reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VI - Criteria for Intermediate Care for Mentally Retarded Persons › Section 12VAC30-130-450 - Patient assessment criteria

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The evaluation process will demonstrate a need for programming an array of
				  skills and abilities or health care services. These have been organized into
				  seven major categories. The level of functioning in each category is graded
				  from the most dependent to the least dependent. In some categories, the
				  dependency status is rated by the degree of assistance required. In other
				  categories, the dependency is established by the frequency of a behavior or
				  ability to perform a given task.
The resident must meet the indicated dependency level in
					 two or more of the categories 1 through 7.
1. Health status. To meet this category:
a. Two or more questions must be answered
				  with a "4," or
b. Question 10 must
				  be answered "yes".
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VII - Hospice Services [Repealed] › Section 12VAC30-130-470 to 12VAC30-130-530

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VIII - Community Mental Health and Mental Retardation Services › Section 12VAC30-130-540

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VIII - Community Mental Health and Mental Retardation Services › Section 12VAC30-130-565

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VIII - Community Mental Health and Mental Retardation Services › Section 12VAC30-130-580

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VIII - Community Mental Health and Mental Retardation Services › Section 12VAC30-130-590

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IX - DMAS-225 Adjustment Process › Section 12VAC30-130-600 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms, when used in this part,
					 shall have the following meanings, unless the context indicates
					 otherwise:
"DMAS" or "the department" means the Virginia Department of
					 Medical Assistance Services.
"DMAS-225" means the Medicaid Communication form used for
					 the provider and the DSS eligibility worker to report changes including
					 requests for adjustments to the patient pay.
"DSS" means the local Department of Social Services.
"Facility" means a nursing facility, intermediate care
					 facility for the mentally retarded, or a long-stay acute care hospital enrolled
					 in the Medicaid program.
"Medical necessity" means an item or service provided for
					 the diagnosis or treatment of a patient's condition consistent with community
					 standards of medical practice and in accordance with Medicaid policy.
"Preauthorization" means obtaining the approval necessary
					 for receipt of a specified service from a specified provider for a specified
					 recipient before the requested service is performed.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IX - DMAS-225 Adjustment Process › Section 12VAC30-130-610 - Purpose and scope

Current through Register Vol. 40, No. 24, July 15, 2024
The department's payment to nursing facilities,
					 intermediate care facilities for the mentally retarded, and long-stay acute
					 care hospitals shall be reduced by the amount of the patient's income, less
					 certain deductions (the patient pay amount) in conformance with 42 CFR 435
					 (rev. October 1, 1992). Amounts for medical or remedial care not subject to
					 payment by a third party, including necessary medical or remedial care not
					 covered under the State Plan for Medical Assistance (the Plan), shall be
					 deducted during the calculation of patient pay amounts.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part X - New Drug Review Program Regulations [Repealed] › Section 12VAC30-130-630 to 12VAC30-130-720

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XII - Health Insurance Premium Payment Program (HIPP) › Section 12VAC30-130-740 - General

Current through Register Vol. 40, No. 24, July 15, 2024
The requirements of this part shall operate in concert with
					 the HIPP program requirements as contained in the State Plan for Medical
					 Assistance, specifically Attachment 4.22-C (VR
					 460-02-4.2230).
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XII - Health Insurance Premium Payment Program (HIPP) › Section 12VAC30-130-750 - Time frames for determining cost effectiveness

Current through Register Vol. 40, No. 24, July 15, 2024
A. The department (DMAS) shall determine
				  eligibility for the program and shall provide notice to the recipient within 45
				  calendar days from the date of receiving an application that contains all
				  information and verifications necessary to determine eligibility.
B. Incomplete applications shall be held for
				  a period of 30 calendar days to enable applicants to provide outstanding
				  information needed for an eligibility determination. Any applicant who fails to
				  provide information or verifications necessary to determine eligibility within
				  30 calendar days of the receipt of the initial application shall have his
				  application denied.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XII - Health Insurance Premium Payment Program (HIPP) › Section 12VAC30-130-760 - Notices

