Title of Regulation: 12VAC35-250. Certification of Peer Recovery and Resiliency Specialists (adding 12VAC35-250-10 through 12VAC35-250-50).

Statutory Authority: §§ 37.2-203 and 37.2-304 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: September 21, 2018.

Agency Contact: Ruth Anne Walker, Regulatory Coordinator, Department of Behavioral Health and Developmental Services, Jefferson Building, 1220 Bank Street, 11th Floor, Richmond, VA 23219, telephone (804) 225-2252, FAX (804) 786-8623, TTY (804) 371-8977, or email ruthanne.walker@dbhds.virginia.gov.

Basis: Sections 37.2-203 and 37.2-304 of the Code of Virginia authorize the State Board of Behavioral Health and Developmental Services (State Board) to adopt regulations that may be necessary to carry out the provisions of Title 37.2 of the Code of Virginia and other laws of the Commonwealth administered by the commissioner and the department.

The proposed regulation is necessary for individuals to be designated as "peer recovery specialists" and to have a pathway to provide peer services through the Virginia ARTS benefit, which was made available to Medicaid members receiving addiction treatment services at all levels of care effective on July 1, 2017.

Chapters 418 and 426 of the 2017 Acts of Assembly authorize the Virginia Board of Counseling to promulgate emergency regulations for the registration of peer recovery specialists who meet the qualifications, education, and experience requirements established by regulations of the State Board. Upon promulgation of regulations by the Board of Counseling, registration will begin with the Board of Counseling.

Upon conclusion of this action by the State Board, permanent regulations, replacing the emergency regulations effective May 17, 2017, will allow the Department of Behavioral Health and Developmental Services (DBHDS) to continue to set out the requirements for qualifications, education, and experience of individuals eligible to register with the Board of Counseling as "registered peer recovery specialists."

Purpose: With the creation of Medicaid coverage for peer services in Virginia, the proposed regulation provides administrative structure for DBHDS qualifications, education, and experience for peer recovery specialists to ensure that individuals providing peer recovery services in Virginia's public system of behavioral health services demonstrate a baseline of practical knowledge. This is a reflection of the need for a standard of commonly understood evidenced-based best practices in the support of people with behavioral health conditions. This field of practice is expected to grow, as is Virginia's network of available peer recovery specialists.

Background: The following background information on billing is taken from the U.S. Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration (SAMHSA-HRSA) Center for Integrated Health Solutions (CIHS) website at http://www.integration.samhsa.gov/work%20force/team-members/peerproviders.

"Billing for Peer Provided Integrated Health Services

• In the field of behavioral health, Medicaid billing for peer support services began in Georgia in 1999, and quickly expanded nationally in 2007 after the Centers for Medicare and Medicaid Services (CMS) sent guidelines to states on how to be reimbursed for services delivered by peer providers. In 2012, Georgia was approved as the first state to bill for a peer whole health and wellness service delivered by WHAM-trained peer providers.

• CMS' Clarifying Guidance on Peer Services Policy from May 2013 states that any peer provider must "complete training and certification as defined by the state" before providing billable services.

• Beginning January 1, 2014, CMS expanded the type of practitioners who can provide Medicaid prevention services beyond physicians and other licensed practitioners, at a state's discretion, which can include peer providers."

The proposed regulations are needed to support a strong peer workforce through financial sustainability that is ensured when peer services meet criteria for reimbursement like Medicaid billing.

General explanation of peer recovery services: According to SAMSHA, the adoption of "recovery" by behavioral health systems in recent years has signaled a dramatic shift in the expectation for positive outcomes for individuals who experience mental or substance use conditions. Today, when individuals with mental illness or substance use disorders seek help, they are met with the knowledge and belief that anyone can recover and manage their conditions successfully. The value of recovery and recovery-oriented behavioral health systems is widely accepted by states, communities, health care providers, peers, families, researchers, and advocates, including the U.S. Surgeon General, the National Academies Health and Medicine Division (HMD), and others.

Peer recovery support services help people enter and navigate systems of care; remove barriers to recovery; stay engaged in the recovery process; and live full lives in communities of their choice.

