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 12VAC30-130-5020 - 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 clearly indicates
					 otherwise:
"Abstinence" means the intentional and consistent restraint
					 from the pathological pursuit of reward or relief, or both, that involves the
					 use of substances.
"Addiction" means a primary, chronic disease of brain
					 reward, motivation, memory, and related circuitry. Addiction is defined as the
					 inability to consistently abstain, impairment in behavioral control,
					 persistence of cravings, diminished recognition of significant problems with
					 one's behaviors and interpersonal relationships, and a dysfunctional emotional
					 response. Like other chronic diseases, addiction often involves cycles of
					 relapse and remission. Without treatment or engagement in recovery activities,
					 addiction is progressive and can result in disability or premature
					 death.
"Addiction-credentialed physician" means a physician who
					 holds a board certification in addiction medicine from the American Board of
					 Addiction Medicine, a subspecialty board certification in addition to
					 certification in psychiatry from the American Board of Psychiatry and
					 Neurology, or subspecialty board certification in addiction medicine from the
					 American Osteopathic Association. DMAS also recognizes physicians with the DATA
					 2000 buprenorphine waiver and physicians treating addiction who have specialty
					 training or experience in addiction medicine or addiction psychiatry. If
					 treating adolescents, "addiction-credentialed physician" means an
					 addiction-credentialed physician who also has experience and specialty training
					 with adolescent medicine.
"Adherence" means the individual receiving treatment has
					 demonstrated his ability to cooperate with, follow, and take personal
					 responsibility for the implementation of his treatment plans.
"Adolescent" means an individual from 12 years of age to 20
					 years of age.
"Allied health professional" means counselor aides or group
					 living workers who meet the DBHDS licensing requirements for unlicensed staff
					 in residential settings.
"ARTS" means addiction and recovery treatment
					 services.
"ARTS care coordinator" means an employee of DMAS, its
					 contractor, or an MCO who is a licensed practitioner of the healing arts,
					 including a physician or medical director, licensed clinical psychologist,
					 licensed clinical social worker, licensed professional counselor, licensed
					 substance abuse treatment practitioner, licensed marriage and family therapist,
					 nurse practitioner, or registered nurse with two years of clinical experience
					 in the treatment of substance use disorders. The ARTS care coordinator performs
					 independent assessments of requests for all ARTS intensive outpatient programs
					 (ASAM Level 2.1); partial hospitalization programs (ASAM Level 2.5);
					 residential treatment services (ASAM Levels 3.1, 3.3, 3.5, and 3.7); and
					 inpatient services (ASAM Level 3.7 and 4.0).
"ASAM" means the American Society of Addiction
					 Medicine.
"ASAM criteria" means the six different life areas used by
					 the ASAM Patient Placement Criteria to develop a holistic biopsychosocial
					 assessment of an individual that is used for service planning, level of care,
					 and length of stay treatment decisions.
"BHA" means behavioral health authority.
"Biomedical" means biological or physical aspects of a
					 member's condition that require assessment and services that are delivered by
					 appropriately credentialed medical staff, who are available to assess and treat
					 co-occurring biomedical disorders that may be the result of, or independent of,
					 a substance use disorder.
"Buprenorphine-waivered practitioner" means a health care
					 provider licensed under Virginia law and registered with the Drug Enforcement
					 Administration (DEA) to prescribe Schedule III, IV, or V medications for
					 treatment of pain. More specifically, a buprenorphine-waivered physician has
					 obtained the buprenorphine waiver through the Drug Addiction Treatment Act of
					 2000 (DATA 2000), while a buprenorphine-waivered nurse practitioner or
					 physician assistant has obtained the buprenorphine waiver through DATA 2000. A
					 buprenorphine-waivered practitioner meets all federal and state requirements
					 and is supervised by or works in collaboration with a qualifying physician in
					 accordance with the applicable regulatory board. In accordance with §
										54.1-2957
					 of the Code of Virginia, a nurse practitioner may practice without a written or
					 electronic practice agreement with a qualifying physician. All
					 buprenorphine-waivered practitioners have a DEA-X number to prescribe
					 buprenorphine for the treatment of opioid use disorder.