Current through Register Vol. 40, No. 24, July 15, 2024
An adequate notice consistent with
					 42 CFR
					 431.210 shall be provided to the recipient,
					 person carrying the group health plan policy or responsible person in the case
					 under the following circumstances:
1.
				  To inform the household of the decision on cost effectiveness and premium
				  payment.
2. To inform the household
				  that premium payments are being discontinued because Medicaid eligibility has
				  been lost by all persons covered under the group health plan.
3. To inform the household that premium
				  payments are being discontinued because the group health plan is no longer
				  available to the family (e.g., the employer drops insurance coverage or the
				  plan is terminated by the insurance company).
4. To inform the household that premium
				  payments are being discontinued because DMAS has determined it is no longer
				  cost effective to pay the premiums.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XII - Health Insurance Premium Payment Program (HIPP) › Section 12VAC30-130-790 - Information required of applicants and recipients

Current through Register Vol. 40, No. 24, July 15, 2024
All applicants and recipients shall be required to provide
					 the information required on the prescribed DMAS HIPP applications forms and all
					 requested information to determine eligibility and cost
					 effectiveness.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIII - Client Medical Management Programs › Section 12VAC30-130-810 - Client Medical Management Program for individuals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Purpose. The Client Medical Management
				  Program for individuals is designed to assist and educate Medicaid individuals
				  in appropriately using essential medical and pharmacy services. Individuals who
				  use these services excessively or inappropriately as determined by DMAS may be
				  assigned to a single primary care provider or pharmacy, or both. The CMM
				  Program for individuals also monitors individual compliance with program
				  guidelines.
B. Authority.
1. The Act and federal regulations at
				  42 CFR
				  456.3 require the Medicaid agency to
				  implement a statewide surveillance and utilization control program that (i)
				  safeguards against unnecessary or inappropriate use of Medicaid services and
				  against excess payments, (ii) assesses the quality of those services, (iii)
				  provides for the control of the utilization of all services provided under the
				  Plan, and (iv) provides for the control of the utilization of inpatient
				  services.
2. Federal regulations at
				  42 CFR
				  431.54(e) allow states to
				  restrict individuals to designated providers when the individuals have utilized
				  services at a frequency or an amount that is not medically necessary in
				  accordance with utilization guidelines established by the state.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIII - Client Medical Management Programs › Section 12VAC30-130-820 - Client Medical Management Program for providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Purpose. The CMM Program for providers is
				  a utilization control program designed to promote improved and cost-efficient
				  medical management of essential health care.
B. Authority.
1. Federal regulations at
				  42 CFR
				  456.3 require the Medicaid agency to
				  implement a statewide surveillance and utilization control program and at
				  42 CFR
				  455.1 through
				  455.16 require the Medicaid agency
				  to conduct investigations of abuse by providers.
2. Federal regulations at
				  42 CFR
				  431.54(f) allow states to
				  restrict providers' participation in the Medicaid program if the agency finds
				  that providers of items or services under the State Plan have provided items or
				  services at a frequency or amount not medically necessary in accordance with
				  utilization guidelines established by the state or have provided items or
				  services of a quality that do not meet professionally recognized standards of
				  health care.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIV - Residential Psychiatric Treatment for Children and Adolescents (Repealed) › Section 12VAC30-130-850

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIV - Residential Psychiatric Treatment for Children and Adolescents (Repealed) › Section 12VAC30-130-860

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIV - Residential Psychiatric Treatment for Children and Adolescents (Repealed) › Section 12VAC30-130-870

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIV - Residential Psychiatric Treatment for Children and Adolescents (Repealed) › Section 12VAC30-130-880

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIV - Residential Psychiatric Treatment for Children and Adolescents (Repealed) › Section 12VAC30-130-890

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XV - Case Management Treatment Foster Care Services › Section 12VAC30-130-910 - Targeted case management for foster care children in treatment foster care (TFC) covered services