The services include culturally and linguistically appropriate services that assist individuals and families working toward recovery from mental illness or substance use disorders. Peer recovery services support enhanced access to evidence-based practices such as supported employment, education, housing, assertive community treatment, illness management, and peer-operated services.

The services may be provided before, during, or after clinical treatment or may be provided to individuals who are not in treatment but seek support services. The services provided by peers are delivered through a variety of community and faith-based groups, treatment providers, schools, and other specialized services.

Substance: The proposed regulations provide administrative structure for DBHDS qualifications, education, and experience for peer recovery specialists to ensure that individuals providing peer recovery services in Virginia's public system of behavioral health services demonstrate a baseline of practical knowledge, as did the emergency regulation. The changes in this proposed regulation that differ from the emergency regulation accommodate the Department of Health Profession's registration of peer recovery specialists, including assuming language for continuing education, and delete a date-specific requirement for training during the transition to permanent regulations. Specifically:

12VAC35-250-10 - the definition for "Registered peer recovery specialist" is added.

12VAC35-250-20 - a new subsection D, "Any person meeting the qualifications for a peer recovery specialist as set forth in this chapter shall be eligible for registration by the Virginia Board of Counseling." is added.

12VAC35-250-30 A 3 - the date by which training must be completed, that is, April 1, 2018, is deleted.

12VAC35-250-45 - the section is deleted.

Issues: Virginia needs comprehensive behavioral health care as it is essential to population health and cost containment.

	National average of state spending	Virginia spending
Hospitals	23% of overall BH budget	46% of overall BH budget
Community	75% of overall BH budget (~$89 per capita)	51% of overall BH budget ($47 per capita)

Behavioral health issues drive up to 35% of medical care costs, and individuals with mental illness or substance use disorders or co-occurring mental illness and substance use disorders cost up to two to three times as much as those without them.

Peer recovery services help to decrease reliance on institutions and increase focus on community services. The services also facilitate integration of behavioral health and primary care, as well as housing, employment, schools, and social services.

The proposed regulatory action makes permanent the formalization of the peer recovery specialist professional qualifications, education, and experience to provide collaborative services to assist individuals in achieving sustained recovery from the effects of mental illness, addiction, or both. With the creation of Medicaid coverage for peer services in Virginia, the proposed regulation provides administrative structure for DBHDS qualifications, education, and experience for peer recovery specialists to ensure that individuals providing peer recovery services in Virginia's public system of behavioral health services demonstrate a baseline of practical knowledge. This is a reflection of the need for a standard of commonly understood evidenced-based best practices in the support of people with behavioral health conditions. For those peer recovery specialists who wish to bill Medicaid for services, the additional option of registering with the Board of Counseling will be available and is noted in the proposed DBHDS regulation.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Pursuant to Chapters 418¹ and 426² of the 2017 Acts of Assembly, the State Board of Behavioral Health and Developmental Services (Board) proposes to promulgate a new regulation, Peer Recovery Specialists. The proposed regulation includes definitions and requirements for an individual to become professionally qualified to be a registered peer recovery specialist. This proposed regulation would replace an existing emergency regulation.³

Result of Analysis. The benefits likely exceed the costs for the proposed regulation.

Estimated Economic Impact.

Peer Support Services: Peer support services are an evidence-based mental health model of care, which consists of a qualified peer recovery specialist who assists individuals with their recovery from mental illness and 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.

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.⁴ 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.⁵

Peer Recovery Specialists: 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. Peer recovery specialists (PRSs) are self-identified consumers who are in successful and ongoing recovery from mental illness and/or substance use disorders, or are family members of individuals who are receiving or have received mental health or substance abuse services. PRSs are employed or seek to be employed to deliver collaborative support to others who are seeking to recover from a primary diagnosis of mental illness, addiction, or both.

As of December 31, 2016, there were 430 certified peer recovery specialists employed across Virginia in public or private mental health or substance use disorder service settings.⁶ The demand for PRS services is expected to expand through the Virginia Medicaid Addiction and Recovery Treatment Services (ARTS) new substance use disorder benefit. Under the ARTS benefit, peer support services began to be funded for Medicaid members on July 1, 2017. In order for peer support services to be funded by Medicaid,⁷ the PRS must be registered by the Department of Health Professions (DHP). This proposed regulation provides requirements that a PRS must meet in order to receive DHP registration.

