Source: http://register.dls.virginia.gov/details.aspx?id=6592
Timestamp: 2018-02-25 23:00:57
Document Index: 216347071

Matched Legal Cases: ['§ 6403', '§ 1905', '§ 1905', 'art 1002', '§ 32', '§ 32', '§ 37', '§ 63', '§ 37', '§ 54', '§ 54']

Vol. 34 Iss. 3 (Fast-Track Regulation) 12VAC30-130, Amount, Duration And Scope Of Selected Services October 02, 2017
Vol. 34 Iss. 3 - October 02, 2017
Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-130, 12VAC30-50-226).
12VAC30-80. Methods and Standards for Establishing Payment Rates; Other Types of Care (amending 12VAC30-80-30, 12VAC30-80-32).
12VAC30-130. Amount, Duration and Scope of Selected Services (adding 12VAC30-130-5160 through 12VAC30-130-5210).
This regulatory package is also authorized by Item 306 MMMM(1) of Chapter 780 of the 2016 Acts of Assembly, which states that DMAS "…shall amend the state plan for medical assistance and/or seek federal authority through an 1115 demonstration waiver, as soon as feasible, to provide coverage of … peer support services to Medicaid individuals in the Fee-for-Service and Managed Care Delivery Systems."
Item 306 MMM(3) states that DMAS "…shall amend the State Plan for Medical Assistance and any waivers thereof to include peer support services to children and adults with mental health conditions and/or substance use disorders. The department shall work with its contractors, the Department of Behavioral Health and Developmental Services, and appropriate stakeholders to develop service definitions, utilization review criteria and provider qualifications."
DMAS shall amend the state plan for medical assistance and seek federal authority for the addition of Peer Support Services to Medicaid's delivery systems of comprehensive behavioral health and addiction and recovery and treatment services.
Purpose: The Commonwealth is currently experiencing a crisis of substance use of overwhelming proportions. More Virginians died from drug overdose in 2013 than from automobile accidents. In 2014, 80% of the people who died from drug overdoses (986 people) died from prescription opioid or heroin overdoses. Virginia's 1.1 million Medicaid/FAMIS members are affected disproportionately by this substance use epidemic as demonstrated by DMAS claims history data showing 216,555 Medicaid members with a substance use diagnosis in state fiscal year 2015. Peer supports are part of a continuum of recovery services offered by DMAS, and, as such, this regulatory action has a direct and specific impact on the health, safety, and welfare of the Commonwealth's Medicaid individuals.
This action adds the necessary component of person centered and recovery-oriented peer support services to the comprehensive program of addiction and recovery and treatment services to include community-based addiction and recovery treatment services established in response to the Governor's bipartisan Task Force on Prescription Drug and Heroin Addiction's numerous recommendations.
The provision of peer support services facilitates recovery from both serious mental illnesses and substance use disorders. Recovery is a process in which people are able to live, work, learn, and fully participate in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite their disability. For others, recovery could mean the reduction or complete remission of symptoms. Peer support services are delivered by peers who have been successful in the recovery process and can extend the reach of treatment beyond the clinical setting into an individual's community and natural environment to support and assist an individual with staying engaged in the recovery process.
Rationale for Using Fast-Track Rulemaking Process: This regulatory action is being promulgated as a fast-track rulemaking action because public comments received about the general concept and features, which have been specified to date, have been positive. The peer supports proposal offers an opportunity for substantial improvement in mental health and substance use treatment, and affected entities are actively participating with DMAS in its design efforts.
Substance: The section of the State Plan for Medical Assistance that is affected by this action is: "Amount, Duration, and Scope of Medical and Remedial Services."
DMAS covers approximately 1.1 million individuals; 80% of members receive care through contracted managed care organizations (MCOs) and 20% of members receive care through fee-for-service (FFS). The majority of members enrolled in Virginia's Medicaid and FAMIS programs include children, pregnant women, and individuals who meet the disability category of being aged, blind, or disabled. The 20% of the individuals receiving care through fee-for-service do so because they meet one of 16 categories of exception to MCO participation, for example: (i) inpatients in state mental hospitals, long-stay hospitals, nursing facilities, or ICF/IIDs, (ii) individuals on spend down, (iii) individuals younger than 21 years of age who are in residential treatment facility Level C programs, (iv) newly eligible individuals in their third trimester of pregnancy, (v) individuals who permanently live outside their area of residence, (vi) individuals receiving hospice services, (vii) individuals with other comprehensive group or individual health insurance, (viii) individuals eligible for Individuals with Disabilities Education Act (IDEA) Part C services, (ix) individuals whose eligibility period is less than three months or is retroactive, and (x) individuals enrolled in the Virginia Birth-Related Neurological Injury Compensation Program.
Historically, Virginia has not funded peer support services but the Commonwealth now has compelling reasons to provide Medicaid coverage for the provision of peer support services to adults and to the caregivers of youth. In a letter to state Medicaid directors, dated August 15, 2007, the Centers for Medicare & Medicaid Services (CMS) stated that they recognize "… the mental health field has seen a big shift in the paradigm of care over the last few years." CMS further states that "…now, more than ever, there is great emphasis on recovery from even the most serious mental illnesses when persons have access in their communities to treatment and supports that are tailored to their needs. CMS recognizes that the experiences of peer support providers, as consumers of mental health and substance use services, can be an important component in a state's delivery of effective treatment. CMS is reaffirming its commitment to state flexibility, increased innovation, consumer choice, self-direction, recovery, and consumer protection through approval of these services."
Beyond health care risk, the economic costs associated with mental illness and substance use disorders are significant. States and the federal government spend billions of tax dollars every year on the collateral impact associated with substance use disorders and mental illness, including criminal justice, public assistance and lost productivity costs.
To address the emphasis on recovery from mental illnesses and substance use disorders and the recommendations from CMS, individuals 21 years of age or older and families or caretakers of youth 21 years of age and younger who participate in Medicaid managed care plan, GAP, FAMIS, FAMIS MOMS, or Medicaid fee-for-service shall be eligible to receive peer support services. These services shall be an added service under the Virginia's community mental health and rehabilitative services for individuals with mental health disorders and under the addiction and recovery treatment services (ARTS) for individuals with substance use disorders and co-occurring substance use and mental health disorders.
To be eligible to receive peer support services, adults 21 years and older shall require recovery oriented assistance and support for the acquisition of skills needed to engage in and maintain recovery, the development of self-advocacy skills to achieve a higher level of community tenure while decreasing dependency on formalized treatment systems, and to increase responsibilities, wellness potential, and shared accountability for their own recovery. Individuals 21 years or older shall have a documented substance use disorder or co-occurring mental health and substance use disorder, shall demonstrate moderate to severe functional impairment as a result of the diagnosis, and the functional impairment shall be of a degree that it interferes with or limits performance educationally, socially, vocationally, or living more independently.
Families or caretakers of individuals under age 21 shall qualify for family support ("family support partners") to assist with the individual's substance use disorder or co-occurring mental health and substance use disorder that has occurred within the past year. The family or caretaker and the individual shall require recovery assistance and two or more of the following:
1. Peer-based recovery oriented support for the maintenance of wellness and acquisition of skills needed to support the youth;
2. Assistance to develop self-advocacy skills to assist the youth in achieving self-management of the youth's health status;
3. Assistance and support to prepare the youth for a successful work or school experience; or
4. Peer modeling to increase helping the youth to assume responsibility for their recovery and resiliency.
Covered peer support services include collaborative recovery-oriented services and person centered activities and experiences, health care advocacy, the development of community roles and natural supports, support of work or other meaningful activity of the person's choosing, crisis support, and effective utilization of the service delivery system.
Peer support services shall be rendered following a documented recommendation for service by a licensed practitioner who is a credentialed addiction treatment professional or a licensed mental health professional who is enrolled as mental health or substance use Medicaid provider or who is working in an agency or facility enrolled as a mental health or substance use provider. The qualified peer will perform peer services under the supervision and clinical direction of the practitioner making the recommendation for services. The peer will be employed by or have a contractual relationship with the licensed and enrolled practitioner or provider agency. These enrolled providers shall only hire peers who have been properly trained and certified by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) and then registered with the Virginia Board of Counseling. Only the licensed and enrolled credentialed addiction treatment professional, licensed mental health professional, or provider agency shall be eligible to bill and receive reimbursement for peer support services.
A recovery, resiliency, and wellness plan based on the individual's, and as applicable the identified family's, perceived recovery needs and multidisciplinary assessment shall be required within 30 calendar days of the initiation of service. Development of the recovery, resiliency, and wellness plan shall include collaboration with the individual and, as applicable, the identified family member or caregiver involved in the individual's recovery. Ongoing and routine review of this plan will ensure effective service delivery.
