TITLE 3. ALCOHOLIC BEVERAGES
ALCOHOLIC BEVERAGE CONTROL AUTHORITY
Proposed Regulation
TITLE 3. ALCOHOLIC BEVERAGES
ALCOHOLIC BEVERAGE CONTROL AUTHORITY
Proposed Regulation
Title of Regulation: 3VAC5-70. Other Provisions (amending 3VAC5-70-210).
Statutory Authority: §§ 4.1-111 and 4.1-227 of the Code of Virginia.
Public Hearing Information: No public hearings are scheduled.
Public Comment Deadline: May 6, 2019.
Agency Contact: LaTonya D. Hucks-Watkins, Legal Liaison, Virginia Alcoholic Beverage Control Authority, 2901 Hermitage Road, Richmond, VA 23220, telephone (804) 213-4698, FAX (804) 213-4574, or email latonya.hucks-watkins@abc.virginia.gov.
Basis: Section 4.1-101 of the Code of Virginia establishes the Virginia Alcoholic Beverage Control Authority. Section 4.1-103 of the Code of Virginia enumerates the powers of the board of directors, which includes the authority to adopt regulations and to do all acts necessary or advisable to carry out the purposes of Title 4.1 of the Code of Virginia, including promulgate regulations in accordance with the Administrative Process Act and § 4.1-111 of the Code of Virginia. Section 4.1-227 of the Code of Virginia permits the board to impose and collect civil penalties.
Purpose: The purpose of the proposed amendments is to amend civil penalties for first-offense violations so that the new schedule of penalties will continue to encourage settlement for first-offense matters where there are no disputed facts and the licensee desires to resolve the matter without a hearing. The penalties remain lower than the maximum penalties listed in the Code of Virginia; however, there is a reasonable increase in previous amounts to reflect the increases in maximum civil penalties listed in § 4.1-227 of the Code of Virginia that were enacted in 2017. This action protects public health, safety, or welfare because increasing the penalties acts as a deterrent to licensees committing violations while still promoting education of the Alcoholic Beverage Control Act in exchange for a lower penalty and making the disciplinary process more efficient.
Substance: Any licensee charged with one of the offenses listed in 3VAC5-70-210, provided that the licensee has no other pending charges and has not had any substantiated violations of regulation or statute within the three years immediately preceding the date of the violation, may enter a written waiver of hearing and accept a period of suspension or pay a civil charge in lieu of a suspension. The amounts of the civil charges are listed in 3VAC5-70-210 and are less than the maximum monetary penalties permitted by § 4.1-227 of the Code of Virginia. The amendments increase the civil charges listed in 3VAC5-70-210 by either $250 or $500. The current civil charges are based on out-of-date maximum penalties that existed prior to the amendments in 2017.
Issues: The primary advantage to the public, that is, licensees, is that the regulation continues to function as a means to allow licensees to resolve low-level first offenses expeditiously through a process that resolves the matter without licensees having to go through the hearing process, which can oftentimes be intimidating and stressful. The "disadvantage" is that these new penalties are higher than the previous penalties, but the General Assembly has increased the statutory maximums, so these penalties should increase as well to maintain a degree of consequence.
The primary advantage to the agency is that the regulation continues to encourage prompt resolution for undisputed, low-level violations. This is very beneficial to the agency as a whole because since becoming an authority, the agency is operating with a part-time board of directors, and the more cases that are resolved through settlement, the less taxing it is on the board. There are no disadvantages to the agency.
Department of Planning and Budget's Economic Impact Analysis:
Summary of the Proposed Amendments to Regulation. Following the 2017 legislative increase in maximum amount of penalties the Alcoholic Beverage Control Authority Board of Directors (Board) is authorized to impose,1 the Board proposes to increase penalties for first-offense violations by either $250 or $500.
Result of Analysis. The benefits likely exceed the costs for all proposed changes.
Estimated Economic Impact. The 2017 General Assembly increased the maximum penalty from $2,500 to $3,000 for first-offense violations involving sale of alcohol to persons prohibited from purchasing alcohol and from $1,000 to $2,000 for other first-offense violations.2 Accordingly, the Board proposes to increase the 26 different civil charges prescribed in this regulation by either $250 or $500. Based on the type and number of violations that occurred in 2017, the Alcoholic Beverage Control Authority (ABC) expects the collections of penalties to increase from $532,225 to $794,250, a $262,025 annual increase. The money collected from penalties is a source of General Fund revenue. Thus, the anticipated increase will be available to pay for general state expenditures.
In addition to the positive revenue impact, higher penalties would likely discourage violations and improve compliance. According to ABC, the Board opted not to increase the penalties to the maximum authorized in the legislation in order to encourage resolution of low-level first offenses expeditiously through a process without licensees having to go through the hearing process, which can oftentimes be intimidating and stressful.
Businesses and Entities Affected. The proposed new civil penalties apply to approximately 18,000 Board licensees. Most of the licensees are likely small businesses such as restaurants, bars, grocery stores, wineries, etc.
Localities Particularly Affected. The proposed changes would not disproportionately affect particular localities.
Projected Impact on Employment. The proposed changes are unlikely to affect employment.
Effects on the Use and Value of Private Property. The proposed changes are unlikely to affect the use and value of private property.
Real Estate Development Costs. The proposed changes would 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 changes would not have costs or other effects on small businesses licensees unless they commit a first-offense.
Alternative Method that Minimizes Adverse Impact. The proposed changes would not impose adverse impacts on small businesses unless they commit a first-offense. There is no known alternative to minimize the adverse impact on such businesses while accomplishing the same goals.
Adverse Impacts:
Businesses. The proposed changes would not impose adverse impacts on non-small business licensees unless they commit a first-offense.
Localities. The proposed changes would not adversely affect localities.
Other Entities. The proposed changes would not adversely affect other entities.
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1http://lis.virginia.gov/cgi-bin/legp604.exe?171+ful+CHAP0698
2Ibid.
Agency's Response to Economic Impact Analysis: The Virginia Alcoholic Beverage Control Authority concurs with the Department of Planning and Budget's economic impact analysis.
Summary:
The proposed amendments increase the civil penalty amounts charged in lieu of suspension for first-offense violations for a licensee that has no other pending charges, has not had a violation in three years, and enters a written waiver of hearing. The proposed increases reflect maximums effective July 2017 in § 4.1-227 of the Code of Virginia.
3VAC5-70-210. Schedule of penalties for first-offense violations.