Current through Register Vol. 40, No. 24, July 15, 2024
Service description. Case management is a component of TFC
					 through which a case manager monitors the treatment plan and links the child to
					 other community resources as necessary to address the special identified needs
					 of the child. Services to the children shall be delivered primarily by
					 treatment foster parents who are trained, supervised and supported by
					 professional child-placing agency staff. TFC case management focuses on a
					 continuity of services, is goal directed and results oriented. Services shall
					 not include room and board. The following activities are considered covered
					 services related to TFC case management services:
1. Care planning, monitoring of the plan of
				  care, and discharge planning;
2.
				  Case management; and
3. Evaluation
				  of the effectiveness of the child's plan of treatment.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XV - Case Management Treatment Foster Care Services › Section 12VAC30-130-920 - Provider qualifications

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  License or certification. Treatment foster care case management shall be
				  provided by child-placing agencies with treatment foster care programs that are
				  licensed or certified by the Virginia Department of Social Services to be in
				  compliance with the Minimum Standards for Licensed Child-Placing Agencies
				  (22VAC40-130-10 et seq.) and meet
				  the provider qualifications for treatment foster care set forth in this
				  part.
B. Caseload size.
1. The treatment foster care case manager
				  shall have a maximum of 12 children in his caseload for a full-time
				  professional staff person. The caseload shall be adjusted downward if:
a. The caseworker's job responsibilities
				  exceed those listed in the agency's job description for a caseworker, as
				  determined by the supervisor; or
b.
				  The difficulty of the client population served requires more intensive
				  supervision and training of the treatment foster parents.
c. Exception: A caseworker may have a maximum
				  caseload of 15 children as long as not more than 10 of the children are in
				  treatment foster care and the above criteria for adjusting the caseload
				  downward do not apply.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XV - Case Management Treatment Foster Care Services › Section 12VAC30-130-940 - Discharge from care

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  discharge summary shall be developed for each child and placed in the child's
				  record within 30 days of discharge. It shall include the date of and reason for
				  discharge, the name of the person with whom the child was placed or to whom he
				  was discharged, and a description of the services provided to the child and
				  progress made while the child was in care. Written recommendations for
				  aftercare shall be made for each child prior to the child's discharge. Such
				  recommendations shall specify the nature, frequency, and duration of aftercare
				  services to be provided to the child and the child's family.
B. The summary shall also include an
				  evaluation of the progress made toward the child's treatment goals.
C. Discharge planning shall be developed with
				  the treatment team and with the child, the child's parents or guardian, and the
				  custodial agency.
D. Children in
				  the custody of a local department of social services or private child-placing
				  agency shall not be discharged without the knowledge, consultation, and
				  notification of the custodial agency.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XV - Case Management Treatment Foster Care Services › Section 12VAC30-130-950 - Entries in case records

Current through Register Vol. 40, No. 24, July 15, 2024
All entries shall be dated and shall identify the
					 individual who performed the service. If a treatment foster care case
					 management provider has offices in more than one location, the record shall
					 identify the office that provided the service. Each child's record shall
					 contain documentation that verifies the services rendered for
					 billing.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVI - Addiction and Recovery Treatment Services › Section 12VAC30-130-1000 - Pharmacy services prior authorization