Issues: There are no disadvantages identified in adding peer support services to the full continuum of addiction and recovery treatment services and community mental health rehabilitative services in Virginia. Peer support services are needed to ensure the success of Virginia's delivery system transformation that will save lives, improve patient outcomes, and decrease costs. There are no disadvantages to affected providers as this is an added service.
The advantages to Medicaid-eligible individuals are discussed above.
CMS will require an independent evaluation of the peer support services to demonstrate any improved outcomes for Medicaid members and cost savings from reducing emergency department visits and inpatient hospital utilization. This evaluation will help the Commonwealth demonstrate the impact of the service on the lives of its citizens, both Medicaid eligible and noneligible, as well as on the Commonwealth's economy.
Summary of the Proposed Amendments to Regulation. Pursuant to Chapter 780 of the 2016 Acts of the Assembly, the Director of the Department of Medical Assistance Services (DMAS) proposes to implement peer support services to children and adults who have mental health conditions and/or substance use disorders.
Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance use disorders. Peer support providers are self-identified consumers who are in successful and ongoing recovery from mental illness and/or substance use disorders.
The provision of Peer Support Services facilitates recovery from both serious mental illnesses and substance use disorders. Recovery is a process in which people are able to live, work, learn and fully participate in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite their disability. For others, recovery could mean the reduction or complete remission of symptoms. Peer Support Services are delivered by peers who have been successful in the recovery process and can extend the reach of treatment beyond the clinical setting into an individual's community and natural environment to support and assist an individual with staying engaged in the recovery process.
The Commonwealth is experiencing a crisis of substance use of overwhelming proportions. More Virginians died from drug overdose in 2013 than from automobile accidents. In 2014, 80% of the people who died from drug overdoses (986 people) died from prescription opioid or heroin overdoses. Virginia's 1.1 million Medicaid/FAMIS members are affected disproportionately by this substance use epidemic as demonstrated by DMAS' claims history data showing 216,555 Medicaid members with a substance use diagnosis in fiscal year 2015.1
Peer Support Services would target individuals 21 years or older with mental health or substance use disorder or co-occurring mental health and substance use disorders. A Peer Support service called Family Support Partners would be provided to individuals under the age of 21 who have a mental health or substance use disorder or co-occurring mental health and substance use disorders which are the focus of the support with their families or caregivers.
Peer support providers would be trained and certified by the Virginia Department of Behavioral Health and Developmental Services, and then registered with the Board of Counseling at the Department of Health Professions. Supervision and care coordination are core components of peer support services.
Research has provided evidence that peer-delivered services generate superior outcomes in terms of decreased substance abuse, engagement of "difficult-to-reach" clients, and reduced rates of hospitalization.2 Further, peer support has been found to increase participants' sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants' level of depression and psychosis.3 To the extent that the implementation of peer support services are successful in reducing the incidences of substance abuse and overdoses, and has significant positive impact on mental health, the benefits of the proposed amendments likely exceed the estimated annual cost of $2,898,654 from the state General Fund and $2,898,654 pass through funds from the federal government.
Businesses and Entities Affected. Based on current membership and data from the Governor's Action Plan program for those with serious mental illness, DMAS estimates approximately 4,600 current Medicaid members would benefit from peer supports. Community Service Boards have a network that could provide these services to approximately 10% of these. Currently there are approximately 5,891 provider entities with a unique National Provider Identifier that could be affected by the new regulations if they choose to participate in the service. At least half if not more of these providers are small businesses.
Projected Impact on Employment. The proposed amendments create peer support provider positions for people who are in successful and ongoing recovery from mental illness and/or substance use disorders. These are individuals who may otherwise have difficulty finding employment.
Effects on the Use and Value of Private Property. The proposed amendments potentially benefit firms that provide mental health and drug treatment services by providing additional business and revenue. The value of these firms may thus be positively affected.
Davidson, L., C. Bellamy, K. Guy, and R. Miller. 2011. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry 11:123-128
Rowe M., C. Bellamy et al. 2007. Reducing alcohol use, drug use, and criminality among persons with severe mental illness: outcomes of a Group- and Peer-Based Intervention. Psychiatric Services 58:955-61.
Solomon P, J. Draine, and M. Delaney. 1995. The working alliance and consumer case management. Journal of Mental Health Administration 22:126-34.
1 Source: Department of Medical Assistance Services
2 See Rowe et al (2007) and Solomon et al (1995)
3 See Davison et al (2012)
Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget. The agency raises no issues with this analysis.
Pursuant to Chapter 780 of the 2016 Acts of the Assembly, the amendments establish peer support services and family support services for children and adults who have mental health conditions or substance use disorders and address (i) eligibility for services; (ii) provider and setting requirements; (iii) development of a recovery, resiliency, and wellness plan; (iv) documentation of services; (v) reimbursement; (vi) service limitations; and (vii) definitions.
B. Early and periodic screening and diagnosis of individuals under younger than 21 years of age, and treatment of conditions found.
1. Payment of medical assistance services shall be made on behalf of individuals under younger than 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities, and the accompanying attendant physician care, in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination.
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 years and over older, provided for by § 1905(a) of the Social Security Act.
"Adolescent or child" means the individual receiving the services described in this section. For the purpose of the use of these terms, adolescent means an individual 12-20 12 through 20 years of age; a child means an individual from birth up to 12 years of age.
"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 the same as defined in 12VAC35-105-20.
(1) Such services must be therapeutic services rendered in a residential setting that. The residential services will 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 Amount, Duration and Scope of Selected Services.
12VAC30-50-226. Community mental health services.
"Affiliated" means any entity or property in which a provider or facility has a direct or indirect ownership interest of 5.0% or more, or any management, partnership, or control of an entity.
"Behavioral health services administrator" or "BHSA" means an entity that manages or directs a behavioral health benefits program under contract with DMAS. DMAS' designated BHSA shall be authorized to constitute, oversee, enroll, and train a provider network; perform service authorization; adjudicate claims; process claims; gather and maintain data; reimburse providers; perform quality assessment and improvement; conduct member outreach and education; resolve member and provider issues; and perform utilization management including care coordination for the provision of Medicaid-covered behavioral health services. Such authority shall include entering into or terminating contracts with providers in accordance with DMAS authority pursuant to 42 CFR Part 1002 and § 32.1-325 D and E of the Code of Virginia. DMAS shall retain authority for and oversight of the BHSA entity or entities.
"Certified prescreener" means an employee of either the local community services board/behavioral health authority or its designee who is skilled in the assessment and treatment of mental illness and who has completed a certification program approved by DBHDS.
"Clinical experience" means, for the purpose of rendering (i) mental health day treatment/partial hospitalization, (ii) intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental health skill building, (v) crisis stabilization, or (vi) crisis intervention services, practical experience in providing direct services to individuals with diagnoses of mental illness or intellectual disability or the provision of direct geriatric services or special education services. Experience shall include supervised internships, supervised practicums, or supervised field experience. Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience. The equivalency of part-time hours to full-time hours for the purpose of this requirement shall be established by DBHDS in the document titled Human Services and Related Fields Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"DMAS" means the Department of Medical Assistance Services and its contractor or contractors consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
"Human services field" means the same as the term is defined by DBHDS in the guidance document entitled Human Services and Related Fields Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Individual" means the patient, client, or recipient of services described in this section.
"Individual service plan" or "ISP" means a comprehensive and regularly updated treatment plan specific to the individual's unique treatment needs as identified in the service-specific provider intake. The ISP contains, but is not limited to, the individual's treatment or training needs, the individual's goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, the estimated timetable for achieving the goals and objectives, and an individualized discharge plan that describes transition to other appropriate services. The individual shall be included in the development of the ISP and the ISP shall be signed by the individual. If the individual is a minor child, the ISP shall also be signed by the individual's parent/legal guardian. Documentation shall be provided if the individual, who is a minor child or an adult who lacks legal capacity, is unable or unwilling to sign the ISP.
"Individualized training" means instruction and practice in functional skills and appropriate behavior related to the individual's health and safety, instrumental activities of daily living skills, and use of community resources; assistance with medical management; and monitoring health, nutrition, and physical condition. The training shall be rehabilitative and based on a variety of incremental (or cumulative) approaches or tools to organize and guide the individual's life planning and shall reflect what is important to the individual in addition to all other factors that affect his functioning, including effects of the disability and issues of health and safety.