A. Any licensee charged with any violation of board regulations or statutes listed below in this subsection, if the licensee has no other pending charges and has not had any substantiated violations of regulation or statute within the three years immediately preceding the date of the violation, may enter a written waiver of hearing and (i) accept the period of license suspension set forth below in this subsection for the violation, or (ii) pay the civil charge set forth below for the violation in lieu of suspension. In the case of a violation involving the sale of beer, wine, or mixed beverages to a person at least 18 but under younger than 21 years of age, or to an intoxicated person, or allowing consumption of such beverages by such person, any retail licensee that can demonstrate that it provided alcohol seller/server seller or server training certified in advance by the board to the employee responsible for such violation within the 12 months immediately preceding the alleged violation may accept the lesser period of license suspension or pay the lesser civil charge listed below for the violation in lieu of suspension. Any notice of hearing served on a licensee for a violation covered by this section shall contain a notice of the licensee's options under this section. Any licensee who fails to notify the board of its intent to exercise one of the options provided for under this section within 20 days after the date of mailing of the notice of hearing shall be deemed to have waived the right to exercise such options, and the case shall proceed to hearing. For good cause shown, the board may, in its discretion, allow a licensee to exercise the options provided for under this section beyond the 20-day period.
VIOLATION | SUSPENSION | CIVIL CHARGE | SUSPENSION WITH CERTIFIED TRAINING | CIVIL CHARGE WITH CERTIFIED TRAINING |
Sale of beer, wine, or mixed beverages to a person at least 18 butunderyounger than 21 years of age. | 25 days | $2,000$2,500
| 5 days | $1,000$1,500
|
Allowing consumption of beer, wine, or mixed beverages by a person at least 18 butunderyounger than 21 years of age. | 25 days | $2,000$2,500
| 5 days | $1,000$1,500
|
Aiding and abetting the purchase of alcoholic beverages by a person at least 18 butunderyounger than 21 years of age. | 10 days | $1,000$1,250
| | |
Keeping unauthorized alcoholic beverages on the premises, upon which appropriate taxes have been paid. | 7 days | $500$750
| | |
Allow an intoxicated person to loiter on the premises. | 7 days | $500$750
| | |
Sale to an intoxicated person. | 25 days | $2,000$2,500
| 5 days | $1,000$1,500
|
Allow consumption by an intoxicated person. | 25 days | $2,000$2,500
| 5 days | $1,000$1,500
|
After hours sales or consumption of alcoholic beverages. | 10 days | $1,000$1,250
| | |
No designated manager on premises. | 7 days | $500$750
| | |
Invalid check to wholesaler or board. | 7 days | $250$500
| | |
Inadequate illumination. | 7 days | $500$750
| | |
ABC license not posted. | 7 days | $500$750
| | |
Not timely submitting report required by statute or regulation. | 7 days | $500$750
| | |
Designated manager not posted. | 7 days | $500$750
| | |
Personlessyounger than 18years of age serving alcoholic beverages;lessyounger than 21years of age acting as bartender. | 7 days | $500$750
| | |
Sale of alcoholic beverages in unauthorized place or manner. | 10 days | $1,000$1,250
| | |
Consumption of alcoholic beverages in unauthorized area. | 7 days | $500$750
| | |
Removal of alcoholic beverages from authorized area. | 7 days | $500$750
| | |
Failure to obliterate mixed beverage stamps. | 7 days | $500$750
| | |
Employee on duty consuming alcoholic beverages. | 7 days | $500$750
| | |
Conducting illegal happy hour. | 7 days | $500$750
| | |
Illegally advertising happy hour. | 7 days | $500$750
| | |
Unauthorized advertising. | 7 days | $500$750
| | |
Failure to remit statebeer/winebeer or wine tax (if deficiency has been corrected). | 10 days | $1,000$1,250
| | |
Wholesaler sale ofwine/beerbeer or wine in unauthorized manner. | 10 days | $1,000$1,250
| | |
Wholesaler sale ofwine/beerbeer or wine to unauthorized person. | 10 days | $1,000$1,250
| | |
B. For purposes of this section, the Virginia Department of Alcoholic Beverage Control Authority will certify alcohol seller/server seller or server training courses that provide instruction on all the topics listed on the Seller/Server Training Evaluation form. The following steps should be completed to submit a training program for approval:
1. Complete the Alcohol Seller/Server Training Data Sheet and review the Seller/Server Training Evaluation form to make sure the program will meet the listed criteria; and
2. Submit the Alcohol Seller/Server Training Data Sheet and a copy of the proposed training program materials for review. Materials submitted should include copies of any lesson plans and instructional materials used in the training program.
Requests for certification of training courses should be sent to:
VirginiaDepartment of Alcoholic Beverage ControlAuthority |
Education Section |
P.O. Box 27491 |
Richmond, VA 23261 |
Emailcorrespondences: education@abc.virginia.gov |
Persons in charge of any certified alcohol server training course shall maintain complete records of all training classes conducted, including the date and location of each class, and the identity of all those successfully completing the course.
C. For a licensee that operates more than one retail establishment, each such establishment shall be considered a separate licensee for the purpose of this section.
VA.R. Doc. No. R18-5365; Filed February 8, 2019, 7:47 a.m.
TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Proposed Regulation
Titles of Regulations: 12VAC30-10. State Plan under
Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-540).
12VAC30-50. Amount, Duration, and Scope of Medical and
Remedial Care Services (amending 12VAC30-50-20, 12VAC30-50-30,
12VAC30-50-60, 12VAC30-50-70, 12VAC30-50-130, 12VAC30-50-226).
12VAC30-60. Standards Established and Methods Used to Assure
High Quality Care (amending 12VAC30-60-5, 12VAC30-60-50,
12VAC30-60-61).
12VAC30-130. Amount, Duration and Scope of Selected Services (repealing 12VAC30-130-850, 12VAC30-130-860,
12VAC30-130-870, 12VAC30-130-880, 12VAC30-130-890).
Statutory Authority: § 32.1-325 of the Code of Virginia;
42 USC § 1396 et seq.
Public Hearing Information: No public hearings are
scheduled.
Public Comment Deadline: May 3, 2019.
Agency Contact: Emily McClellan, Regulatory Supervisor,
Policy Division, Department of Medical Assistance Services, 600 East Broad
Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)
786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants
to the Board of Medical Assistance Services the authority to administer and
amend the State Plan for Medical Assistance and promulgate regulations. Section
32.1-324 of the Code of Virginia authorizes the Director of the Department of
Medical Assistance Services (DMAS) to administer and amend the State Plan for
Medical Assistance according to the board's requirements and promulgate
regulations. The Medicaid authority as established by § 1902(a) of the Social
Security Act (42 USC § 1396a) provides governing authority for payments
for services.
The agency is proposing this regulatory action to comply with
Item 301 OO and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly. Items
301 PP states: "The Department of Medical Assistance Services shall make
programmatic changes in the provision of Residential Treatment Facility (Level
C) and Levels A and B residential services (group homes) for children with
serious emotional disturbances in order to ensure appropriate utilization and
cost efficiency. The department shall consider all available options including,
but not limited to, prior authorization, utilization review and provider
qualifications. The department shall have authority to promulgate regulations
to implement these changes within 280 days or less from the enactment date of
this act."
Purpose: This regulatory action is essential to protect
the health, safety, or welfare of Medicaid-covered individuals who require
behavioral health services and their families to ensure that families are well
informed about their family member's behavioral health condition about service
options prior to receiving these services, that the services are medically
necessary, and that the services are rendered by providers who use
evidence-based treatment approaches.
