for the date the request was discussed.
11. Other standards to ensure quality of services:
e. Billable time is permitted for the LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S to better define behaviors and develop documentation strategies to measure treatment performance and the efficacy of the ISP objectives, provided that these activities are documented in a progress note as described in subdivision 11 c of this subsection.
12. Failure to comply with any of the requirements in 12VAC30-50-130 or in this section shall result in retraction.
2. Services that shall be provided outside the MCO network shall include, but are not limited to, those services identified and defined by the contract between DMAS and the MCO. Services reimbursed by DMAS include (i) dental and orthodontic services for children up to age 21 years; (ii) for all others, dental services (as described in 12VAC30-50-190), (iii) school health services, (iv) community mental health services (12VAC30-50-130 and 12VAC30-50-226); (v) early intervention services provided pursuant to Part C of the Individuals with Disabilities Education Act (IDEA) of 2004 (as defined in 12VAC30-50-131 and 12VAC30-50-415), and); (vi) long-term care services provided under the § 1915(c) home-based and community-based waivers including related transportation to such authorized waiver services; and (vii) behavioral therapy services as defined in 12VAC30-50-130.
3. Providers shall be required to refund payments if they fail to maintain adequate documentation to support billed activities.
VA.R. Doc. No. R13-3527; Filed June 30, 2017, 3:41 p.m.