"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as "supervisee" is defined in 18VAC140-20-10 for licensed clinical social workers. An LMHP-supervisee in social work shall be in continuous compliance with the regulatory requirements for supervised practice as found in 18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered a "supervisee" until the supervision for specific clinical duties at a specific site is preapproved in writing by the Virginia Board of Social Work. For purposes of Medicaid reimbursement to their supervisors for services provided by supervisees, these persons shall use the title "Supervisee in Social Work" after their signatures to indicate such status.
"Qualified mental health professional-child" or "QMHP-C" means the same as defined in 12VAC35-105-20.
"Review of ISP" means that the provider evaluates and updates the individual's progress toward meeting the individualized service plan objectives and documents the outcome of this review. For DMAS to determine that these reviews are satisfactory and complete, the reviews shall (i) update the goals, objectives, and strategies of the ISP to reflect any change in the individual's progress and treatment needs as well as any newly identified problems; (ii) be conducted in a manner that enables the individual to participate in the process; and (iii) be documented in the individual's medical record no later than 15 calendar days from the date of the review.
"Service authorization" means the process to approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by a DMAS service authorization contractor prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS and DMAS contractor criteria for reimbursement. Service authorization does not guarantee payment for the service.
"Service-specific provider intake" means the same as defined in 12VAC30-50-130 and also includes individuals who are older than 21 years of age.
B. Mental health services. The following services, with their definitions, shall be covered: day treatment/partial hospitalization, psychosocial rehabilitation, crisis services, intensive community treatment (ICT), and mental health skill building. Staff travel time shall not be included in billable time for reimbursement. These services, in order to be covered, shall meet medical necessity criteria based upon diagnoses made by LMHPs who are practicing within the scope of their licenses and are reflected in provider records and on providers' claims for services by recognized diagnosis codes that support and are consistent with the requested professional services. These services are intended to be delivered in a person-centered manner. The individuals who are receiving these services shall be included in all service planning activities. All services which do not require service authorization require registration. This registration shall transmit service-specific information to DMAS or its contractor in accordance with service authorization requirements.
1. Day treatment/partial hospitalization services shall be provided in sessions of two or more consecutive hours per day, which may be scheduled multiple times per week, to groups of individuals in a nonresidential setting. These services, limited annually to 780 units, include the major diagnostic, medical, psychiatric, psychosocial, and psychoeducational treatment modalities designed for individuals who require coordinated, intensive, comprehensive, and multidisciplinary treatment but who do not require inpatient treatment. One unit of service shall be defined as a minimum of two but less than four hours on a given day. Two units of service shall be defined as at least four but less than seven hours in a given day. Three units of service shall be defined as seven or more hours in a given day. Authorization is required for Medicaid reimbursement.
a. Day treatment/partial hospitalization services shall be time limited interventions that are more intensive than outpatient services and are required to stabilize an individual's psychiatric condition. The services are delivered when the individual is at risk of psychiatric hospitalization or is transitioning from a psychiatric hospitalization to the community. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual is at risk of psychiatric hospitalization or is transitioning from a psychiatric hospitalization to the community.
b. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that 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:
(1) Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness or isolation from social supports;
(2) Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;
(3) Exhibit such inappropriate behavior that the individual requires repeated interventions or monitoring by the mental health, social services, or judicial system that have been documented; or
(4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.
c. Individuals shall be discharged from this service when they are no longer in an acute psychiatric state and other less intensive services may achieve psychiatric stabilization.
d. Admission and services for time periods longer than 90 calendar days must be authorized based upon a face-to-face evaluation by a physician, psychiatrist, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, or psychiatric clinical nurse specialist.
e. These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
2. Psychosocial rehabilitation shall be provided at least two or more hours per day to groups of individuals in a nonresidential setting. These services, limited annually to 936 units, include assessment, education to teach the patient about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. One unit of service is defined as a minimum of two but less than four hours on a given day. Two units are defined as at least four but less than seven hours in a given day. Three units of service shall be defined as seven or more hours in a given day. Authorization is required for Medicaid reimbursement. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service.
a. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals: (i) who without these services would be unable to remain in the community or (ii) who meet at least two of the following criteria on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports;
(3) Exhibit such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior.
b. These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
3. Crisis intervention shall provide immediate mental health care, available 24 hours a day, seven days per week, to assist individuals who are experiencing acute psychiatric dysfunction requiring immediate clinical attention. This service's objectives shall be to prevent exacerbation of a condition, to prevent injury to the client or others, and to provide treatment in the context of the least restrictive setting. Crisis intervention activities shall include assessing the crisis situation, providing short-term counseling designed to stabilize the individual, providing access to further immediate assessment and follow-up, and linking the individual and family with ongoing care to prevent future crises. Crisis intervention services may include office visits, home visits, preadmission screenings, telephone contacts, and other client-related activities for the prevention of institutionalization. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. The provision of this service to an individual shall be registered with either DMAS, DMAS contractors, or the BHSA within one business day or the completion of the service-specific provider intake to avoid duplication of services and to ensure informed care coordination.
a. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization. Individuals must meet at least two of the following criteria at the time of admission to the service:
(3) Exhibit such inappropriate behavior that immediate interventions documented by mental health, social services, or the judicial system are or have been necessary; or
b. The annual limit for crisis intervention is 720 units per year. A unit shall equal 15 minutes.
c. These services may only be rendered by an LMHP, an LMHP-supervisee, LMHP-resident, LMHP-RP, or a certified prescreener.
4. Intensive community treatment (ICT), initially covered for a maximum of 26 weeks based on an initial service-specific provider intake and may be reauthorized for up to an additional 26 weeks annually based on written intake and certification of need by a licensed mental health provider (LMHP), shall be defined by 12VAC35-105-20 or LMHP-S, LMHP-R, and LMHP-RP and shall include medical psychotherapy, psychiatric assessment, medication management, and care coordination activities offered to outpatients outside the clinic, hospital, or office setting for individuals who are best served in the community. Authorization is required for Medicaid reimbursement.
a. To qualify for ICT, the individual must meet at least one of the following criteria:
(1) The individual must be at high risk for psychiatric hospitalization or becoming or remaining homeless due to mental illness or require intervention by the mental health or criminal justice system due to inappropriate social behavior.
(2) The individual has a history (three months or more) of a need for intensive mental health treatment or treatment for co-occurring serious mental illness and substance use disorder and demonstrates a resistance to seek out and utilize appropriate treatment options.
b. A written, service-specific provider intake, as defined at 12VAC30-50-130, that documents the individual's eligibility and the need for this service must be completed prior to the initiation of services. This intake must be maintained in the individual's records.
c. An individual service plan shall be initiated at the time of admission and must be fully developed, as defined in this section, within 30 days of the initiation of services.
d. The annual unit limit shall be 130 units with a unit equaling one hour.
e. These services may only be rendered by a team that meets the requirements of 12VAC35-105-1370.
5. Crisis stabilization services for nonhospitalized individuals shall provide direct mental health care to individuals experiencing an acute psychiatric crisis which may jeopardize their current community living situation. Services may be provided for up to a 15-day period per crisis episode following a face-to-face service-specific provider intake by an LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP. Only one unit of service shall be reimbursed for this intake. The provision of this service to an individual shall be registered with either DMAS, DMAS contractors, or the BHSA within one business day of the completion of the service-specific provider intake to avoid duplication of services and to ensure informed care coordination.
a. The goals of crisis stabilization programs shall be to avert hospitalization or rehospitalization, provide normative environments with a high assurance of safety and security for crisis intervention, stabilize individuals in psychiatric crisis, and mobilize the resources of the community support system and family members and others for on-going maintenance and rehabilitation. The services must be documented in the individual's records as having been provided consistent with the ISP in order to receive Medicaid reimbursement.
b. The crisis stabilization program shall provide to individuals, as appropriate, psychiatric assessment including medication evaluation, treatment planning, symptom and behavior management, and individual and group counseling.
c. This service may be provided in any of the following settings, but shall not be limited to: (i) the home of an individual who lives with family or other primary caregiver; (ii) the home of an individual who lives independently; or (iii) community-based programs licensed by DBHDS to provide residential services but which are not institutions for mental disease (IMDs).
d. This service shall not be reimbursed for (i) individuals with medical conditions that require hospital care; (ii) individuals with primary diagnosis of substance abuse; or (iii) individuals with psychiatric conditions that cannot be managed in the community (i.e., individuals who are of imminent danger to themselves or others).
e. The maximum limit on this service is 60 days annually.
f. Services must be documented through daily progress notes and a daily log of times spent in the delivery of services. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization. Individuals must meet at least two of the following criteria at the time of admission to the service:
(1) Experience difficulty in establishing and maintaining normal interpersonal relationships to such a degree that the individual is at risk of psychiatric hospitalization, homelessness, or isolation from social supports;
(3) Exhibit such inappropriate behavior that immediate interventions documented by the mental health, social services, or judicial system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that the individual is unable to recognize personal danger or significantly inappropriate social behavior.
g. These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E or a certified prescreener.
