Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-226 - Community mental health services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words and terms
				  when used in this section shall have the following meanings unless the context
				  clearly indicates otherwise:
"Activities of daily living" or "ADLs" means personal care
					 tasks such as bathing, dressing, toileting, transferring, and eating or
					 feeding. An individual's degree of independence in performing these activities
					 is a part of determining appropriate level of care and service needs.
"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.
"Certified prescreener" means an employee of either the
					 local community services board or 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.
"Certified prescreener assessment" means an assessment for
					 crisis intervention and crisis stabilization completed by a certified
					 prescreener that meets the elements of a comprehensive needs assessment.
"Code" means the Code of Virginia.
"Comprehensive needs assessment" means the same as defined
					 in
					 12VAC30-50-130
					 and also includes individuals who are older than 21 years of age. Requirements
					 for the comprehensive needs assessment are set out in
					 12VAC30-60-143.
"DBHDS" means the Department of Behavioral Health and
					 Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.) of
					 Title 37.2 of the Code of Virginia.
"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 qualified mental health
					 professional (QMHP-A, QMHP-C, or QMHP-E) as defined in
					 12VAC35-105-20 with
					 at least two consecutive years of documented experience as a QMHP, and who has
					 documented completion of the DBHDS PRS supervisor training; or (iii) shall be
					 an LMHP, LMHP-R, LMHP-RP, or LMHP-S who has documented completion of the DBHDS
					 PRS supervisor training who is acting within his scope of practice under state
					 law. An LMHP, LMHP-R, LMHP-RP, or LMHP-S providing services before April 1,
					 2018, shall have until April 1, 2018, to complete the DBHDS PRS supervisor
					 training.
"DMAS" means the Department of Medical Assistance Services
					 and its contractor consistent with Chapter 10 (§ 32.1-323 et seq.) of
					 Title 32.1 of the Code of Virginia.
"DSM-5" means the Diagnostic and Statistical Manual of
					 Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric
					 Association.
"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 comprehensive needs assessment. 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 or 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 the
					 individual's functioning, including effects of the disability and issues of
					 health and safety.
"Licensed mental health professional" or "LMHP" means the
					 same as defined in
					 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the same as "resident" as
					 defined in (i)
					 18VAC115-20-10 for
					 licensed professional counselors; (ii)
					 18VAC115-50-10 for
					 licensed marriage and family therapists; or (iii)
					 18VAC115-60-10 for
					 licensed substance abuse treatment practitioners. An LMHP-resident shall be in
					 continuous compliance with the regulatory requirements of the applicable
					 counseling profession for supervised practice and shall not perform the
					 functions of the LMHP-R or be considered a "resident" until the supervision for
					 specific clinical duties at a specific site has been preapproved in writing by
					 the Virginia Board of Counseling.
"LMHP-resident in psychology" or "LMHP-RP" means the same
					 as an individual in a residency, as that term is defined in
					 18VAC125-20-10,
					 program for clinical psychologists. An LMHP-resident in psychology shall be in
					 continuous compliance with the regulatory requirements for supervised
					 experience as found in
					 18VAC125-20-65 and
					 shall not perform the functions of the LMHP-RP or be considered a "resident"
					 until the supervision for specific clinical duties at a specific site has been
					 preapproved in writing by the Virginia Board of Psychology.
"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.
"Peer recovery specialist" or "PRS" means the same as
					 defined in
					 12VAC35-250-10.
"Peer recovery support services" means the same as defined
					 in
					 12VAC35-250-10.
"Person centered" means the same as defined in
					 12VAC30-130-5160.
"Qualified mental health professional-adult" or "QMHP-A"
					 means the same as defined in § 54.1-3500 of the Code.
"Qualified mental health professional-child" or "QMHP-C"
					 means the same as defined in § 54.1-3500 of the Code.
"Qualified mental health professional-eligible" or "QMHP-E"
					 means the same as the term "qualified mental health professional - trainee" as
					 defined in § 54.1-3500 of the Code.
"Qualified paraprofessional in mental health" or "QPPMH"
					 means the same as defined in
					 12VAC35-105-20.
"Recovery-oriented services" means the same as defined in
					 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the same as
					 defined in
					 12VAC30-130-5160.
"Register" or "registration" means notifying DMAS or its
					 contractor that an individual will be receiving services that do not require
					 service authorization.
"Resiliency" means the same as defined in
					 12VAC30-130-5160.
"Self-advocacy" means the same as defined in
					 12VAC30-130-5160.
"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.
"Strength-based" means the same as defined in
					 12VAC30-130-5160.
"Supervision" means the same as defined in
					 12VAC30-130-5160.
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 an LMHP, LMHP-R, LMHP-RP, or LMHP-S who is practicing within the scope
				  of their license and that 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 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 comprehensive needs
				  assessment 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 an LMHP, LMHP-R, LMHP-RP, or LMHP-S.
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.