Requirements: The Board proposes to require the following for persons seeking to become a registered PRS:

1. Have a high school diploma or equivalent.

2. Sign and abide by the Virginia Peer Recovery Specialist Code of Ethics.⁸

3. Complete the Department of Behavioral Health and Developmental Services (DBHDS) peer recovery specialist training.

4. Show current certification in good standing from one of the following:

a. U.S. Department of Veterans Affairs

b. National Association for Alcoholism and Drug Abuse Counselors

c. A member board of the International Certification and Reciprocity

Consortium (IC&RC)

d. Any other certifying body approved by DBHDS

DBHDS peer recovery specialist training lasts 72 hours⁹ and includes training on the following topics: 1) the current body of mental health and substance abuse knowledge, 2) the recovery process, 3) promoting services, supports, and strategies for recovery, 4) peer-to-peer services, 5) crisis intervention, 6) the value of the role of a peer recovery specialist, 7) basic principles related to health and wellness, 8) recovery, resiliency, and wellness plans, 9) stage-appropriate pathways in recovery support, 10) ethics and ethical boundaries. 11) cultural sensitivity and practice, 12) trauma and its impact on recovery, 13) community resources, and 14) delivering peer services within agencies and organizations. Currently, there is no fee for DBHDS peer recovery specialist training.

The Virginia Certification Board¹⁰ is the Virginia member board of the IC&RC. Requirements to become a Certified Peer Recovery Specialists via the Virginia Certification Board consist of:

1. High school diploma or GED.

2. Complete the DBHDS peer recovery specialist training.

3. 500 hours of volunteer or paid experience providing peer recovery support services.¹¹ Volunteer and part-time experience is acceptable if it is provided under direct supervision. Actual time spent in a supervised substance abuse or mental health internship, or practicum may be applied toward the employment requirement.

4. Pass the IC&RC Peer Recovery Specialist Examination.

5. Virginia residency.

The fee for a two-year certification from the Virginia Certification Board, which includes the application and examination, is $175. The fee for certification renewal is $75. Twenty hours of peer support specific continuing education, including six hours in ethics, is also required for certification renewal.¹²

Thus for a Virginian who chooses to become certified through the Virginia Certification Board in order to become professionally qualified to be a registered peer recovery specialist, she must: 1) have a high school diploma or GED, 2) sign and abide by the Virginia Peer Recovery Specialist Code of Ethics, 3) complete the DBHDS peer recovery specialist training, 4) have at least 500 hours of volunteer or paid experience providing peer recovery support services, 5) pass the IC&RC Peer Recovery Specialist Examination, and 6) pay $175 to the Virginia Certification Board.

Conclusion

The U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services specifies that:

"Peer support providers must complete training and certification as defined by the State. Training must provide peer support providers with a basic set of competencies necessary to perform the peer support function. The peer must demonstrate the ability to support the recovery of others from mental illness and/or substance use disorders. Similar to other provider types, ongoing continuing educational requirements for peer support providers must be in place."

The proposed regulation meets those requirements, helping enable Virginia providers of peer support services to receive Medicaid funding.

Businesses and Entities Affected. The proposed regulation affects businesses and other entities that either provide or are considering providing peer support services. According to the Department of Medical Assistance Services, there are approximately 5,891 provider entities with a unique National Provider Identifier that could be affected if they choose to participate in the ARTS program. At least half, if not more of these providers, are small businesses.¹³

Localities Particularly Affected. The proposed regulation does not disproportionately affect particular localities.

Projected Impact on Employment. The proposed regulation helps businesses and other entities that either provide or are considering providing peer support services qualify for Medicaid funding. This will likely increase the number of peer recovery specialist positions in the Commonwealth.

Effects on the Use and Value of Private Property. The proposed regulation helps enable Virginia providers of peer support services to receive Medicaid funding. Consequently, there may be greater provision of peer support services by private firms, and their values may increase.

Real Estate Development Costs. The proposed regulation does not affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. The proposed regulation is beneficial for small businesses in that it helps meet the federal requirements concerning set qualifications for peer support providers, helping enable small businesses that provide or are considering providing peer support services to receive Medicaid funding.