6. Mental health skill-building services (MHSS) shall be defined as goal-directed training to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed. These services may be authorized up to six consecutive months as long as the individual meets the coverage criteria for this service. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. These services shall provide goal-directed training in the following areas in order to be reimbursed by Medicaid or the BHSA: (i) functional skills and appropriate behavior related to the individual's health and safety, instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring of health, nutrition, and physical condition with goals towards self-monitoring and self-regulation of all of these activities. Providers shall be reimbursed only for training activities defined in the ISP and only where services meet the service definition, eligibility, and service provision criteria and this section. A review of MHSS services by an LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be repeated for all individuals who have received at least six months of MHSS to determine the continued need for this service.
a. Individuals qualifying for this service shall demonstrate a clinical 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. Services are provided to individuals who require individualized goal-directed training in order to achieve or maintain stability and independence in the community.
b. Individuals ages 21 and older shall meet all of the following criteria in order to be eligible to receive mental health skill-building services:
(1) The individual shall have one of the following as a primary mental health diagnosis:
(a) Schizophrenia or other psychotic disorder as set out in the DSM-5;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician has documented specific to the identified individual within the past year and that includes all of the following: (i) is a serious mental illness; (ii) results in severe and recurrent disability; (iii) produces functional limitations in the individual's major life activities that are documented in the individual's medical record; and (iv) requires individualized training for the individual in order to achieve or maintain independent living in the community.
(2) The individual shall require individualized goal-directed training in order to acquire or maintain self-regulation of basic living skills, such as symptom management; adherence to psychiatric and physical health medication treatment plans; appropriate use of social skills and personal support systems; skills to manage personal hygiene, food preparation, and the maintenance of personal adequate nutrition; money management; and use of community resources.
(3) The individual shall have a prior history of any of the following: (i) psychiatric hospitalization; (ii) either residential or nonresidential crisis stabilization; (iii) intensive community treatment (ICT) or program of assertive community treatment (PACT) services; (iv) placement in a psychiatric residential treatment facility (RTC-Level C) as a result of decompensation related to the individual's serious mental illness; or (v) a temporary detention order (TDO) evaluation, pursuant to § 37.2-809 B of the Code of Virginia. This criterion shall be met in order to be initially admitted to services and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
(4) The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the service-specific provider intake date. If a physician or other practitioner who is authorized by his license to prescribe medications indicates that antipsychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual, the provider shall obtain medical records signed by the physician or other licensed prescriber detailing the contraindication. This documentation shall be maintained in the individual's mental health skill-building services record, and the provider shall document and describe how the individual will be able to actively participate in and benefit from services without the assistance of medication. This criterion shall be met upon admission to services and shall not be required for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
c. Individuals aged 18 to 21 years shall meet all of the following criteria in order to be eligible to receive mental health skill-building services:
(1) The individual shall not be living in a supervised setting as described in § 63.2-905.1 of the Code of Virginia. If the individual is transitioning into an independent living situation, MHSS shall only be authorized for up to six months prior to the date of transition.
(2) The individual shall have at least one of the following as a primary mental health diagnosis.
(c) Recurrent Bipolar-I or Bipolar II; or
(d) Any other serious mental health disorder that a physician has documented specific to the identified individual within the past year and that includes all of the following: (i) is a serious mental illness or serious emotional disturbance; (ii) results in severe and recurrent disability; (iii) produces functional limitations in the individual's major life activities that are documented in the individual's medical record; and (iv) requires individualized training for the individual in order to achieve or maintain independent living in the community.
(3) The individual shall require individualized goal-directed training in order to acquire or maintain self-regulation of basic living skills such as symptom management; adherence to psychiatric and physical health medication treatment plans; appropriate use of social skills and personal support systems; skills to manage personal hygiene, food preparation, and the maintenance of personal adequate nutrition; money management; and use of community resources.
(4) The individual shall have a prior history of any of the following: (i) psychiatric hospitalization; (ii) either residential or nonresidential crisis stabilization; (iii) intensive community treatment (ICT) or program of assertive community treatment (PACT) services; (iv) placement in a psychiatric residential treatment facility (RTC-Level C) as a result of decompensation related to the individual's serious mental illness; or (v) temporary detention order (TDO) evaluation pursuant to § 37.2-809 B of the Code of Virginia. This criterion shall be met in order to be initially admitted to services and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
(5) The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications, within the 12 months prior to the assessment date. If a physician or other practitioner who is authorized by his license to prescribe medications indicates that antipsychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual, the provider shall obtain medical records signed by the physician or other licensed prescriber detailing the contraindication. This documentation of medication management shall be maintained in the individual's mental health skill-building services record. For individuals not prescribed antipsychotic, mood stabilizing, or antidepressant medications, the provider shall have documentation from the medication management physician describing how the individual will be able to actively participate in and benefit from services without the assistance of medication. This criterion shall be met in order to be initially admitted to services and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
(6) An independent clinical assessment, established in 12VAC30-130-3020, shall be completed for the individual.
d. Service-specific provider intakes shall be required at the onset of services and individual service plans (ISPs) shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for service-specific provider intakes and ISPs are set out in 12VAC30-50-130.
e. The yearly limit for mental health skill-building services is 520 units. Only direct face-to-face contacts and services to the individual shall be reimbursable. One unit is 1 to 2.99 hours per day, two units is 3 to 4.99 hours per day.
f. These services may only be rendered by an LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or QPPMH.
g. The provider shall clearly document details of the services provided during the entire amount of time billed.
h. The ISP shall not include activities that contradict or duplicate those in the treatment plan established by the group home or assisted living facility. The provider shall coordinate mental health skill-building services with the treatment plan established by the group home or assisted living facility and shall document all coordination activities in the medical record.
i. Limits and exclusions.
(1) Group home (Level A or B) and assisted living facility providers shall not serve as the mental health skill-building services provider for individuals residing in the provider's respective facility. Individuals residing in facilities may, however, receive MHSS from another MHSS agency not affiliated with the owner of the facility in which they reside.
(2) Mental health skill-building services shall not be reimbursed for individuals who are receiving in-home residential services or congregate residential services through the Intellectual Disability Waiver or Individual and Family Developmental Disabilities Support Waiver.
(3) Mental health skill-building services shall not be reimbursed for individuals who are also receiving services under the Department of Social Services independent living program (22VAC40-151), independent living services (22VAC40-131 and 22VAC40-151), or independent living arrangement (22VAC40-131) or any Comprehensive Services Act-funded independent living skills programs.
(4) Mental health skill-building services shall not be available to individuals who are receiving treatment foster care (12VAC30-130-900 et seq.).
(5) Mental health skill-building services shall not be available to individuals who reside in intermediate care facilities for individuals with intellectual disabilities or hospitals.
(6) Mental health skill-building services shall not be available to individuals who reside in nursing facilities, except for up to 60 days prior to discharge. If the individual has not been discharged from the nursing facility during the 60-day period of services, mental health skill-building services shall be terminated and no further service authorizations shall be available to the individual unless a provider can demonstrate and document that mental health skill-building services are necessary. Such documentation shall include facts demonstrating a change in the individual's circumstances and a new plan for discharge requiring up to 60 days of mental health skill-building services.
(7) Mental health skill-building services shall not be available for residents of residential treatment centers (Level C facilities) except for the intake code H0032 (modifier U8) in the seven days immediately prior to discharge.
(8) Mental health skill-building services shall not be reimbursed if personal care services or attendant care services are being received simultaneously, unless justification is provided why this is necessary in the individual's mental health skill-building services record. Medical record documentation shall fully substantiate the need for services when personal care or attendant care services are being provided. This applies to individuals who are receiving additional services through the Intellectual Disability Waiver (12VAC30-120-1000 et seq.), Individual and Family Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.), the Elderly or Disabled with Consumer Direction Waiver (12VAC30-120-900 et seq.), and EPSDT services (12VAC30-50-130).
(9) Mental health skill-building services shall not be duplicative of other services. Providers shall be required to ensure that if an individual is receiving additional therapeutic services that there will be coordination of services by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or QPPMH to avoid duplication of services.