When residential treatment services were initially implemented
by DMAS, individuals did not have access to standardized methods of effective
care coordination upon entry into residential treatment due to placement
processes at the time and DMAS reimbursement limitations. This resulted in a
fragmented coordination approach for these individuals who were at risk for
high levels of care and remained at risk of repeated placements at this level
of care. Also, at the time of the appropriations act mandate, the process in
place for Medicaid enrolled children placed in residential settings yielded an
average stay of 260 days and had high readmission rates.
While residential treatment is not a service that should be
approved with great frequency for a large number of individuals, it is a
service that should be accessible to the families and individuals who require
that level of care. The service model had significant operational layers to be
navigated to access residential services. The processes involved coordination
of care by local family access and planning teams (FAPTs) who have, over time,
demonstrated some influence on determining an individual's eligibility for FAPT
funded services. The local influence on the programs administration caused
limitations on individualized freedom of provider choice and inconsistent
authorization of funding for persons deemed to need psychiatric care out of the
home setting. This local administration of the primary referral source for
residential treatment was outside the purview of DMAS, and this situation
produced outcomes that are inadequate to meet Centers for Medicare and Medicaid
Services (CMS) requirements on ensuring the individual freedom of choice of
providers.
Also, the state rules on FAPT composition were not consistent
with the federal Medicaid requirement for certifying a child for
Medicaid-funded residential treatment placement. Changes to the program were
necessary to address concerns that arose from the reliance upon the FAPT to
fulfill the role as the federally mandated independent team to certify
residential treatment.
The residential treatment model requires an enhanced care
coordination model to support the individuals who receive this level of service
to ensure an effective return to the family or caregiver home environment with
follow up services to facilitate ongoing treatment progress in the least
restrictive environment. The added coordination is required to navigate a very
complex service environment for the individual as the individual returns to a
community setting to establish an effective aftercare environment that involves
service providers who may be contracted with a variety of entities such as DMAS
contracted managed care organizations (MCOs), enrolled providers, the local
FAPT team, local school divisions, and the local community services board
(CSB). The proposed amendments allow DMAS to implement a contracted care
coordination team to focus on attaining specific clinical outcomes for all residential
care episodes and to provide a single liaison who will ensure coordination of
care in a complex service environment for individuals upon discharge from
residential treatment and prior to the time when they will enroll in an MCO.
During this transition period, the individual is very vulnerable to repeated
admissions to residential or inpatient care and must be supported in the
fee-for-service (FFS) environment with resources from the local CSB and
enrolled service providers and requires ongoing support and coordination to
receive post-discharge follow up and transition services.
DMAS has the goal that individuals receive the correct level of
service at the correct time for the treatment (service) needs related to the
individual's medical or psychiatric condition. Residential treatment services
consist of behavioral health interventions and are intended to provide high
intensity clinical treatment that should be provided for a short duration.
Stakeholder feedback supported observations by DMAS of lengthy durations of
stay for many individuals. Residential treatment services will benefit from
clarification of the service definition and eligibility requirements to ensure
that residential treatment does not evolve into a long-term level of support
instead of the high intensity psychiatric treatment modality that defines this
level of care.
Substance: The sections of the State Plan for Medical
Assistance that are affected by this action are: Inspection of Care in
Intermediate Care Facilities (12VAC30-10-540), Mandatory Coverage:
Categorically Needy and other required special groups (12VAC30-30-10), the
Amount, Duration, and Scope of Medical and Remedial Services Provided to
Categorically/Medically Needy Individuals-EPSDT Services (12VAC30-50-130);
Applicability of utilization review requirements (12VAC30-60-5), Utilization
control: Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and
Institutions for Mental Disease (IMD) (12VAC30-60-50) and Services related to
the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT);
community mental health services for children (12VAC30-60-61). The state-only
regulations that are affected by this action are Residential Psychiatric
Treatment for Children and Adolescents (plans of care; review of plans of care
(12VAC30-130-850 through 130-890).
The proposed regulatory action will serve to better clarify
policy interpretations that revise program standards to allow for more evidence
based service delivery, allow DMAS to implement more effective utilization
management in collaboration with the BHSA, enhance individualized coordination
of care, implement standardized coordination of individualized aftercare
resources by ensuring access to medical and behavioral health service providers
in the individual's home community, and support DMAS audit practices. The
proposed regulatory changes move toward a service model that will reduce
lengths of stay and facilitate an evidence based treatment approach to better
support the individual's discharge into their home environment. These changes
also align DMAS in meeting the requirements set forth by the Centers for
Medicare and Medicaid Services (CMS) in 42 CFR 441 Subpart D and 42 CFR
441.453.
The proposed regulatory action incorporates changes made in the
emergency regulation, including changes to the following areas: (i) provider
qualifications including acceptable licensing standards; (ii) preadmission
assessment requirements, (iii) program requirements; (iv) new discharge
planning and care coordination requirements; and (iv) language enhancements for
utilization review requirements to clarify program requirements, to ensure
adequate documentation of service delivery, and to help providers avoid payment
retractions. These changes are part of a review of the services to ensure that
services are effectively delivered and utilized for individuals who meet the
medical necessity criteria. For each individual seeking residential treatment
treatment needs are assessed with enhanced requirements by the current independent
certification teams who coordinate clinical assessment information and assess
local resources for each individual requesting residential care to determine an
appropriate level of care. The certification teams are also better able to
coordinate referrals for care to determine, in accordance with DOJ
requirements, whether or not the individual seeking services can be safely
served using community based services in the least restrictive setting.
Independent team certifications are conducted prior to the onset of specified
services, as required by CMS guidelines, by the DMAS behavioral health services
administrator.
The proposed regulatory action includes changes to program
requirements that ensure that effective levels of care coordination and
discharge planning occurs for each individual during the individual's
residential stay by enhancing program rules and utilization management
principles that facilitate effective discharge planning, family engagement and
establish community-based services prior to the individual's discharge from
residential care. The proposed regulatory action requires enhanced care
coordination to provide the necessary objective evaluations of treatment
progress and to facilitate evidence based practices during the treatment to
reduce the length of stay by ensuring that medical necessity indicates the
correct level of care and that appropriate and effective care is delivered in a
person centered manner. The proposed regulatory action requires that service
providers and local systems use standardized preadmission and discharge
processes to ensure effective services are delivered.
Issues: The primary advantages of the proposed
regulatory action to the Commonwealth and to Medicaid members are that the
proposed amendments (i) better clarify policy interpretations that revise
program standards to allow for more evidence based service delivery, (ii) allow
DMAS to implement more effective utilization management in collaboration with
the behavioral health services administrator, (iii) enhance individualized
coordination of care and implement standardized coordination of individualized
aftercare resources by ensuring access to medical and behavioral health service
providers in the individual's home community, (iv) support DMAS audit
practices, and (v) move toward a service model that will reduce lengths of stay
and facilitate an evidence based treatment approach to better support the
individual's discharge into their home environment. There are no disadvantages
to the Commonwealth or the public as a result of the proposed regulatory
action.