Alternative Method that Minimizes Adverse Impact. The proposed regulation is beneficial in that it helps meet the federal requirements concerning set qualifications for peer support providers, helping enable small businesses that provide or are considering providing peer support services to receive Medicaid funding. That said, there is flexibility in determining qualification requirements. Given that in order to become a registered peer recovery specialist the candidate must complete extensive training and pass a qualification exam, requiring 500 hours of supervised experience providing peer recovery support services prior to becoming certified or registered may be more than is necessary for assuring competence. Small firms looking to hire registered peer recovery specialists in order to provide peer support services and receive Medicaid funding could hire and employ registered peer recovery specialists sooner if the experience requirement were fewer hours.

Adverse Impacts:

Businesses. The proposed regulation does not adversely affect businesses.

Localities. The proposed regulation does not adversely affect localities.

Other Entities. The proposed regulation does not adversely affect other entities.

References

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.

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¹See http://leg1.state.va.us/cgi-bin/legp504.exe?171+ful+CHAP0418.

²See http://leg1.state.va.us/cgi-bin/legp504.exe?171+ful+CHAP0426.

³See http://townhall.virginia.gov/l/ViewStage.cfm?stageid=7902.

⁴See Rowe et al (2007) and Solomon et al (1995).

⁵See Davison et al (2012).

⁶Source: Department of Behavioral Health and Developmental Services.

⁷Sources: Department of Medical Assistance Services, and Department of Behavioral Health and Developmental Services.

⁸See http://www.dbhds.virginia.gov/library/recovery/code%20of%20 ethical%20conduct%20for%20cprs.pdf.

⁹Source: Department of Behavioral Health and Developmental Services.

¹⁰See https://www.vacertboard.org/.

¹¹At least 25 of the hours must be supervised and specific to the four domains: advocacy, ethical responsibility, mentoring and education, and recovery/wellness support.

¹²See https://www.vacertboard.org/sites/default/files/VCBRecert
Application.pdf.

¹³Source: Department of Medical Assistance Services.

Agency's Response to Economic Impact Analysis: The agency concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

Chapters 418 and 426 of the 2017 Acts of Assembly authorize the State Board of Behavioral Health and Developmental Specialists to adopt regulations that establish the qualifications, education, and experience for registration of peer recovery specialists by the Board of Counseling. Peer recovery specialist (PRS) staff are individuals who are, or family members of minor or adult children who are, receiving or have received mental health or substance abuse services. PRS staff are employed or seek to be employed to deliver collaborative support to others who are seeking to recover from a primary diagnosis of mental illness, addiction, or both. As of December 31, 2016, there were 430 certified peer recovery specialists employed across Virginia in public or private mental health or substance use disorder service settings.

The proposed regulation provides individuals who will be designated as "peer recovery specialists" a pathway to provide peer recovery services through the Virginia Medicaid Addiction and Recovery Treatment Services new substance use disorder benefit, which became available to Medicaid members receiving addiction treatment services at all levels of care effective July 1, 2017. The proposed regulations ensure that individuals providing peer recovery services in Virginia's public system of behavioral health services meet a baseline of practical knowledge and appropriate education and qualifications.

CHAPTER 250
PEER RECOVERY SPECIALISTS

12VAC35-250-10. Definitions.

"Certifying body" means an organization approved by DBHDS that has as one of its purposes the certification of peer recovery specialists.

"DBHDS" means the Department of Behavioral Health and Developmental Services.

"DBHDS peer recovery specialist training" means the curriculum developed and approved by DBHDS for the training of persons seeking registration as peer recovery specialists.

"Individual" means a person who is receiving peer recovery support services. This term includes the terms "consumer," "patient," "resident," "recipient," and "client."

"Peer recovery specialist" means a person who by education and experience is professionally qualified to provide collaborative services to assist individuals in achieving sustained recovery from the effects of mental illness, addiction, or both.

"Peer recovery support services" means collaborative nonclinical, peer-to-peer services that engage, educate, and support an individual's self-help efforts to improve his health, recovery, resiliency, and wellness to assist individuals in achieving sustained recovery from the effects of mental illness, addiction, or both.