(10) Individuals who have organic disorders, such as delirium, dementia, or other cognitive disorders not elsewhere classified, will be prohibited from receiving mental health skill-building services unless their physicians issue signed and dated statements indicating that the individuals can benefit from this service.
(11) Individuals who are not diagnosed with a serious mental health disorder but who have personality disorders or other mental health disorders, or both, that may lead to chronic disability shall not be excluded from the mental health skill-building services eligibility criteria provided that the individual has a primary mental health diagnosis from the list included in subdivision B 6 b (1) or B 6 c (2) of this section and that the provider can document and describe how the individual is expected to actively participate in and benefit from mental health skill-building services.
7. Mental health peer support services.
a. Mental health peer support services are peer recovery support services and are nonclinical, peer-to-peer activities that engage, educate, and support an individual's self-help efforts to improve health recovery, resiliency, and wellness. Mental health peer support services for adults is a person centered, strength-based, and recovery-oriented rehabilitative service for individuals 21 years or older provided by a peer recovery specialist successful in the recovery process with lived experience with a mental health disorder, who is trained to offer support and assistance in helping others in the recovery to reduce the disabling effects of a mental health disorder that is the focus of support. Services assist the individual with developing and maintaining a path to recovery, resiliency, and wellness. Specific peer support service activities shall emphasize the acquisition, development, and enhancement of recovery, resiliency, and wellness. Services are designed to promote empowerment, self-determination, understanding, and coping skills through mentoring and service coordination supports, as well as to assist individuals in achieving positive coping mechanisms for the stressors and barriers encountered when recovering from their illnesses or disorders.
b. Under the clinical oversight of the LMHP making the recommendation for mental health support services, the peer recovery specialist in consultation with his direct supervisor shall develop a recovery, resiliency, and wellness plan based on the LMHP's recommendation for service, the individual's perceived recovery needs, and any clinical assessments or service specific provider intakes as defined in this section within 30 calendar days of the initiation of service. Development of the recovery, resiliency, and wellness plan shall include collaboration with the individual. Individualized goals and strategies shall be focused on the individual's identified needs for self-advocacy and recovery. The recovery, resiliency, and wellness plan shall also include documentation of how many days per week and how many hours per week are required to carry out the services in order to meet the goals of the plan. The recovery, resiliency, and wellness plan shall be completed, signed, and dated by the LMHP, the PRS, the direct supervisor, and the individual within 30 calendar days of the initiation of service. The PRS shall act as an advocate for the individual, encouraging the individual to take a proactive role in developing and updating goals and objectives in the individualized recovery planning.
c. Documentation of required activities shall be required as set forth in 12VAC30-130-5200 A and C through J.
d. Limitations and exclusions to service delivery shall be the same as set forth in 12VAC30-130-5210.
e. Individuals 21 years or older qualifying for mental health peer support services shall meet the following requirements:
(1) Require recovery-oriented assistance and support services for the acquisition of skills needed to engage in and maintain recovery; for the development of self-advocacy skills to achieve a decreasing dependency on formalized treatment systems; and to increase responsibilities, wellness potential, and shared accountability for the individual's own recovery.
(2) Have a documented mental health disorder diagnosis.
(3) Demonstrate moderate to severe functional impairment because of a diagnosis that interferes with or limits performance in at least one of the following domains: educational (e.g., obtaining a high school or college degree); social (e.g., developing a social support system); vocational (e.g., obtaining part-time or full-time employment); self-maintenance (e.g., managing symptoms, understanding his illness, living more independently).
f. To qualify for continued mental health peer support services, the requirements for continued services set forth in 12VAC30-130-5180 D shall be met.
g. Discharge criteria from mental health peer support services is the same as set forth in 12VAC30-130-5180 E.
h. Mental health peer support services shall be rendered on an individual basis or in a group.
i. Prior to service initiation, a documented recommendation for mental health peer support services shall be made by a licensed mental health professional acting within the scope of practice under state law The recommendation shall verify that the individual meets the medical necessity criteria set forth in subdivision 7 e of this subsection. The recommendation shall be valid for no longer than 30 calendar days.
j. Effective July 1, 2017, a peer recovery specialist shall have the qualifications, education, experience, and certification established by DBHDS in order to be eligible to register with the Board of Counseling on or after July 1, 2018. Upon the promulgation of regulations by the Board of Counseling, registration of peer recovery specialists by the Board of Counseling shall be required. The PRS shall perform mental health peer support services under the oversight of the LMHP making the recommendation for services and providing the clinical oversight of the recovery, resiliency, and wellness plan. The PRS shall be employed by or have a contractual relationship with an enrolled provider licensed for one of the following:
(1) Acute care general hospital licensed by the Department of Health.
(2) Freestanding psychiatric hospital and inpatient psychiatric unit licensed by the Department of Behavioral Health and Developmental Services.
(3) Outpatient mental health clinic services licensed by the Department of Behavioral Health and Developmental Services.
(4) Outpatient psychiatric services provider.
(5) Rural health clinics and federally qualified health centers.
(6) Hospital emergency department services licensed by the Department of Health.
(7) Community mental health and rehabilitative services provider licensed by the Department of Behavioral Health and Developmental Services as a provider of one of the following community mental health and rehabilitative services defined in this section or 12VAC30-50-420 for which the individual meets medical necessity criteria:
(a) Day treatment or partial hospitalization;
(b) Psychosocial rehabilitation;
(c) Crisis intervention;
(d) Intensive community treatment;
(e) Crisis stabilization;
(f) Mental health skill building; or
(g) Mental health case management.
k. Only the licensed and enrolled provider referenced in subdivision 7 j of this subsection shall be eligible to bill mental health peer support services. Payments shall not be permitted to providers that fail to enter into an enrollment agreement with DMAS or its contractor. Reimbursement shall be subject to retraction for any billed service that is determined to not to be in compliance with DMAS requirements.
l. Supervision of the PRS shall be required as set forth in 12VAC30-130-5190 E and 12VAC30-130-5200 G.
3. Mental health services including: (i) community mental health services, (ii) services of a licensed clinical psychologist, or (iii) mental health services provided by a physician, or (iv) peer support services.
b. Effective July 1, 2011, the supplemental payment amount for freestanding children's hospital physician services shall be the difference between the Medicaid payments otherwise made for freestanding children's hospital physician services and 143% of Medicare rates subject to the following reduction. Final payments shall be reduced on a prorated basis so that total payments for freestanding children's hospital physician services are $400,000 less annually than would be calculated based on the formula in the previous sentence. Payments shall be made quarterly no later than 90 days after the end of the quarter. The methodology for determining the Medicare equivalent of the average commercial rate is described in 12VAC30-80-300.
18. Supplemental payments for services provided by physicians affiliated with publicly funded medical schools in Tidewater.
a. In addition to payments for physician services specified elsewhere in the State Plan, the Department of Medical Assistance Services provides supplemental payments to physicians affiliated with publicly funded medical schools in Tidewater for furnished services provided on or after October 1, 2012. A physician affiliated with a publicly funded medical school is a physician who is employed by a publicly funded medical school that is a political subdivision of the Commonwealth of Virginia, who provides clinical services through the faculty practice plan affiliated with the publicly funded medical school, and who has entered into contractual agreements for the assignment of payments in accordance with 42 CFR 447.10.
b. Effective October 1, 2012, the supplemental payment amount for services furnished by physicians affiliated with publicly funded medical schools in Tidewater shall be the difference between the Medicaid payments otherwise made for physician services and 135% of Medicare rates. The methodology for determining the Medicare equivalent of the average commercial rate is described in 12VAC30-80-300.
19. Supplemental payments to nonstate government-owned or operated clinics.
(1) Calculating for each clinic the annual difference between the upper payment limit attributed to each clinic according to subdivision 19 d of this subsection and the amount otherwise actually paid for the services by the Medicaid program;
(2) Dividing the difference determined in subdivision 19 b (1) of this subsection for each qualifying clinic by the aggregate difference for all such qualifying clinics; and
(3) Multiplying the proportion determined in subdivision 19 b (2) of this subsection by the aggregate upper payment limit amount for all such clinics as determined in accordance with 42 CFR 447.321 less all payments made to such clinics other than under this section.
d. To determine the aggregate upper payment limit referred to in subdivision 19 b (3) of this subsection, Medicaid payments to nonstate government-owned or government-operated clinics will be divided by the "additional factor" whose calculation is described in Attachment 4.19-B, Supplement 4 (12VAC30-80-190 B 2) in regard to the state agency fee schedule for Resource Based Relative Value Scale. Medicaid payments will be estimated using payments for dates of service from the prior fiscal year adjusted for expected claim payments. Additional adjustments will be made for any program changes in Medicare or Medicaid payments.