Department of Planning and Budget's Economic Impact
Analysis:
Summary of the Proposed Amendments to Regulation. Pursuant to
legislative mandates, the Board of Medical Assistance Services (Board) proposes
numerous changes to the provision of psychiatric residential treatment
services. These changes were already implemented under an emergency regulation
on July 1, 2017.1 The proposed regulation is a permanent replacement
for the emergency regulation.
Result of Analysis. The benefits likely exceed the costs for
the proposed amendments.
Estimated Economic Impact. Pursuant to Item 301 OO paragraphs 7
through 18 and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly, the
Board proposes to eliminate Level A group homes as they did not meet the
federal Centers for Medicare and Medicaid Services requirements and to change
the definition of "Level B" group homes to "Therapeutic Group
Homes." In response to the legislative mandates, the Board also proposes
changes to plan of care requirements, medical necessity requirements, discharge
planning, required clinical activities and documentation for Therapeutic Group
Homes (TGH); changes to Early and Periodic Screening, Diagnostic and Treatment
criteria, Independent Assessment, Certification and Coordination Team (IACCT)
provider requirements and required activities, admission practices, and plan of
care requirements for Psychiatric Residential Treatment Facilities (PRTF); and
changes to service authorization and continued stay requirements both for PRTF
and TGH.
According to DMAS, since 2001, when residential treatment
services were first implemented, individuals have not had access to
standardized methods of effective care coordination upon entry into residential
treatment due to locality influence and DMAS reimbursement limitations. This
has resulted in a fragmented coordination approach for these individuals who
are at risk for high level care and remain at risk of repeated placements at
this level of care. The residential treatment prior authorization and
utilization management structures require an enhanced care coordination model
to support the individuals who receive this level of service to ensure an
effective return to the family or caregiver home environment with follow up
services to facilitate ongoing treatment progress in the least restrictive
environment. The added coordination is required to navigate a very complex
service environment for the individual as they return to a community setting to
establish an effective aftercare environment that involves service providers
who may be contracted with a variety of entities such as managed care
organizations, enrolled providers, the local Family Assessment and Planning
Team (FAPT), local school divisions and the local Community Service Boards.
DMAS states that FAPT composition prior to the emergency
regulation was not consistent with the federal Medicaid requirement for
certifying a child for a Medicaid-funded residential treatment placement.
Changes to the program were necessary to address the concerns that arose from
the reliance upon the FAPT to fulfill the role as the federally mandated
independent team to certify residential treatment. The emergency regulation
implemented the IACCT approach to attain specific clinical outcomes for all
residential care episodes prior to managed care enrollment thorough discharge
from residential treatment. IACCT ensures meaningful communication across all
parts of the Children's Services Act providers, Department of Behavioral Health
and Developmental Services, Managed Care Organizations, and fee-for-servicer
systems to maximize efficiency of activities, eliminate duplicative and/or
conflicting efforts, and ensure established timelines are met. In addition, the
Virginia Independent Clinical Assessment Program (VICAP) process was originally
used to streamline high quality comprehensive assessments for services;
however, VICAP was sunset in order to use funds to pay for the IACCT.
These proposed changes are intended to ensure appropriate
utilization and cost efficiencies. Prior to the emergency regulation, the total
expenditures relating to the affected services were approximately $113 million.
In fiscal year 2018, the total expenditures decreased to $89.2 million. While
the precise total financial impact of these changes have not been quantified,
available data show that members utilizing PRTF have decreased from 1,104 in
the first quarter of 2016 to 887 in the third quarter of 2018 (a 20%
reduction); that members utilizing TGH have decreased from 349 in the first
quarter of 2016 to 311 in the third quarter of 2018 (an 11% reduction); that
members utilizing Level A group homes have decreased from 349 in the first
quarter of 2016 to 0 in the third quarter of 2018 (because it was completely
eliminated); that average length of stay in PRTF decreased from 215.2 days to
209 days (a 6.2-day reduction); and that average length of stay in TGH
decreased from 142.8 days to 120.9 days (a 21.9-day reduction).
Moreover, between September 2017 and August 2018, 3,231 IACCT
inquiries were received; 2,353 of these inquiries were referred for assessment.
Primary reasons for inquiries not leading to assessment included families not
returning calls, families deciding to continue with community services instead,
members being placed in juvenile detention, and families declining residential
services; 2,009 of the assessments recommended a residential placement (1,421
PRTF and 588 in a TGH). The remaining 344 individuals who received an
assessment but were not recommended for a residential placement, were
recommended for community services.
According to DMAS, the proposed changes are essential for
compliance with 42 CFR 441.153, which is prerequisite for federal match and for
members to receive services as appropriate.
Finally, this regulation has not been updated since 2001 when
psychiatric residential treatment services were first provided. Since then
major changes have occurred such as provision of behavioral health services
through Magellan, the Behavioral Health Service Administrator, implementation
of more evidence based service delivery systems, enhanced individualized
coordination of care, audit practices, etc. As a result, the proposed changes
also clarify provider qualifications including licensing standards; preadmission
assessment requirements, program requirements, discharge planning and care
coordination requirements in greater detail. Changes such as those are not
expected to create any significant economic impact upon promulgation of this
regulation. Added clarity of the regulatory requirements however would improve
compliance and produce a net benefit.
Businesses and Entities Affected. This regulation applies to 90
therapeutic group homes, 18 residential treatment facilities, 23 organizations
(including Community Service Boards, Comprehensive Services Act providers, and
private entities) providing Independent Assessment Certification and
Coordination services, and 128 Family Assessment and Planning Teams.
Localities Particularly Affected. No locality should be
affected any more than others.
Projected Impact on Employment. The proposed amendments were
implemented in July 2017. No impact on employment is expected upon promulgation
of the proposed amendments. However, the implementation of the emergency
regulations may have had a negative impact on group homes' and residential
treatment facilities' demand for labor to the extent it improved efficiencies
and eliminated duplicative and/or conflicting efforts. The establishment of the
IACCT approach should have added to demand for labor for them to perform their
functions.
Effects on the Use and Value of Private Property. No effects on
the use and value of private property is expected upon promulgation of the
proposed amendments.
Real Estate Development Costs. No impact on real estate
development costs is expected.
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 amendments do not impose
costs on small businesses; however, to the extent they improve efficiencies and
eliminate duplicative and/or conflicting efforts, they may reduce group homes
and residential treatment facility revenues.
Alternative Method that Minimizes Adverse Impact. There is no
known alternative method that would minimize the adverse impact while
accomplishing the same goals.
Adverse Impacts:
Businesses. The proposed amendments should not adversely affect
businesses upon promulgation.
Localities. The proposed amendments do not adversely affect
localities.
Other Entities. The proposed amendments do not adversely affect
other entities.
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1http://townhall.virginia.gov/L/viewstage.cfm?stageid=7424
Agency's Response to Economic Impact Analysis: The
agency has reviewed the economic impact analysis prepared by the Department of
Planning and Budget and raises no issues with this analysis.