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words and terms
				  used in this part shall have the following meanings unless the context clearly
				  indicates otherwise:
"Contractor" means an independent contractor that
					 implements and administers, pursuant to its contract, the department's pharmacy
					 prior authorization programs as set out in the Title XIX State Plan.
"Grandfather clause" means procedure by which selected
					 therapeutic classes or drugs as designated by the P&T Committee may be
					 automatically approved if the patient is currently and appropriately receiving
					 the drug.
"Pharmacy and Therapeutics Committee," "P&T Committee"
					 or "committee" means the committee formulated to review therapeutic classes,
					 conduct clinical reviews of specific drugs, recommend additions or deletions to
					 the preferred drug list, and perform other functions as required by the
					 department. The Pharmacy and Therapeutics Committee shall be composed of eight
					 to 12 members, including the Commissioner of the Department of Mental Health,
					 Mental Retardation and Substance Abuse Services, or his designee. Other members
					 shall be selected or approved by the department. The membership shall include a
					 ratio of physicians to pharmacists of 2:
1. Physicians on the committee shall be
				  licensed in Virginia, one of whom shall be a psychiatrist, and one of whom
				  specializes in care for the aging. Pharmacists on the committee shall be
				  licensed in Virginia, one of whom shall have clinical expertise in mental
				  health drugs, and one of whom has clinical expertise in community-based mental
				  health treatment.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVII - Marketing of Provider Services › Section 12VAC30-130-2000 - Marketing requirements and restrictions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Purpose. The purpose of these rules shall
				  be to define how providers shall be permitted to market their services to
				  potential Medicaid or FAMIS beneficiaries and individuals who may or may not be
				  currently enrolled with the particular provider. This shall apply to providers
				  of community mental health services (12VAC30-50-226
				  ) and Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)
				  community mental health services (12VAC30-50-130
				  ) with the exception of Part C services.
B. Definitions.
"Beneficiaries" means individuals of any age and their
					 families who are using or who may use community mental health rehabilitative
					 services.
"DMAS" means the Department of Medical Assistance
					 Services.
"FAMIS" means Family Access to Medical Insurance
					 Security.
"Marketing materials" means any material created to promote
					 services through any media including written materials, television, radio,
					 websites, and social media.
"Provider" means an individual or organizational entity
					 that is appropriately licensed as required and enrolled as a DMAS provider of
					 community mental health and substance abuse services.
C. Requirements.
1. Marketing and promotional activities
				  (including provider promotional activities) shall comply with all applicable
				  federal and state laws.
2.
				  Providers shall provide clearly written materials that completely and
				  accurately describe the Medicaid or FAMIS behavioral health services offered,
				  the beneficiary eligibility requirements to receive the services, applicable
				  fees and other charges, and all other information required for beneficiaries
				  and their families to make fully informed decisions about enrollment into the
				  services offered by the provider that is marketing its services.
3. Providers shall distribute their marketing
				  materials only in the service locations approved within the license issued by
				  the Licensing Division of the Department of Behavioral Health and Developmental
				  Services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVIII - Behavioral Health Services › Section 12VAC30-130-3000

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVIII - Behavioral Health Services › Section 12VAC30-130-3010

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVIII - Behavioral Health Services › Section 12VAC30-130-3020

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XVIII - Behavioral Health Services › Section 12VAC30-130-3030

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5000 - Addiction and recovery treatment services

Current through Register Vol. 40, No. 24, July 15, 2024
The services provided for in this part shall be known as
					 either addiction and recovery treatment services or substance use disorder
					 services.
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5010 - Addiction and recovery treatment services; purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The purpose of this part shall be to establish coverage of
					 treatment for substance use disorders as defined in the American Society of
					 Addiction Medicine (ASAM) Criteria: Treatment Criteria for Addictive,
					 Substance-Related and Co-Occurring Conditions, Third Edition, as published by
					 the American Society of Addiction Medicine including outpatient physician,
					 nurse practitioner, and clinic services that include evidence-based medication
					 assisted treatment, intensive outpatient services, partial hospitalization
					 services, residential treatment services, and inpatient withdrawal management
					 services as defined in
					 12VAC30-130-5040
					 through
					 12VAC30-130-5150.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5030 - Eligible individuals

Current through Register Vol. 40, No. 24, July 15, 2024
Children and adults who participate in Medicaid managed
					 care plans and Medicaid fee for service and meet ASAM medical necessity
					 criteria shall be eligible for ARTS.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5040 - Covered services: requirements; limits; standards