20. Personal assistance services (PAS) for individuals enrolled in the Medicaid Buy-In program described in 12VAC30-60-200. These services are reimbursed in accordance with the state agency fee schedule described in 12VAC30-80-190. The state agency fee schedule is published on the DMAS website at http://www.dmas.virginia.gov.
12VAC30-80-32. Reimbursement for substance abuse use disorder services.
A. Physician services described in 12VAC30-50-140, other licensed practitioner services described in 12VAC30-50-150, and clinic services described in 12VAC30-50-180 for assessment and evaluation or treatment of substance use disorders shall be reimbursed using the methodology in 12VAC30-80-30 and 12VAC30-80-190 subject to the following reductions for psychotherapy services for other licensed practitioners.
1. Psychotherapy services of licensed clinical psychologists shall be reimbursed at 90% of the reimbursement rate for psychiatrists.
2. Psychotherapy services provided by independently enrolled licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, licensed psychiatric nurse practitioners, licensed substance abuse treatment practitioners, or licensed clinical nurse specialists-psychiatric shall be reimbursed at 75% of the reimbursement rate for licensed clinical psychologists.
3. The same rates shall be paid to governmental and private providers. These services are reimbursed based on the Common Procedural Terminology codes and Healthcare Common Procedure Coding System codes. The agency's rates were set as of July 1, 2007, and are updated as described in 12VAC30-80-190. All rates are published on the Department of Medical Assistance Services (DMAS) website at www.dmas.virginia.gov.
B. Rates for the following addiction and recovery treatment services (ARTS) physician and clinic services shall be based on the agency fee schedule: medication assisted treatment induction with a visit unit of service; individual and group opioid treatment service with a 15-minute unit of service; and substance use care coordination with a monthly unit of service. The agency's rates shall be set as of April 1, 2017. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payments shall be consistent with economy, efficiency, and quality of care. The same rates shall be paid to public and private providers. All rates are published on the DMAS website at www.dmas.virginia.gov.
C. Community ARTS rehabilitation services. Per diem rates for clinically managed low intensity residential services (ASAM Level 3.1), partial hospitalization (ASAM Level 2.5), and intensive outpatient (ASAM Level 2.1) for ARTS shall be based on the agency fee schedule. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payments shall be consistent with economy, efficiency, and quality of care. The same rates shall be paid to governmental and private providers. The agency's rates shall be set as of April 1, 2017, and are effective for services on or after that date. All rates are published on the DMAS website at: www.dmas.virginia.gov.
D. ARTS federally qualified health center or rural health clinic services (ASAM Level 1.0) for assessment and evaluation or treatment of substance use disorder, as described in 12VAC30-130-5000 et seq., shall be reimbursed using the methodology described in 12VAC30-80-25.
E. Substance use case management services. Substance use case management services, as described in 12VAC30-50-491, shall be reimbursed a monthly rate based on the agency fee schedule. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payment shall be consistent with economy, efficiency, and quality of care. The same rates shall be paid to governmental and private providers. The agency's rates shall be set as of April 1, 2017, and are effective for services on or after that date. All rates are published on the DMAS website at www.dmas.virginia.gov.
F. Peer support services. Peer support services as described in 12VAC30-130-5160 through 12VAC30-130-5210 furnished by enrolled providers or provider agencies as described in 12VAC30-130-5190 shall be reimbursed based on the agency fee schedule for 15-minute units of service. The agency's rates set as of July 1, 2017, are effective for services on or after that date. All rates are published on the DMAS website at: www.dmas.virginia.gov.
12VAC30-130-5160. Peer support services and family support partners: definitions.
"Behavioral health service" means treatments and services for mental or substance use disorders.
"Caregiver" means the family members, friends, or neighbors who provide unpaid assistance to a Medicaid member with a mental health or substance use disorder or co-occurring mental health and substance use disorder. "Caregiver" does not include individuals who are employed to care for the member.
"Direct supervisor" means the person who provides direct supervision to the peer recovery specialist. The direct supervisor (i) shall have two consecutive years of documented practical experience rendering peer support services or family support services, have certification training as a PRS under a certifying body approved by DBHDS, and have documented completion of the DBHDS PRS supervisor training; (ii) shall be a practitioner who has documented completion of the DBHDS PRS supervisor training, meets clauses (i) through (xii) of the definition of "credentialed addiction treatment professional" found in 12VAC30-130-5020, and is acting within his scope of practice under state law; or (iii) shall be a certified substance abuse counselor (CSAC) as defined in § 54.1-3507.1 of the Code of Virginia who has documented completion of the DBHDS PRS supervisor training if he is acting under the supervision or direction of a licensed substance use treatment practitioner or licensed mental health professional. If a practitioner referenced in clause (ii) of this definition or a CSAC referenced in clause (iii) of this definition provides services before April 1, 2018, he shall have until April 1, 2018, to complete the DBHDS PRS supervisor training.
"Peer recovery specialist" or "PRS" means a person who has the qualifications, education, and experience established by the Department of Behavioral Health and Developmental Services and who has received certification in good standing by a certifying body recognized by DBHDS. A PRS is professionally qualified and trained (i) to provide collaborative services to assist individuals in achieving sustained recovery from the effects of mental health disorders, substance use disorders, or both; (ii) to provide peer support as a self-identified individual successful in the recovery process with lived experience with mental health disorders or substance use disorders, or co-occurring mental health and substance use disorders; and (iii) to offer support and assistance in helping others in the recovery and community-integration process. A PRS may be a parent of a minor or adult child with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder, or an adult with personal experience with a family member with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services.
"Person centered" means a collaborative process where the individual participates in the development of his treatment goals and makes decisions about the services provided.
"Recovery-oriented services" means providing support and assistance to an individual with mental health or substance use disorders or both so that the individual (i) improves his health, recovery, resiliency, and wellness; (ii) lives a self-directed life; and (iii) strives to reach his full potential.
"Recovery, resiliency, and wellness plan" means a written set of goals, strategies, and actions to guide the individual and the health care team to move the individual toward the maximum achievable independence and autonomy in the community. The documented comprehensive wellness plan shall be developed by the individual or caregiver, as applicable, the PRS, and the direct supervisor within 30 days of the initiation of services and shall describe how the plan for peer support services and activities will meet the individual's needs. This document shall be updated as the needs and progress of the individual change and shall document the individual's or caregiver's, as applicable, request for any changes in peer support services. The recovery, resiliency, and wellness plan is a component of the individual's overall plan of care and shall be maintained by the enrolled provider in the individual's medical record.
"Resiliency" means the ability to respond to stress, anxiety, trauma, crisis, or disaster.
"Self-advocacy" means an empowerment skill that allows the individual to effectively communicate preferences and choice.
"Strength-based" means to emphasize individual strengths, assets, and resiliencies.
"Supervision" means the ongoing process performed by a direct supervisor who monitors the performance of the PRS and provides regular documented consultation and instruction with respect to the skills and competencies of the PRS.
12VAC30-130-5170. Peer support services and family support partners: service definitions.
A. ARTS peer support services and ARTS family support partners are peer recovery support services and are nonclinical, peer-to-peer activities that engage, educate, and support an individual's, and as applicable the caregiver's, self-help efforts to improve health recovery, resiliency, and wellness. These services shall be available to either:
1. Individuals 21 years of age or older with mental health or substance use disorders or co-occurring mental health and substance use disorders that are the focus of the support; or
2. The caregiver of individuals younger than 21 years of age with mental health or substance use disorders or co-occurring mental health and substance use disorders that are the focus of the support.
3. Individuals 18 through 20 years of age who meet the medical necessity criteria set forth in 12VAC30-130-5180 A who would benefit from receiving peer supports directly, and who choose to receive ARTS peer support services directly instead of through their family shall be permitted to receive peer support services by an appropriate PRS.
B. ARTS peer support services for adults is a person centered, strength-based, and recovery-oriented rehabilitative service for individuals 21 years of age or older provided by a peer recovery specialist successful in the recovery process with lived experience with substance use disorders or co-occurring mental health and substance use disorders who is trained to offer support and assistance in helping others in recovery to reduce the disabling effects of a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. Services assist the individual with developing and maintaining a path to recovery, resiliency, and wellness. Specific peer support service activities shall emphasize the acquisition, development, and enhancement of recovery, resiliency, and wellness. Services are designed to promote empowerment, self-determination, understanding, and coping skills through mentoring and service coordination supports, as well as to assist individuals in achieving positive coping mechanisms for the stressors and barriers encountered when recovering from their illness or disorder.