Summary:
The proposed regulatory action implements Items 301 OO and
301 PP of Chapter 665 of the 2015 Acts of Assembly, which required the
department to develop and implement a care coordination model and make
programmatic changes in the provision of residential treatment for children.
The proposed action replaces emergency regulations published in 33:13 VA.R. 1436-1469 February 20, 2017,
and extended in 35:9 VA.R. 1130 December 24, 2018.
The proposed amendments clarify policy interpretations and
revise program standards to allow for more evidence-based service delivery,
allow the department to implement more effective utilization management in
collaboration with the behavioral health service administrator, enhance
individualized coordination of care, implement standardized coordination of
individualized aftercare resources by ensuring access to medical and behavioral
health service providers in the individual's home community, and support
department audit practices. The proposed action meets the requirements set
forth by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR
441 Subpart D and 42 CFR 441.453.
The proposed amendments include changes to the following
areas: (i) provider qualifications, including acceptable licensing standards;
(ii) preadmission assessment requirements; (iii) program requirements; (iv) new
discharge planning and care coordination requirements; and (v) language
enhancements for utilization review requirements to clarify program
requirements, ensure adequate documentation of service delivery, and help
providers avoid payment retractions.
The proposed action requires enhanced care coordination to
provide the necessary objective evaluations of treatment progress and to
facilitate evidence-based practices during the treatment to reduce the length
of stay by ensuring that medical necessity indicates the correct level of care,
that appropriate and effective care is delivered in a person centered manner,
and that service providers and local systems use standardized preadmission and
discharge processes to ensure effective services are delivered.
12VAC30-10-540. Inspection of care in intermediate care
facilities for the mentally retarded persons with intellectual and
developmental disabilities, facilities providing inpatient psychiatric
services for individuals under younger than 21 years of age,
and mental hospitals.
All applicable requirements of 42 CFR 456, Subpart I,
are met with respect to periodic inspections of care and services.*
Inpatient psychiatric services for individuals under age
21 are not provided under this plan.
*Inspection of Care (IOC) in Intermediate Care Facilities
for the Mentally Retarded and Institutions for Mental Diseases are Inspection
of care in intermediate care facilities for persons with intellectual and
developmental disabilities is completed through contractual arrangements
with the Virginia Department of Health.
12VAC30-50-20. Services provided to the categorically needy
without limitation.
The following services as described in Part III
(12VAC30-50-100 et seq.) of this chapter are provided to the categorically
needy without limitation:
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Services for individuals age 65 years of age
or over older in institutions for mental diseases: inpatient
hospital services; skilled nursing facility services; and services in an
intermediate care facility.
3. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined, in
accordance with § 1902(a)(31)(A) of the Social Security Act (the Act),
to be in need of such care, including such services in a public institution (or
distinct part thereof) for the mentally retarded or persons with intellectual
or developmental disability or related conditions.
4. Hospice care (in accordance with § 1905(o) of the Act).
5. Any other medical care and any type of remedial care recognized
under state law, specified by the U.S. Secretary of Health and Human
Services: care and services provided in religious nonmedical health care
institutions;, nursing facility services for patients under
younger than 21 years of age;, or emergency hospital
services.
6. Private health insurance premiums, coinsurance, and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
7. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for categorically needy individuals without limitation.
8. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21
years of age.
12VAC30-50-30. Services not provided to the categorically
needy.
The following services and devices are not provided to the
categorically needy:
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Other diagnostic and preventive services other than those
provided elsewhere in this plan: diagnostic services (see 12VAC30-50-95 et
seq.).
5. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
6. Special tuberculosis (TB) related services under § 1902(z)(2)(F)
of the Social Security Act (the Act).
7. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
8. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
9. Any other medical care and any type of remedial care
recognized under state law specified by the U.S. Secretary of Health
and Human Services: personal care services in recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12VAC30-50-60. Services provided to all medically needy groups
without limitations.
Services as described in Part III (12VAC30-50-100 et seq.) of
this chapter are provided to all medically needy groups without limitations.
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Early and periodic screening and diagnosis of individuals under
younger than 21 years of age, and treatment of conditions found.
3. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
4. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the
Act) to be in need of such care.
5. Hospice care (in accordance with § 1905(o) of the Act).
6. Any other medical care or any other type of remedial care
recognized under state law, specified by the secretary U.S. Secretary
of Health and Human Services, including: care and services provided in
religious nonmedical health care institutions;, skilled nursing
facility services for patients under younger than 21 years of age;,
and emergency hospital services.
7. Private health insurance premiums, coinsurance and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
8. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for medically needy individuals without limitation.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21 years
of age.
12VAC30-50-70. Services or devices not provided to the
medically needy.
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Diagnostic or preventive services other than those provided
elsewhere in the State Plan.
5. Inpatient hospital services, skilled nursing facility
services, and intermediate care facility services for individuals age 65
years of age or older in institutions for mental disease(s) diseases.
6. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the Act),
to be in need of such care in a public institution, or a distinct part thereof,
for the mentally retarded or persons with intellectual or
developmental disability or related conditions.
7. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
8. Special tuberculosis (TB) services under §
1902(z)(2)(F) of the Act.
9. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
10. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
11. Personal care services in a recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12. Home and community care for functionally disabled elderly
individuals, as defined, described and limited in 12VAC30-50-460 and
12VAC30-50-470.
13. Personal care services furnished to an individual who is
not an inpatient or resident of a hospital, nursing facility, intermediate care
facility for the mentally retarded intellectually or developmentally
disabled persons, or institution for mental disease that are (i) authorized
for the individual by a physician in accordance with a plan of treatment, (ii)
provided by an individual who is qualified to provide such services and who is
not a member of the individual's family, and (iii) furnished in a home.
12VAC30-50-130. Nursing facility services, EPSDT, including
school health services, and family planning.
A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or
performed within the scope of a license of the practitioner of the healing
arts.
B. Early General provisions for early and
periodic screening and, diagnosis, and treatment (EPSDT)
of individuals younger than 21 years of age, and treatment of conditions
found.
1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid
eligible, for medically necessary stays in acute care facilities,
and the accompanying attendant physician care, in excess of 21 days per
admission when such services are rendered for the purpose of diagnosis and
treatment of health conditions identified through a physical examination.
2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local departments
of social services departments on specific referral from those
departments.
3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department DMAS shall place appropriate
utilization controls upon this service.
4. Consistent with § 6403 of the Omnibus Budget
Reconciliation Act of 1989 § 6403, early and periodic screening,
diagnostic, and treatment services means the following services: screening
services, vision services, dental services, hearing services, and such other
necessary health care, diagnostic services, treatment, and other measures
described in Social Security Act § 1905(a) to correct or ameliorate defects and
physical and mental illnesses and conditions discovered by the screening
services and that are medically necessary, whether or not such services are
covered under the State Plan and notwithstanding the limitations, applicable to
recipients ages 21 years of age and older, provided for by §
1905(a) of the Social Security Act.