Current through Register Vol. 40, No. 24, July 15, 2024
A. Addiction and recovery treatment services.
1. In order to be covered, ARTS shall (i)
				  meet medical necessity criteria based upon the multidimensional assessment
				  completed by a CATP or a CSAC under the supervision of a CATP and (ii) be
				  accurately reflected in provider medical record documentation and on provider
				  claims for services by recognized diagnosis codes that support and are
				  consistent with the requested professional services. ARTS services require a
				  primary substance use diagnosis, and the purpose for treatment shall be related
				  to the substance use disorder. Individuals may have a secondary, co-occurring
				  diagnosis. A CATP or a CSAC under the supervision of a CATP shall complete the
				  multidimensional assessments. A CATP must sign and date assessments performed
				  by a CSAC within one business day.
2. These ARTS services, with their service
				  definitions, shall be covered in all levels of care:
(i) medically managed intensive inpatient
				  services (ASAM Level 4);
(ii)
				  substance use residential or inpatient services (ASAM Levels 3.1, 3.3, 3.5, and
				  3.7);
(iii) substance use intensive
				  outpatient and partial hospitalization programs (ASAM Levels 2.1 and 2.5);
(iv) opioid treatment services
				  (opioid treatment programs and preferred office-based opioid treatment);
(v) substance use outpatient
				  services (ASAM Level 1.0);
(vi)
				  early intervention services (ASAM Level 0.5);
(vii) substance use care coordination,
(viii) substance use case
				  management services; and
(ix)
				  withdrawal management services, which shall be provided when medically
				  necessary.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5070 - Covered services: practitioner services - early intervention/screening brief intervention and referral to treatment (ASAM Level 05)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Early
				  intervention (ASAM Level 0.5) settings for screening, brief intervention, and
				  referral to treatment (SBIRT) services shall include health care settings,
				  including local health departments, FQHCs, RHCs, CSBs, BHAs, health systems,
				  emergency departments, pharmacies, physician offices, and outpatient clinics.
				  Providers shall be licensed by the Department of Health Professions and either
				  directly contracted by DMAS or its contractor or an MCO to perform the
				  interpretation and intervention for this level of care or shall be employed by
				  organizations that are contracted by DMAS or its contractor or an
				  MCO.
B. Early intervention or SBIRT
				  (ASAM Level 0.5) service components shall include:
1. Identifying individuals who may have
				  alcohol or other substance use problems using an evidence-based screening
				  tool.
2. Following administration
				  of the evidence-based screening tool, a brief intervention by a CATP acting
				  within the scope of the CATP's practice shall be provided to educate
				  individuals about substance use, alert these individuals to possible
				  consequences, and if needed, begin to motivate individuals to take steps to
				  change their behaviors. Billing shall occur through the licensed provider or
				  agency.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5090 - Covered services: community based services - intensive outpatient services (ASAM Level 2.1)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Intensive
				  outpatient services (ASAM Level 2.1) shall be a structured program of skilled
				  treatment services for adults, children, and adolescents delivering a minimum
				  of three service hours per service day for adults to achieve an average of nine
				  to 19 hours of services per week and a minimum of two service hours per service
				  day for children and adolescents to achieve an average of six to 19 hours of
				  services per week. Withdrawal management services may be provided as necessary.
				  The following service components shall be provided weekly as directed by the
				  ISP for reimbursement:
1. Medical,
				  psychological, psychiatric, laboratory, and toxicology services, which are
				  available through consultation or referral.
2. Psychiatric and other individualized
				  treatment planning.
3. Individual,
				  family, and group psychotherapy, substance use disorder counseling, medication
				  management, and psychoeducation.
4.
				  Medication assisted treatment that is provided onsite or through
				  referral.
5. Occupational and
				  recreational therapies, motivational interviewing, enhancement, and engagement
				  strategies to inspire an individual's motivation to change behaviors.
6. Psychiatric and medical consultation,
				  which shall be available within 24 hours of the requested consult by telephone
				  and preferably within 72 hours of the requested consult in person or via
				  telemedicine.
7.
				  Psychopharmacological consultation.
8. Addiction medication management and
				  24-hour crisis services.
9.
				  Medical, psychological, psychiatric, laboratory, and toxicology
				  services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5100 - Covered services: community based care - partial hospitalization services (ASAM Level 2.5)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Partial
