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 IV - Eligibility Requirements › Section 12VAC30-50-491 - Substance use case management services for individuals who have a primary diagnosis of substance use disorder

Current through Register Vol. 40, No. 24, July 15, 2024
A. Target group: The Medicaid eligible
				  individual shall meet the Diagnostic and Statistical Manual of Mental Disorders
				  (DSM-5) diagnostic criteria for a substance use disorder. Tobacco-related
				  disorders or caffeine-related disorders and nonsubstance-related disorders
				  shall not be covered. Substance use case management shall include an active
				  individual service plan (ISP) that requires a minimum of two substance use case
				  management service activities each month and at least one face-to-face contact
				  with the individual at least every 90 calendar days.
B. Services will be provided to the entire
				  state.
C. Comparability of
				  services: Services are not comparable in amount, duration, and scope. Authority
				  of § 1915(g)(1) of the Act is invoked to provide services without regard
				  to the requirements of § 1902(a)(10)(B) of the Act.
D. Definition of services: Substance use case
				  management services assist individuals and their family members in accessing
				  needed medical, psychiatric, psychological, social, educational, vocational,
				  recovery, and other supports essential to meeting the individual's basic needs.
				  Substance use case management is reimbursable on a monthly basis only when the
				  minimum substance use case management service activities are met. Substance use
				  case management services are not reimbursable for individuals while they are
				  residing in institutions, including institutions for mental disease, except
				  that substance use case management may be reimbursed during the month prior to
				  discharge to allow for discharge planning. This is limited to two one-month
				  periods during a 12-month period. Tobacco-related disorders or caffeine-related
				  disorders and nonsubstance-related disorders shall not be covered. Substance
				  use case management does not include maintaining service waiting lists or
				  periodically contacting or tracking individuals to determine potential service
				  needs. Substance use case management services are to be person centered,
				  individualized, and culturally and linguistically appropriate to meet the
				  individual's and family member's needs.
Substance use case management service activities to be
					 provided shall include:
1. Assessing
				  needs and planning services to include developing a substance use case
				  management individual service plan (ISP). The ISP shall utilize accepted
				  placement criteria and shall be fully completed within 30 calendar days of
				  initiation of service;
2. Enhancing
				  community integration through increased opportunities for community access and
				  involvement and enhancing community living skills to promote community
				  adjustment including, to the maximum extent possible, the use of local
				  community resources available to the general public;
3. Making collateral contacts with the
				  individual's significant others with properly authorized releases to promote
				  implementation of the individual's ISP and his community adjustment;
4. Linking the individual to those community
				  supports that are most likely to promote the personal habilitative or
				  rehabilitative, recovery, and life goals of the individual as developed in the
				  ISP;
5. Assisting the individual
				  directly to locate, develop, or obtain needed services, resources, and
				  appropriate public benefits;
6.
				  Assuring the coordination of services and service planning within a provider
				  agency, with other providers, and with other human service agencies and
				  systems, such as local health and social services departments.
7. Monitoring service delivery through
				  contacts with individuals receiving services and service providers and site and
				  home visits to assess the quality of care and satisfaction of the
				  individual;
8. Providing follow-up
				  instruction, education, and counseling to guide the individual and develop a
				  supportive relationship that promotes the ISP;
9. Advocating for individuals in response to
				  their changing needs, based on changes in the ISP;
10. Planning for transitions in the
				  individual's life;
11. Knowing and
				  monitoring the individual's health status, any medical condition, and
				  medications and potential side effects and assisting the individual in
				  accessing primary care and other medical services, as needed; and
12. Understanding the capabilities of
				  services to meet the individual's identified needs and preferences and to serve
				  the individual without placing the individual, other participants, or staff at
				  risk of serious harm.