5. C. Community mental health services provided
through early and periodic screening diagnosis and treatment (EPSDT) for
individuals younger than 21 years of age. These services in order to be
covered (i) shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and (ii) are
shall be reflected in provider records and on providers' provider
claims for services by recognized diagnosis codes that support and are
consistent with the requested professional services.
a. 1. Definitions. The following words and terms
when used in this section shall have the following meanings unless the context
clearly indicates otherwise:
"Activities of daily living" means personal care
activities and includes bathing, dressing, transferring, toileting, feeding,
and eating.
"Adolescent or child" means the individual
receiving the services described in this section. For the purpose of the use of
these terms this term, adolescent means an individual 12 through
20 years of age; a child means an individual from birth up to 12 years of
age.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.
"Care coordination" means the collaboration
and sharing of information among health care providers, who are involved
with an individual's health care, to improve the care.
"Caregiver" means the same as defined
in 12VAC30-130-5160.
"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.
"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Child" means an individual ages birth through 11
years.
"DBHDS" means the Department of Behavioral Health
and Developmental Services.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined
in 12VAC35-105-20 with at least two consecutive years of documented
experience as a QMHP, and who has documented completion of the DBHDS PRS
supervisor training; or (iii) shall be an LMHP who has documented completion of
the DBHDS PRS supervisor training who is acting within his scope of practice
under state law. An LMHP providing services before April 1, 2018, shall have
until April 1, 2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractors.
"EPSDT" means early and periodic screening,
diagnosis, and treatment.
"Family support partners" means the same as defined
in 12VAC30-130-5170.
"Human services field" means the same as the term is
defined by DBHDS the Department of Health Professions in the
document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013 Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment practitioners.
An LMHP-resident shall be in continuous compliance with the regulatory
requirements of the applicable counseling profession for supervised practice
and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title "Resident"
in connection with the applicable profession after their signatures to indicate
such status.
"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the supervision
for specific clinical duties at a specific site has been preapproved in writing
by the Virginia Board of Psychology. For purposes of Medicaid reimbursement
by supervisors for services provided by such residents, they shall use the
title "Resident in Psychology" after their signatures to indicate
such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status,
staff interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.
"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.
"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.
"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590 including a
"QMHP-trainee" as defined by the Department of Health Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member as appropriate, about
the child's or adolescent's mental health status. It includes documented
history of the severity, intensity, and duration of mental health care problems
and issues and shall contain all of the following elements: (i) the presenting issue/reason
issue or reason for referral, (ii) mental health
history/hospitalizations, (iii) previous interventions by providers and
timeframes and response to treatment, (iv) medical profile, (v) developmental
history including history of abuse, if appropriate, (vi) educational/vocational
educational or vocational status, (vii) current living situation and
family history and relationships, (viii) legal status, (ix) drug and alcohol
profile, (x) resources and strengths, (xi) mental status exam and profile,
(xii) diagnosis, (xiii) professional summary and clinical formulation, (xiv)
recommended care and treatment goals, and (xv) the dated signature of the LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
"Services provided under arrangement" means the
same as defined in 12VAC30-130-850.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
b. 2. Intensive in-home services (IIH) to
children and adolescents younger than 21 years of age shall be time-limited
interventions provided in the individual's residence and when clinically
necessary in community settings. All interventions and the settings of the
intervention shall be defined in the Individual Service Plan. All IIH services
shall be designed to specifically improve family dynamics, and
provide modeling, and the clinically necessary interventions that
increase functional and therapeutic interpersonal relations between family
members in the home. IIH services are designed to promote psychoeducational
benefits of psychoeducation in the home setting of an individual who is
at risk of being moved into an out-of-home placement or who is being transitioned
to home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his the individual's parents or guardians, as appropriate, to
understand and practice appropriate problem solving, anger management, and
interpersonal interaction, etc.); care coordination with other required
services; and 24-hour emergency response.
(1) a. Service authorization shall be required
for Medicaid reimbursement prior to the onset of services. Services rendered
before the date of authorization shall not be reimbursed.
(2) b. Service-specific provider intakes shall
be required prior to the start of services at the onset of services and
ISPs shall be required during the entire duration of services. Services based
upon incomplete, missing, or outdated service-specific provider intakes or ISPs
shall be denied reimbursement. Requirements for service-specific provider
intakes and ISPs are set out in this section.
(3) c. These services may shall
only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C,
or a QMHP-E.
c. 3. Therapeutic day treatment (TDT) shall be
provided two or more hours per day in order to provide therapeutic
interventions (a unit is defined in 12VAC30-60-61 D 11). Day treatment
programs provide evaluation; medication education and management; opportunities
to learn and use daily living skills and to enhance social and interpersonal
skills (e.g., problem solving, anger management, community responsibility,
increased impulse control, and appropriate peer relations, etc.); and
individual, group, and family counseling.
(1) a. Service authorization shall be required
for Medicaid reimbursement.
(2) b. Service-specific provider intakes shall
be required at prior to the onset start of services,
and ISPs shall be required during the entire duration of services. Services
based upon incomplete, missing, or outdated service-specific provider intakes
or ISPs shall be denied reimbursement. Requirements for service-specific
provider intakes and ISPs are set out in this section.
(3) c. These services may shall be
rendered only by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or
a QMHP-E.
d. Community-based services for children and adolescents
younger than 21 years of age (Level A) pursuant to 42 CFR 440.031(d).
(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.
(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.
(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.
(5) Room and board costs shall not be reimbursed. DMAS
shall reimburse only for services provided in facilities or programs with no
more than 16 beds.
(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).
(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include development or maintenance of daily living skills, anger management,
social skills, family living skills, communication skills, stress management,
and any care coordination activities.
(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
(9) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.
(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.
D. Therapeutic group home services and psychiatric
residential treatment facility (PRTF) services for early and periodic screening
diagnosis and treatment (EPSDT) of individuals younger than 21 years of age.
1. Definitions. The following words and terms when used in
this subsection shall have the following meanings:
"Active treatment" means implementation of an
initial plan of care (IPOC) and comprehensive individual plan of care (CIPOC).
"Assessment" means the face-to-face interaction
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S to obtain information from the child or
adolescent and parent, guardian, or other family member, as appropriate,
utilizing a tool or series of tools to provide a comprehensive evaluation and review
of the child's or adolescent's mental health status. The assessment shall
include a documented history of the severity, intensity, and duration of mental
health problems and behavioral and emotional issues.
"Certificate of need" or "CON" means a
written statement by an independent certification team that services in a
therapeutic group home or PRTF are or were needed.
"Combined treatment services" means a structured,
therapeutic milieu and planned interventions that promote (i) the development
or restoration of adaptive functioning, self-care, and social skills; (ii)
community integrated activities and community living skills that each
individual requires to live in less restrictive environments; (iii) behavioral
consultation; (iv) individual and group therapy; (v) skills restoration, the
restoration of coping skills, family living and health awareness, interpersonal
skills, communication skills, and stress management skills; (vi) family
education and family therapy; and (vii) individualized treatment planning.