"Care coordination" means collaboration and sharing of
					 information among health care providers who are involved with an individual's
					 health care to assist in improving the care of the individual. This includes
					 e-consultations from primary care providers to specialists.
"Certified substance abuse counselor" or "CSAC" means the
					 same as that term is defined in §
										54.1-3507.1
					 of the Code of Virginia.
"Certified substance abuse counseling assistant" or
					 "CSAC-A" means the same as that term is defined in §
										54.1-3507.2
					 of the Code of Virginia.
"Certified substance abuse counselor-supervisee" means an
					 individual who has completed the educational requirements described in clause
					 (i) of §
										54.1-3507.1C
					 of the Code of Virginia, but who has not completed the practice hours described
					 in clause (ii) of §
										54.1-3507.1C
					 of the Code of Virginia.
"Child" means an individual from birth up to 12 years of
					 age.
"Clinical experience" means, for the purpose of these ARTS
					 requirements, practical experience in providing direct services to individuals
					 with diagnoses of substance use disorder. Clinical experience shall include
					 supervised internships, supervised practicums, or supervised field experience.
					 Clinical experience shall not include unsupervised internships, unsupervised
					 practicums, and unsupervised field experience.
"Counseling" means the same as that term is defined in
					 §
										54.1-3500 of the Code
					 of Virginia.
"Credentialed addiction treatment professional" or "CATP"
					 means an individual licensed or registered with the appropriate board in the
					 following roles:
(i) an addiction-credentialed physician or physician with
					 experience or training in addiction medicine;
(ii) physician extenders with experience or training in
					 addiction medicine;
(iii) a licensed psychiatrist;
(iv) a licensed clinical psychologist;
(v) a licensed clinical social worker;
(vi) a licensed professional counselor;
(vii) a certified psychiatric clinical nurse
					 specialist;
(viii) a licensed psychiatric nurse practitioner;
(ix) a licensed marriage and family therapist;
(x) a licensed substance abuse treatment
					 practitioner;
(xi) a resident who is under the supervision of a licensed
					 professional counselor (18VAC115-20-10
					 ), licensed marriage and family therapist (18VAC115-50-10
					 ), or licensed substance abuse treatment practitioner (18VAC115-60-10
					 ) and is registered with the Virginia Board of Counseling;
(xii) a resident in psychology who is under supervision of
					 a licensed clinical psychologist and is registered with the Virginia Board of
					 Psychology (18VAC125-20-10 );
					 or
(xiii) a supervisee in social work who is under the
					 supervision of a licensed clinical social worker and is registered with the
					 Virginia Board of Social Work (18VAC140-20-10
					 ).
"CSB" means community services board.
"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.
"DMAS" means the Department of Medical Assistance Services
					 and its contractors 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.
"Evidence-based" means an empirically-supported clinical
					 practice or intervention with a proven ability to produce positive
					 outcomes.
"Face-to-face" means encounters that occur in person or
					 through telemedicine.
"FQHC" means federally qualified health center.
"Individual" means the patient, client, beneficiary, or
					 member who receives services set out in
					 12VAC30-130-5000
					 et seq. These terms are used interchangeably.
"Individual service plan" or "ISP" means an initial and
					 comprehensive treatment plan that is regularly updated and specific to an
					 individual's unique treatment needs as identified in the assessment. An ISP
					 contains an individual's treatment or training needs, the individual's goals
					 and measureable objectives to meet the identified needs, services to be
					 provided with the recommended frequency to accomplish the measurable goals and
					 objectives, and an individualized discharge plan that describes transition to
					 other appropriate services. An individual is included in the development of the
					 ISP, and the ISP is signed by the individual. If the individual is a minor, the
					 ISP is also signed by the individual's parent or legal guardian. An ISP
					 includes documentation if the individual is a minor child or an adult who lacks
					 legal capacity and is unable or unwilling to sign the ISP.