				  hospitalization services (ASAM Level 2.5) components. Partial hospitalization
				  services components shall include the following, as defined in the ISP and
				  provided on a weekly basis:
1. Individualized
				  treatment planning.
2. A minimum of
				  20 hours per week and at least five service hours per service day of skilled
				  treatment services with a planned format, including individual and group
				  psychotherapy, substance use disorder counseling, medication management,
				  education groups, occupational and recreational therapy, and other therapies.
				  Withdrawal management services may be provided as necessary. Time not spent in
				  skilled, clinically intensive treatment is not billable.
3. Family psychotherapy and substance use
				  disorder counseling involving family members, guardians, or significant others
				  in the assessment, treatment, and continuing care of the individual.
4. Motivational interviewing, enhancement,
				  and engagement strategies.
5.
				  Medication assisted treatment that is provided onsite or through
				  referral.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5110 - Covered services: clinically managed low intensity residential services (ASAM Level 3.1)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Clinically
				  managed low intensity residential services (ASAM Level 3.1). The agency-based
				  residential group home services (ASAM Level 3.1) shall be licensed by DBHDS as
				  a mental health and substance abuse group home service for adults or children
				  or licensed by DBHDS as a supervised living residence for adults and contracted
				  by DMAS or its contractor or an MCO. Clinically directed program activities
				  constituting at least five hours per week of professionally directed treatment
				  shall be designed to stabilize and maintain substance use disorder symptoms and
				  to develop and apply recovery skills. Activities shall include relapse
				  prevention, interpersonal choice exploration, and development of social
				  networks in support of recovery. This service shall not include settings where
				  clinical treatment services are not provided. ASAM Level 3.1 clinically managed
				  low intensity residential service providers shall meet the service components
				  and staff requirements of this section.
B. Clinically managed low intensity
				  residential services (ASAM Level 3.1) service components.
1. Physician consultation and emergency
				  services, which shall be available 24 hours a day and seven days per
				  week.
2. Arrangements for medically
				  necessary procedures including laboratory and toxicology tests that are
				  appropriate to the severity and urgency of an individual's condition.
3. Arrangements for pharmacotherapy for
				  psychiatric needs.
4. Medication
				  assisted treatment that is provided onsite or through referral.
5. Arrangements for higher and lower levels
				  of care and other services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5120 - Covered services: clinically managed population - specific high intensity residential service (ASAM Level 3.3)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Clinically managed population-specific
				  high intensity residential service (ASAM Level 3.3). The facility-based
				  provider shall be licensed by DBHDS as (i) a supervised residential treatment
				  service for adults ; (ii) a substance abuse residential treatment service for
				  adults; (iii) a substance abuse residential treatment service for women with
				  children; (iv) a substance abuse and mental health residential treatment
				  service for adults that has substance abuse listed on its license or within the
				  "licensed as" statement or be a Level C (psychiatric residential treatment
				  facility) service provider; or (v) a "mental health residential-children"
				  provider that has substance abuse listed on its license or within the "licensed
				  as" statements. All providers shall be contracted by DMAS or its contractor or
				  an MCO. ASAM Level 3.3 settings do not include sober houses, boarding houses,
				  or group homes where treatment services are not provided. Residential treatment
				  service providers for clinically managed population-specific high intensity
				  residential service (ASAM Level 3.3) shall meet the service components and
				  staff requirements in this section.
B. Clinically managed population-specific
				  high intensity residential service (ASAM Level 3.3) service components.
1. Clinically managed population-specific
				  high intensity residential service components shall include:
a. Access to a consulting physician or
				  physician extender who is either employed by or contracted with the agency or
				  through referral arrangements with the agency and who has a DEA-X number to
				  prescribe buprenorphine and emergency services 24 hours a day and seven days a
				  week;
b. Arrangements for higher
				  and lower levels of care;
c.
				  Arrangements for laboratory and toxicology services appropriate to the severity
				  of need; and
d. Arrangements for
				  addiction pharmacotherapy, including medication assisted treatment that is
				  provided onsite or through referral.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5130 - Covered services: clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5)