"Comprehensive individual plan of care" or
"CIPOC" means a person centered plan of care that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Crisis" means a deteriorating or unstable
situation that produces an acute, heightened emotional, mental, physical,
medical, or behavioral event.
"Crisis management" means immediately provided
activities and interventions designed to rapidly manage a crisis. The
activities and interventions include behavioral health care to provide
immediate assistance to individuals experiencing acute behavioral health
problems that require immediate intervention to stabilize and prevent harm and
higher level of acuity. Activities shall include assessment and short-term
counseling designed to stabilize the individual. Individuals are referred to
long-term services once the crisis has been stabilized.
"Daily supervision" means the supervision
provided in a PRTF through a resident-to-staff ratio approved by the Office of
Licensure at the Department of Behavioral Health and Developmental Services
with documented supervision checks every 15 minutes throughout a 24-hour
period.
"Discharge planning" means family and
locality-based care coordination that begins upon admission to a PRTF or
therapeutic group home with the goal of transitioning the individual out of the
PRTF or therapeutic group home to a less restrictive care setting with
continued, clinically-appropriate, and possibly intensive, services as soon as
possible upon discharge. Discharge plans shall be recommended by the treating
physician, psychiatrist, or treating LMHP responsible for the overall supervision
of the plan of care and shall be approved by the DMAS contractor.
"DSM-5" means the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric
Association.
"Emergency admissions" means those admissions that
are made when, pending a review for the certificate of need, it appears that
the individual is in need of an immediate admission to a therapeutic group home
or PRTF and likely does not meet the medical necessity criteria to receive
crisis intervention, crisis stabilization, or acute psychiatric inpatient
services.
"Emergency services" means unscheduled and
sometimes scheduled crisis intervention, stabilization, acute psychiatric
inpatient services, and referral assistance provided over the telephone or
face-to-face if indicated, and available 24 hours a day, seven days per week.
"Family engagement" means a family-centered and
strengths-based approach to partnering with families in making decisions,
setting goals, achieving desired outcomes, and promoting safety, permanency,
and well-being for children, adolescents, and families. Family engagement
requires ongoing opportunities for an individual to build and maintain
meaningful relationships with family members, for example, frequent,
unscheduled, and noncontingent telephone calls and visits between an individual
and family members. Family engagement may also include enhancing or
facilitating the development of the individual's relationship with other family
members and supportive adults responsible for the individual's care and
well-being upon discharge.
"Family engagement activity" means an
intervention consisting of family psychoeducational training or coaching,
transition planning with the family, family and independent living skills, and
training on accessing community supports as identified in the plan of care.
Family engagement activity does not include and is not the same as family
therapy.
"Family therapy" means counseling services
involving the individual's family and significant others to advance the
treatment goals when (i) the counseling with the family member and significant
others is for the direct benefit of the individual, (ii) the counseling is not
aimed at addressing treatment needs of the individual's family or significant
others, and (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals. Family therapy shall be aligned with the goals of
the individual's plan of care. All family therapy services furnished are for
the direct benefit of the individual, in accordance with the individual's needs
and treatment goals identified in the individual's plan of care, and for the
purpose of assisting in the individual's recovery.
"FAPT" means the family assessment and planning
team.
"ICD-10" means International Statistical
Classification of Diseases and Related Health Problems, 10th Revision,
published by the World Health Organization.
"Independent certification team" means a team
that has competence in diagnosis and treatment of mental illness, preferably in
child psychiatry; has knowledge of the individual's situation; and is composed
of at least one physician and one LMHP. The independent certification team
shall be a DMAS-authorized contractor with contractual or employment
relationships with the required team members.
"Individual" means the child or adolescent
younger than 21 years of age who is receiving therapeutic group home or PRTF
services.
"Individual and group therapy" means the
application of principles, standards, and methods of the counseling profession
in (i) conducting assessments and diagnosis for the purpose of establishing
treatment goals and objectives and (ii) planning, implementing, and evaluating
plans of care using treatment interventions to facilitate human development and
to identify and remediate mental, emotional, or behavioral disorders and
associated distresses that interfere with mental health.
"Initial plan of care" or "IPOC" means
a person centered plan of care established at admission that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Intervention" means scheduled therapeutic
treatment such as individual or group psychoeducation; skills restoration;
structured behavior support and training activities; recreation, art, and music
therapies; community integration activities that promote or assist in the
child's or adolescent's ability to acquire coping and functional or
self-regulating behavior skills; day and overnight passes; and family
engagement activities. Interventions shall not include individual, group, and
family therapy; medical or dental appointments; or physician services,
medication evaluation, or management provided by a licensed clinician or
physician and shall not include school attendance. Interventions shall be
provided in the therapeutic group home or PRTF and, when clinically necessary,
in a community setting or as part of a therapeutic pass. All interventions and
settings of the intervention shall be established in the plan of care.
"Plan of care" means the initial plan of care
(IPOC) and the comprehensive individual plan of care (CIPOC).
"Physician" means an individual licensed to
practice medicine or osteopathic medicine in Virginia, as defined in §
54.1-2900 of the Code of Virginia.
"Psychiatric residential treatment facility" or
"PRTF" means the same as defined in 42 CFR 483.352 and is a 24-hour,
supervised, clinically and medically necessary, out-of-home active treatment
program designed to provide necessary support and address mental health,
behavioral, substance abuse, cognitive, and training needs of an individual
younger than 21 years of age in order to prevent or minimize the need for more
intensive treatment.
"Recertification" means a certification for each
applicant or recipient for whom therapeutic group home or PRTF services are
needed.
"Room and board" means a component of the total
daily cost for placement in a licensed PRTF. Residential room and board costs
are maintenance costs associated with placement in a licensed PRTF and include
a semi-private room, three meals and two snacks per day, and personal care
items. Room and board costs are reimbursed only for PRTF settings.
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in a freestanding psychiatric hospital or PRTF that
are billed by the arranged practitioners separately from the freestanding
psychiatric hospital's or PRTF's per diem.
"Skills restoration" means a face-to-face service
to assist individuals in the restoration of lost skills that are necessary to
achieve the goals established in the beneficiary's plan of care. Services
include assisting the individual in restoring self-management, interpersonal,
communication, and problem solving skills through modeling, coaching, and
cueing.
"Therapeutic group home" means a congregate
residential service providing 24-hour supervision in a community-based home
having eight or fewer residents.
"Therapeutic pass" means time at home or
time with family consisting of partial or entire days of time away from the
therapeutic group home or psychiatric residential treatment facility as
clinically indicated in the plan of care and as paired with facility-based and
community-based interventions to promote discharge planning, community
integration, and family engagement activities. Therapeutic passes are not
recreational but are a therapeutic component of the plan of care and are
designed for the direct benefit of the individual.