C. ARTS family support partners is a peer support service and a strength-based, individualized service provided to the caregiver of a Medicaid-eligible individual younger than 21 years of age with a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. The services provided to the caregiver and the individual must be directed exclusively toward the benefit of the Medicaid-eligible individual. Services are expected to improve outcomes for an individual younger than 21 years of age with complex needs who is involved with multiple systems and increase the individual's and family's confidence and capacity to manage their own services and supports while promoting recovery and healthy relationships. These services are rendered by a PRS who is (i) a parent of a minor or adult child with a similar substance use disorder or co-occurring mental health and substance use disorder or (ii) an adult with personal experience with a family member with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services. The PRS shall perform the service within the scope of his knowledge, lived experience, and education.
D. ARTS peer support services shall be rendered on an individual basis or in a group.
12VAC30-130-5180. Peer support services and family support partners: medical necessity criteria.
A. In order to receive ARTS peer support services, individuals 21 years of age or older shall meet the following requirements:
1. The individual shall have a substance use disorder or co-occurring mental health and substance use disorders diagnosis.
2. The individual shall require recovery-oriented assistance and support services for:
a. The acquisition of skills needed to engage in and maintain recovery;
b. The development of self-advocacy skills to achieve a decreasing dependency on formalized treatment systems; and
c. Increasing responsibilities, wellness potential, and shared accountability for the individual's own recovery.
3. The individual shall demonstrate moderate to severe functional impairment as a result of the diagnosis, and the functional impairment shall be of a degree that it interferes with or limits performance in at least one of the following domains: educational (e.g., obtaining a high school or college degree); social (e.g., developing a social support system); vocational (e.g., obtaining part-time or full-time employment); or self-maintenance (e.g., managing symptoms, understanding his illness, living more independently).
B. Caregivers of individuals younger than 21 years of age who qualify for ARTS family support partners (i) have an individual with a substance use disorder or co-occurring mental health and substance use disorders who requires recovery assistance and (ii) meet two or more of the following:
1. Individual and his caregiver need peer-based recovery oriented services for the maintenance of wellness and acquisition of skills needed to support the individual.
2. Individual and his caregiver need assistance to develop self-advocacy skills to assist the individual in achieving self-management of the individual's health status.
3. Individual and his caregiver need assistance and support to prepare the individual for a successful work or school experience.
4. Individual and his caregiver need assistance to help the individual and caregiver assume responsibility for recovery.
C. Individuals 18 through 20 years of age who meet the medical necessity criteria in subsection A of this section, who would benefit from receiving peer supports directly, and who choose to receive peer support services directly instead of through their family shall be permitted to receive peer support services by an appropriate PRS.
D. To qualify for continued ARTS peer support services and ARTS family support partners, medical necessity criteria shall continue to be met and progress notes shall document the status of progress relative to the goals identified in the recovery resiliency and wellness plan.
E. Discharge shall occur when one or more of the following is met:
1. Goals of the recovery resiliency and wellness plan have been met;
2. The individual, or as applicable for individuals younger than 21 years of age, the caregiver, requests discharge; or
3. The individual, or as applicable for individuals younger than 21 years of age, the caregiver, fail to make minimum contact requirements set forth in 12VAC30-130-5210 L and M or the individual or caregiver, as applicable, discontinues participation in services.
12VAC30-130-5190. Peer support services and family support partners: provider and setting requirements.
A. Effective July 1, 2017, a peer recovery specialist shall have the qualifications, education, and experience established by DBHDS and show certification in good standing by the U.S. Department of Veterans Affairs, NAADAC - the Association of Addiction Professionals, a member board of the International Certification and Reciprocity Consortium, or any other certifying body or state certification with standards comparable to or higher than those specified by DBHDS to be eligible to register with the Board of Counseling on or after July 1, 2018. Upon the promulgation of regulations by the Board of Counseling, registration of peer recovery specialists by the Board of Counseling shall be required.
B. Prior to service initiation, a documented recommendation for service by a practitioner who meets clauses (i) through (xii) of the definition of "credentialed addiction treatment professional" found in 12VAC30-130-5020 and who is acting within his scope of practice under state law shall be required. A certified substance abuse counselor, as defined in § 54.1-3507.1 of the Code of Virginia, may also provide a documented recommendation for service if he is acting under the supervision or direction of a licensed substance use treatment practitioner or licensed mental health professional. The PRS shall perform ARTS peer services under the oversight of the practitioner described in this subsection making the recommendation for services and providing the clinical oversight of the recovery, resiliency, and wellness plan. The recommendation shall verify that the individual meets the medical necessity criteria set forth in 12VAC30-130-5180 A or B, as applicable.
C. The PRS shall be employed by or have a contractual relationship with the enrolled provider licensed for one of the following:
1. Acute care general hospital (ASAM Level 4.0) licensed by the Department of Health as defined in 12VAC30-130-5150.
2. Freestanding psychiatric hospital or inpatient psychiatric unit (ASAM Levels 3.5 and 3.7) licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5130 and 12VAC30-130-5140.
3. Residential placements (ASAM Levels 3.1, 3.3, 3.5, and 3.7) licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5110 through 12VAC30-130-5140.
4. ASAM Levels 2.1 and 2.5, licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5090 and 12VAC30-130-5100.
5. ASAM Level 1.0 as defined in 12VAC30-30-5080.
6. Opioid treatment services as defined in 12VAC30-130-5050.
7. Office-based opioid treatment as defined in 12VAC30-130-5060.
8. Hospital emergency department services licensed by the Department of Health.
9. Pharmacy services licensed by the Department of Health.
D. Only a licensed and enrolled provider referenced in subsection C of this section shall be eligible to bill and receive reimbursement from DMAS or its contractor for ARTS peer support services. Payments shall not be permitted to providers that fail to enter into a enrollment agreement with DMAS or its contractor. Reimbursement shall be subject to retraction for any billed service that is determined to not to be in compliance with DMAS requirements.
E. The direct supervisor, as defined in 12VAC30-130-5160, shall perform direct supervision of the PRS as needed based on the level of urgency and intensity of service being provided. The direct supervisor shall have an employment or contract relationship with the same provider entity that employs or contracts with the PRS. Direct supervisors shall maintain documentation of all supervisory sessions. In no instance shall supervisory sessions be performed less than as provided below:
1. If the PRS has less than 12 months experience delivering ARTS peer support services or ARTS family support partners, he shall receive face-to-face, one-to-one supervisory meetings of sufficient length to address identified challenges for a minimum of 30 minutes, two times a month. The direct supervisor must be available at least by telephone while the PRS is on duty.
2. If the PRS has been delivering ARTS peer recovery services over 12 months and fewer than 24 months, he must receive monthly face-to-face, one-to-one supervision of sufficient length to address identified challenges for a minimum of 30 minutes. The direct supervisor must be available by telephone for consult within 24 hours of service delivery if needed for challenging situations.
F. The caseload assignment of a full-time PRS shall not exceed 12 to 15 individuals at any one time and 30 to 40 individuals annually allowing for new case assignments as those on the existing caseload begin to self-manage with less support. The caseload assignment of a part-time PRS shall not exceed six to nine individuals at any one time and 15 annually.
12VAC30-130-5200. Peer support services and family support partners: documentation of required activities.
A. The recommendation for services shall include the dated signature and credentials of the practitioner described in 12VAC30-130-5190 B who made the recommendation. The recommendation shall be included as part of the recovery, resiliency, and wellness plan and medical record. The recommendation shall verify that the individual meets the medical necessity criteria and shall be valid for no longer than 30 calendar days.
B. Under the clinical oversight of the practitioner making the recommendation described in 12VAC50-130-5190 B for ARTS peer support services or ARTS family support partners, the peer recovery specialist in consultation with his direct supervisor shall develop a recovery, resiliency, and wellness plan based on the recommendation for service, the individual's, and, as applicable the caregiver's, perceived recovery needs and multidisciplinary assessment as defined in this section within 30 calendar days of the initiation of service. Development of the recovery, resiliency, and wellness plan shall include collaboration with the individual and, as applicable, the identified family member or caregiver involved in the individual's recovery. Individualized goals and strategies shall be focused on the individual's identified needs for self-advocacy and recovery. The recovery, resiliency, and wellness plan shall also include documentation of how many days per week and how many hours per week are required to carry out the services in order to meet the goals of the plan. The recovery, resiliency, and wellness plan shall be completed, signed, and dated by the practitioner making the recommendation, the PRS, the direct supervisor, the individual, and, as applicable, the identified family member or caregiver involved in the individual's recovery within 30 calendar days of the initiation of service. The PRS shall act as an advocate for the individual, encouraging the individual, and as applicable the caregiver, to take a proactive role in developing and updating goals and objectives in the individualized recovery planning.