"Induction phase" means the medically monitored initiation
					 of buprenorphine, buprenorphine and naloxone, naltrexone, or methadone
					 treatment performed in a qualified practitioner's office or licensed OTP. The
					 goal of the induction phase is to find the individual's ideal dose of
					 buprenorphine, buprenorphine and naloxone, naltrexone, or methadone. The ideal
					 dose minimizes both side effects and drug craving.
"Licensed practical nurse" means a professional who is
					 licensed by the Commonwealth as a practical nurse or holds a multistate
					 licensure privilege to practice practical nursing according to
					 18VAC90-19-80.
"Managed care organization" or "MCO" means an organization
					 that offers managed care health insurance plans (MCHIP), as defined by §
										38.2-5800 of the Code
					 of Virginia, which means an arrangement for the delivery of health care in
					 which a health carrier undertakes to provide, arrange for, pay for, or
					 reimburse any of the costs of health care services for a covered person on a
					 prepaid or insured basis that (i) contains one or more incentive arrangements,
					 including any credentialing requirements intended to influence the cost or
					 level of health care services between the health carrier and one or more
					 providers with respect to the delivery of health care services and (ii)
					 requires or creates benefit payment differential incentives for covered persons
					 to use providers that are directly or indirectly managed, owned, under contract
					 with, or employed by the health carrier.
"Medication assisted treatment" or "MAT" means the same as
					 that term is defined in
					 42
					 CFR 8.2.
"Multidimensional assessment" or "assessment" means the
					 individualized, person-centered biopsychosocial assessment performed
					 face-to-face, in which the provider obtains comprehensive information from the
					 individual, and family members and significant others as needed, including
					 history of the present illness; family history; developmental history; alcohol,
					 tobacco, and other drug use or addictive behavior history; personal or social
					 history; legal history; psychiatric history; medical history; spiritual history
					 as appropriate; review of systems; mental status exam; physical examination;
					 formulation and diagnoses; survey of assets, vulnerabilities and supports; and
					 treatment recommendations. The ASAM multidimensional assessment is a
					 theoretical framework for this individualized, person-centered assessment that
					 includes the following dimensions:
(i) acute intoxication or likelihood of withdrawal, or
					 both;
(ii) medical conditions and complications, both historical
					 and current;
(iii) emotional, behavioral, or cognitive status and any
					 identified issues;
(iv) an individual's readiness to change;
(v) risks for relapse or continued use; and
(vi) home environment. The level of care determination,
					 ISP, and recovery strategies development may be based upon this
					 multidimensional assessment.
"Opioid" means any psychoactive chemical that resembles
					 morphine in pharmacological effects, including opiates and synthetic or
					 semisynthetic agents that exert their effects by binding to highly selective
					 receptors in the brain where morphine and endogenous opioids affect their
					 actions.
"Opioid treatment program" or "OTP" means the same as that
					 term is defined in
					 42
					 CFR 8.2.
"Opioid treatment services" or "OTS" means preferred
					 office-based opioid treatment (OBOT) and OTPs that encompass a variety of
					 pharmacological and nonpharmacological treatment modalities, including
					 substance use disorder counseling and psychotherapy.
"Overdose" means the inadvertent or deliberate consumption
					 of a dose of a chemical substance much larger than either habitually used by
					 the individual or ordinarily used for treatment of an illness that is likely to
					 result in a serious toxic reaction or death.
"Physician extenders" means licensed nurse practitioners as
					 defined in §
										54.1-3000 of the Code
					 of Virginia and licensed physician assistants as defined in §
										54.1-2900 of the Code
					 of Virginia.
"Preferred office-based opioid treatment" or "preferred
					 OBOT" means addiction treatment services for individuals with a primary opioid
					 use disorder provided by buprenorphine-waivered practitioners working in
					 collaboration with CATPs providing psychotherapy and substance use disorder
					 counseling in public and private practice settings.
"Program of assertive community treatment" or "PACT" means
					 the same as that term is defined in
					 12VAC35-105-20.
"Psychoeducation" means
(i) a specific form of education aimed at helping
					 individuals who have a substance use disorder or mental illness and their
					 family members or caregivers to access clear and concise information about
					 substance use disorders or mental illness and (ii) a way of accessing and
					 learning strategies to deal with substance use disorders or mental illness and
					 its effects in order to design effective treatment plans and strategies.