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Clinically managed high intensity residential services (adult) and clinically
				  managed medium intensity residential services (adolescent) (ASAM Level 3.5)
				  settings for services. The facility based residential treatment service
				  provider (ASAM Level 3.5) shall be licensed as (i) a substance abuse
				  residential treatment service for adults or children, (ii) a psychiatric unit
				  that has substance abuse listed on its license or within the "licensed as"
				  statements, (iii) a substance abuse residential treatment service for women
				  with children, (iv) a substance abuse and mental health residential treatment
				  service for adults and children that has substance abuse listed on its license
				  or within the "licensed as" statements, (v) a Level C (psychiatric residential
				  treatment facility) provider, or (vi) a "mental health residential-children"
				  provider that has substance abuse on its license or within the "licensed as"
				  statements and shall be contracted by DMAS or its contractor or an MCO.
				  Residential treatment providers (ASAM Level 3.5) shall meet the service
				  components and staff requirements in this section.
B. Clinically managed high intensity
				  residential services (adult) and clinically managed medium intensity
				  residential services (adolescent) (ASAM Level 3.5) service components.
1. These residential treatment services, as
				  required by ASAM, include:
a. Telephone or
				  in-person consultation with a physician or physician extender who shall be
				  available to perform required physician services. Emergency services shall be
				  available 24 hours per day and seven days per week;
b. Arrangements for more and less intensive
				  levels of care and other services such as sheltered workshops, literacy
				  training, and adult education;
c.
				  Arrangements for needed procedures, including medical, psychiatric,
				  psychological, laboratory, and toxicology services appropriate to the severity
				  of need; and
d. Arrangements for
				  addiction pharmacotherapy, including medication assisted treatment that is
				  provided onsite or through referral.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5150 - Covered services: medically managed intensive inpatient services (ASAM Level 4.0)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Medically
				  managed intensive inpatient services (ASAM Level 4.0) settings for services.
				  Acute care hospitals licensed by the Virginia Department of Health shall be the
				  designated setting for medically managed intensive inpatient treatment and
				  shall offer medically directed acute withdrawal management and related
				  treatment designed to alleviate acute emotional, behavioral, cognitive, or
				  biomedical distress resulting from, or occurring with, an individual's use of
				  alcohol and other drugs. Such service settings shall offer medically directed
				  acute withdrawal management and related treatment designed to alleviate acute
				  emotional, behavioral, cognitive, or biomedical distress, or all of these,
				  resulting from, or co-occurring with, an individual's use of alcohol or other
				  drugs, with the exception of tobacco-related disorders, caffeine-related
				  disorders or dependence or non-substance-related disorders.
B. Medically managed intensive inpatient
				  services (ASAM Level 4.0) service components.
1. The service components of medically
				  managed intensive inpatient services shall be:
a. An evaluation or analysis of substance use
				  disorders shall be provided, including the diagnosis of substance use disorders
				  and the assessment of treatment needs for medically necessary
				  services.
b. Observation and
				  monitoring the individual's course of withdrawal shall be provided. This shall
				  be conducted as frequently as deemed appropriate for the individual and the
				  level of care the individual is receiving. This may include, for example,
				  observation of the individual's health status.
c. Medication services, including the
				  prescription or administration related to substance use disorder treatment
				  services or the assessment of the side effects or results of that medication,
				  conducted by appropriate licensed staff who provide such services within their
				  scope of practice or license.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5170 - Peer support services and family support partners: service definitions

Current through Register Vol. 40, No. 24, July 15, 2024
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.