C. Services shall be delivered in accordance with the individual's goals and objectives as identified in the recovery, resiliency, and wellness plan and consistent with the recommendation of the referring practitioner who recommended services. As determined by the goals identified in the recovery, resiliency, and wellness plan, services may be rendered in the provider's office or in the community, or both. The level of services provided and total time billed by the enrolled provider for the week shall not exceed the frequency established in the recovery, resiliency, and wellness plan.
D. Under the clinical oversight of the practitioner described in 12VAC30-130-5190 B making the recommendation, the peer recovery specialist in consultation with his direct supervisor shall conduct and document a review of the recovery, resiliency, and wellness plan every 90 calendar days with the individual and the caregiver, as applicable. The review shall be signed by the PRS and the individual and, as applicable, the identified family member or caregiver. Review of the recovery, resiliency, and wellness plan means the PRS evaluates and updates the individual's progress every 90 days toward meeting the plan's goals and documents the outcome of this review in the individual's medical record. For DMAS to determine that these reviews are complete, the reviews shall (i) update the goals and objectives as needed to reflect any change in the individual's recovery as well as any newly identified needs, (ii) be conducted in a manner that enables the individual to actively participate in the process, and (iii) be documented by the PRS in the individual's medical record no later than 15 calendar days from the date of the review.
E. Progress notes as defined in 12VAC30-50-130 shall be required and shall record the date, time, place of service, participants, face-to-face or telephone contact, and circumstance of contact, regardless of whether or not a billable service was provided, and shall summarize the purpose and content of the session along with the specific strategies and activities utilized as related to the goals in the recovery, resiliency, and wellness plan. Documentation of specific strategies and activities shall fully disclose the details of services rendered and align with the recovery, resiliency, and wellness plan. Strategies and activities shall include at a minimum:
1. Person centered, strength-based planning to promote the development of self-advocacy skills;
2. Empowering the individual to take a proactive role in the development and updating of his recovery, resiliency, and wellness plan;
3. Crisis support; and
4. Assisting in the use of positive self-management techniques, problem-solving skills, coping mechanisms, symptom management, and communication strategies identified in the recovery, resiliency, and wellness plan so that the individual:
a. Remains in the least restrictive setting;
b. Achieves his goals and objectives identified in the recovery resiliency and wellness plan;
c. Self-advocates for quality physical and behavioral health services; and
d. Has access to strength-based behavioral health services, social services, educational services, and other supports and resources.
F. Progress notes shall reflect collaboration between the PRS and the individual in the development of the progress notes. If contact with the individual cannot be made, the service is not billable. However, the progress notes shall reflect attempts to contact the individual. Progress notes shall contain the dated signature of the PRS who provided the service.
G. The enrolled provider shall ensure that documentation of all supervision sessions is maintained in a supervisor's log or the personnel file of the PRS.
H. The enrolled provider shall have oversight of the individual's record and maintain individual records in accordance with state and federal requirements. The enrolled provider shall ensure documentation of all activities and documentation of all relevant information about the Medicaid individuals receiving services. Such documentation shall fully disclose the extent of services provided in order to support providers claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered.
I. The enrolled provider may integrate an individual's peer support record with the individual's other records maintained within same provider agency or facility, provided all peer support documentation is clearly identified. Logs and progress notes documenting the provision of services shall corroborate billed services.
J. Collaboration shall be required with behavioral health service providers and shall include the PRS and the individual, or caregiver as applicable, and shall involve discussion regarding initiation of services and updates on the individual's status and changes in the individual's progress. Documentation of all collaboration shall be maintained in the individual's record.
12VAC30-130-5210. Peer support services and family support partners: limitations and exclusions to service delivery.
A. An approved service authorization submitted by the enrolled provider shall be required prior to service delivery in order for reimbursement to occur. To obtain service authorization, all provider information supplied to the Department of Medical Assistance Services or its contractor shall be fully substantiated throughout the individual's record.
B. Service shall be initiated within 30 calendar days of the documented recommendation. The recommendation shall be valid for no longer than 30 calendar days.
C. Services rendered in a group setting shall have a ratio of no more than 10 individuals to one PRS, and progress notes shall be included in each individual's record.
D. General support groups that are made available to the public to promote education and global advocacy do not qualify as peer support services or family support partners.
E. Noncovered activities include transportation, recordkeeping or documentation activities (including progress notes, tracking hours and billing, and other administrative paperwork), services performed by volunteers, household tasks, chores, grocery shopping, on-the-job training, case management, outreach to potential clients, and room and board.
F. A unit of service shall be defined as 15 minutes. Peer support services and family support partners shall be limited to four hours per day (up to 16 units per calendar day) and 900 hours per calendar year. Service delivery limits may be exceeded based upon documented medical necessity and service authorization approval.
G. If a service recommendation for mental health peer support services or mental health family support partners as set forth in 12VAC30-50-130 or 12VAC30-50-226 is made in addition to a service recommendation for ARTS peer support services or ARTS family support partners as set forth in 12VAC30-130-5160 through 12VAC30-130-5210, the enrolled provider shall coordinate services to ensure the four-hour daily service limit is not exceeded. No more than a total of four hours of one type of service, or a total of four hours of a combination of service types, up to 16 units of total service, shall be provided per calendar day. The enrolled provider cannot bill DMAS separately for (i) mental health peer services (mental health peer support services or mental health family support partners) and (ii) ARTS peer services (peer support services or ARTS family support partners) rendered on the same calendar day unless the mental health peer services and ARTS peer services are rendered at different times. A separate annual service limit of up to 900 hours shall apply to mental health peer support services or mental health family support partners service and ARTS peer support services or ARTS family support partners.
H. The PRS shall document each 15-minute unit in which the individual was actively engaged in peer support services or family support partners. Meals and breaks and other noncovered services listed in this section shall not be included in the reporting of units of service delivered. Should an individual receive other services during the range of documented time in/time out for peer support hours, the absence of or interrupted services must be documented.
I. Service delivery shall be based on the individual's identified needs, established medical necessity criteria, and goals identified in the individual recovery resiliency and wellness plan.
J. Billing shall occur only for services provided with the individual present. Telephone time is supplemental rather than replacement of face-to-face contact and is limited to 25% or less of total time per recipient per calendar year. Justification for services rendered with the individual via telephone shall be documented. Any telephone time rendered over the 25% limit will be subject to retraction.
K. Peer support services or family support partners may operate in the same building as other day services; however, there must be a distinct separation between services in staffing, program description, and physical space. Peer support services shall be an ancillary service and shall not impede, interrupt, or interfere with the provision of the primary service setting.
L. Contact shall be made with the individual receiving peer support services or family support partners a minimum of twice each month. At least one of these contacts must be face-to-face and the second may be either face-to-face or telephone contact depending on the individual's support needs and documented preferences.
M. In the absence of the required monthly face-to-face contact and if at least two unsuccessful attempts to make face-to-face contact have been tried and documented, the provider may bill for a maximum of two telephone contacts in that specified month, not to exceed two units. After two consecutive months of unsuccessful attempts to make face-to-face contact, discharge shall occur.
N. Family support partners is not billable for siblings of the targeted individual for whom a need is specified unless there is applicability to the targeted individual or family. The applicability to the targeted individual must be documented.
O. Family support partners services shall not be billed for an individual who resides in a congregate setting in which the caregivers are paid, such as child caring institutions or any other living environment that is not comprised of more permanent caregivers. An exception would be for an individual actively preparing for transition back to a single-family unit, the caregiver is present during the intervention, and the service is directed to supporting the unification or reunification of the individual and his caregiver and takes place in that home and community. The circumstances surrounding the exception shall be documented.
P. Individuals with the following conditions are excluded from family support partners unless there is clearly documented evidence and diagnosis of a substance use disorder or mental health disorder overlaying the diagnosis: developmental disability including intellectual disabilities, organic mental disorder including dementia or Alzheimer's, or traumatic brain injury. There must be documented evidence that the individual is able to participate in the service and benefit from family support partners.
Q. Claims that are not adequately supported by appropriate up-to-date documentation may be subject to recovery of expenditures. Progress notes, as defined in 12VAC30-50-130, shall disclose the extent of services provided and corroborate the units billed. Claims not supported by corroborating progress notes shall be subject to recovery of expenditures.
R. The enrolled provider shall be subject to utilization reviews conducted by DMAS or its designated contractor.
VA.R. Doc. No. R18-4955; Filed September 11, 2017, 10:37 a.m.