"Psychotherapy" or "therapy" means the use of psychological
					 methods in a professional relationship to assist a person to acquire great
					 human effectiveness or to modify feelings, conditions, attitudes, and behaviors
					 that are emotionally, intellectually, or socially ineffectual or
					 maladaptive.
"Recovery" means a process of sustained effort that
					 addresses the biological, psychological, social, and spiritual disturbances
					 inherent in addiction and consistently pursues abstinence, behavior control,
					 dealing with cravings, recognizing problems in one's behaviors and
					 interpersonal relationships, and more effective coping with emotional responses
					 leading to reversal of negative, self-defeating internal processes and
					 behaviors and allowing healing of relationships with self and others. The
					 concepts of humility, acceptance, and surrender are useful in this
					 process.
"Registered nurse" or "RN" means the same as "professional
					 nurse" is defined in §
										54.1-3000 of the Code
					 of Virginia.
"Relapse" means a process in which an individual who has
					 established abstinence or sobriety experiences recurrence of signs and symptoms
					 of active addiction, often including resumption of the pathological pursuit of
					 reward or relief through the use of substances and other behaviors often
					 leading to disengagement from recovery activities. Relapse can be triggered by
					 exposure to (i) rewarding substances and behaviors, (ii) environmental cues to
					 use, and (iii) emotional stressors that trigger heightened activity in brain
					 stress circuits. The event of using or acting out is the latter part of the
					 process, which can be prevented by early intervention.
"RHC" means rural health clinic.
"SBIRT" means screening, brief intervention, and referral
					 to treatment. SBIRT services are an evidence-based and community-based practice
					 designed to identify, reduce, and prevent problematic substance use
					 disorders.
"Service authorization" means the process to approve
					 specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by
					 DMAS or its contractor, or an MCO 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.
"Substance use care coordinator" means staff in an OTP or
					 preferred OBOT setting who have:
1. At least a bachelor's degree in one of the following
					 fields: social work, psychology, psychiatric rehabilitation, sociology,
					 counseling, vocational rehabilitation, or human services counseling, and at
					 least either (i) one year of substance use disorder related direct experience
					 or training or a combination of experience or training in providing services to
					 individuals with a diagnosis of substance use disorder or (ii) a minimum of one
					 year of clinical experience or training in working with individuals with
					 co-occurring diagnoses of substance use disorder and mental illness; or
2. Licensure by the Commonwealth as a registered nurse with
					 at least either (i) one year of direct experience or training or a combination
					 of experience and training in providing services to individuals with a
					 diagnosis of substance use disorder or (ii) a minimum of one year of clinical
					 experience or training or a combination of experience and training in working
					 with individuals with co-occurring diagnoses of substance use disorder and
					 mental illness; or
3. Certification as a CSAC or a CSAC-A.
"Substance use case management" means the same as set out
					 in
					 12VAC30-50-491.
"Substance use disorder" or "SUD" means a substance-related
					 addictive disorder, as defined in the DSM-5 with the exception of
					 tobacco-related disorders and non-substance-related disorders, marked by a
					 cluster of cognitive, behavioral, and physiological symptoms indicating that
					 the individual continues to use, is seeking treatment for the use of, or is in
					 active recovery from the use of alcohol or other drugs despite significant
					 related problems.
"Substance use disorder counseling" means the same as
					 "substance abuse counseling" is defined in
					 18VAC115-30-10.
"Telemedicine" means the real-time, two-way transfer of
					 medical data and information using an interactive audio-video connection for
					 the purposes of medical diagnosis and treatment. The member is located at the
					 originating site, while the provider renders services from a remote location
					 via the audio-video connection. Equipment utilized for telemedicine shall be of
					 sufficient audio quality and visual clarity as to be functionally equivalent to
					 a face-to-face encounter for professional medical services.
"Tolerance" or "tolerate" means a state of adaptation in
					 which exposure to a drug induces changes that result in diminution of one or
					 more of the drug's effects over time.
"Withdrawal management" means services to assist an
					 individual's withdrawal from the use of substances.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.