"Recovery, resiliency, and wellness plan" means a set of goals, strategies, and actions an individual creates to guide him and his health care team to move the individual toward the maximum achievable independence and autonomy in the community.

"Registered peer recovery specialist" means a peer recovery specialist who is registered by the Virginia Board of Counseling.

12VAC35-250-20. Peer recovery specialist.

A. Any person seeking to be a peer recovery specialist under this chapter shall (i) meet the qualifications, education, and experience requirements established in this chapter and (ii) hold a certification as a peer recovery specialist from a certifying body approved by DBHDS.

B. If the conditions in clauses (i) and (ii) of subsection A of this section are met, a person who is one of the following may act as a peer recovery specialist:

1. A parent of a minor or adult child with a mental illness or substance use disorder or co-occurring mental illness and substance use disorder similar to the individual receiving peer recovery services; or

2. An adult with personal experience with a family member with a mental illness or substance use disorder or co-occurring mental illness and substance use disorder similar to the individual receiving peer recovery services.

C. A registered peer recovery specialist shall provide such services as an employee or independent contractor of DBHDS, a provider licensed by DBHDS, a practitioner licensed by or holding a permit issued from the Department of Health Professions, or a facility licensed by the Department of Health.

D. Any person meeting the qualifications for a peer recovery specialist set forth in this chapter shall be eligible for registration by the Virginia Board of Counseling.

12VAC35-250-30. Qualifications.

A. Any person seeking to be a peer recovery specialist under this chapter shall:

1. Have a high school diploma or equivalent.

2. Sign and abide by the Virginia Peer Recovery Specialist Code of Ethics, Department of Behavioral Health and Developmental Services, effective April 4, 2017.

3. Complete the DBHDS peer recovery specialist training.

4. Show current certification in good standing by the U.S. Department of Veterans Affairs or one of the following certifying bodies:

a. National Association for Alcoholism and Drug Abuse Counselors (NAADAC);

b. A member board of the International Certification and Reciprocity Consortium (IC&RC); or

c. Any other certifying body approved by DBHDS.

B. Individuals certified through the Virginia member board of the IC&RC between April 16, 2015, through December 31, 2016, shall be exempt from completing the DBHDS peer recovery specialist training.

12VAC35-250-40. Minimum standards for certifying bodies.

DBHDS may approve a certification obtained from a certifying body that requires its certificate holders to:

1. Adhere to a code of ethics that is substantially comparable to the Virginia Peer Recovery Specialist Code of Ethics, Department of Behavioral Health and Developmental Services, effective April 4, 2017.

2. Have at least one year of recovery for persons having lived experience with mental illness or substance use disorder conditions, or lived experience as a family member of someone with mental illness or substance use disorder conditions.

3. Complete at least 46 hours of training from the list of curriculum subjects in 12VAC35-250-50.

4. Obtain a passing score on an examination offered by the certifying body testing knowledge of the curriculum subjects identified in 12VAC35-250-50.

5. Obtain and document at least 500 hours of supervised paid or volunteer experience providing peer recovery support services in the three years prior to applying for certification. The experience hours shall have been in nonclinical, peer-to-peer recovery-oriented support activities designed to address an individual's recovery and wellness goals.

12VAC35-250-50. Curriculum requirements.

A. Unless the exception in 12VAC35-250-30 B is met, any person seeking to be a peer recovery specialist under this chapter shall complete the DBHDS peer recovery specialist training.

B. The curriculum of the peer recovery specialist training shall include training on the following topics:

1. The current body of mental health and substance abuse knowledge;

2. The recovery process;

3. Promoting services, supports, and strategies for recovery;

4. Peer-to-peer services;

5. Crisis intervention;

6. The value of the role of a peer recovery specialist;

7. Basic principles related to health and wellness;

8. Recovery, resiliency, and wellness plans;

9. Stage-appropriate pathways in recovery support;

10. Ethics and ethical boundaries;

11. Cultural sensitivity and practice;

12. Trauma and its impact on recovery;

13. Community resources; and

14. Delivering peer services within agencies and organizations.

DOCUMENTS INCORPORATED BY REFERENCE (12VAC35-250)

The Virginia Peer Recovery Support Specialist Code of Ethics, Department of Behavioral Health and Developmental Services (eff. 4/2017)