"Treatment planning" means development of a
person centered plan of care that is specific to the individual's unique
treatment needs and acuity levels.
e. 2. Therapeutic behavioral group
home services (Level B) pursuant to 42 CFR 440.130(d).
(1) Such services must be therapeutic services rendered in
a residential setting. The residential services will provide structure for
daily activities, psychoeducation, therapeutic supervision, care coordination,
and psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual ® Criteria, or an equivalent standard authorized in advance by DMAS
shall be required for this service.
(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.
(3) a. Therapeutic group home services for children
and adolescents younger than 21 years of age shall provide therapeutic services
to restore or maintain appropriate skills necessary to promote prosocial
behavior and healthy living, including skills restoration, family living and
health awareness, interpersonal skills, communication skills, and stress
management skills. Therapeutic services shall also engage families and reflect
family-driven practices that correlate to sustained positive outcomes
post-discharge for youth and their family members. Each component of
therapeutic group home services is provided for the direct benefit of the
individual, in accordance with the individual's needs and treatment goals
identified in the individual's plan of care, and for the purpose of assisting
in the individual's recovery. These services are provided under 42 CFR
440.130(d) in accordance with the rehabilitative services benefit.
b. The plan of care shall include individualized
activities, including a minimum of one intervention per 24-hour period in
addition to individual, group, and family therapies. Daily interventions are
not required when there is documentation to justify clinical or medical reasons
for the individual's deviations from the plan of care. Interventions shall be
documented on a progress note and shall be outlined in and aligned with the
treatment goals and objectives in the IPOC and CIPOC. Any deviation from the
plan of care shall be documented along with a clinical or medical justification
for the deviation.
c. Medical necessity criteria for admission to a
therapeutic group home. The following requirements for severity of need and
intensity and quality of service shall be met to satisfy the medical necessity
criteria for admission.
(1) Severity of need required for admission. All of the
following criteria shall be met to satisfy the criteria for severity of need:
(a) The individual's behavioral health condition can only
be safely and effectively treated in a 24-hour therapeutic milieu with onsite
behavioral health therapy due to significant impairments in home, school, and
community functioning caused by current mental health symptoms consistent with
a DSM-5 diagnosis.
(b) The certificate of need must demonstrate all of the
following: (i) ambulatory care resources (all available modalities of treatment
less restrictive than inpatient treatment) available in the community do not
meet the treatment needs of the individual; (ii) proper treatment of the
individual's psychiatric condition requires services on an inpatient basis
under the direction of a physician; and (iii) the services can reasonably be
expected to improve the individual's condition or prevent further regression so
that the services will no longer be needed.
(c) The state uniform assessment tool shall be completed.
The assessment shall demonstrate at least two areas of moderate impairment in
major life activities. A moderate impairment is defined as a major or
persistent disruption in major life activities. A moderate impairment is
evidenced by, but not limited to (i) frequent conflict in the family setting
such as credible threats of physical harm, where "frequent" means
more than expected for the individual's age and developmental level; (ii)
frequent inability to accept age-appropriate direction and supervision from
caretakers, from family members, at school, or in the home or community; (iii)
severely limited involvement in social support, which means significant
avoidance of appropriate social interaction, deterioration of existing
relationships, or refusal to participate in therapeutic interventions; (iv)
impaired ability to form a trusting relationship with at least one caretaker in
the home, school, or community; (v) limited ability to consider the effect of
one's inappropriate conduct on others; and (vi) interactions consistently
involving conflict, which may include impulsive or abusive behaviors.
(d) Less restrictive community-based services have been
given a fully adequate trial and were unsuccessful or, if not attempted, have
been considered, but in either situation were determined to be unable to meet
the individual's treatment needs and the reasons for that are discussed in the
certificate of need.
(e) The individual's symptoms, or the need for treatment in
a 24 hours a day, seven days a week level of care (LOC), are not primarily due
to any of the following: (i) intellectual disability, developmental disability,
or autistic spectrum disorder; (ii) organic mental disorders, traumatic brain
injury, or other medical condition; or (iii) the individual does not require a
more intensive level of care.
(f) The individual does not require primary medical or
surgical treatment.
(2) Intensity and quality of service necessary for admission.
All of the following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The therapeutic group home service has been prescribed
by a psychiatrist, psychologist, or other LMHP who has documented that a
residential setting is the least restrictive clinically appropriate service
that can meet the specifically identified treatment needs of the individual.
(b) The therapeutic group home is not being used for
clinically inappropriate reasons, including (i) an alternative to incarceration
or preventative detention; (ii) an alternative to a parent's, guardian's, or
agency's capacity to provide a place of residence for the individual; or (iii)
a treatment intervention when other less restrictive alternatives are available.
(c) The individual's treatment goals are included in the
service specific provider intake and include behaviorally defined objectives
that require and can reasonably be achieved within a therapeutic group home
setting.
(d) The therapeutic group home is required to coordinate
with the individual's community resources, including schools and FAPT as
appropriate, with the goal of transitioning the individual out of the program
to a less restrictive care setting for continued, sometimes intensive, services
as soon as possible and appropriate.
(e) The therapeutic group home program must incorporate
nationally established, evidence-based, trauma-informed services and supports
that promote recovery and resiliency.
(f) Discharge planning begins upon admission, with concrete
plans for the individual to transition back into the community beginning within
the first week of admission, with clear action steps and target dates outlined
in the plan of care.
(3) Continued stay criteria. The following criteria shall
be met in order to satisfy the criteria for continued stay:
(a) All of the admission guidelines continue to be met and
continue to be supported by the written clinical documentation.
(b) The individual shall meet one of the following
criteria: (i) the desired outcome or level of functioning has not been restored
or improved in the timeframe outlined in the individual's plan of care or the
individual continues to be at risk for relapse based on history or (ii) the
nature of the functional gains is tenuous and use of less intensive services
will not achieve stabilization.
(c) The individual shall meet one of the following
criteria: (i) the individual has achieved initial CIPOC goals, but additional
goals are indicated that cannot be met at a lower level of care; (ii) the
individual is making satisfactory progress toward meeting goals but has not
attained plan of care goals, and the goals cannot be addressed at a lower level
of care; (iii) the individual is not making progress, and the plan of care has
been modified to identify more effective interventions; or (iv) there are
current indications that the individual requires this level of treatment to
maintain level of functioning as evidenced by failure to achieve goals
identified for therapeutic visits or stays in a nontreatment residential
setting or in a lower level of residential treatment.
(d) There is a written, up-to-date discharge plan that (i)
identifies the custodial parent or custodial caregiver at discharge; (ii)
identifies the school the individual will attend at discharge, if applicable;
(iii) includes individualized education program (IEP) and FAPT recommendations,
if necessary; (iv) outlines the aftercare treatment plan (discharge to another
residential level of care is not an acceptable discharge goal); and (v) lists
barriers to community reintegration and progress made on resolving these
barriers since last review.
(e) The active plan of care includes structure for combined
treatment services and activities to ensure the attainment of therapeutic
mental health goals as identified in the plan of care. Combined treatment
services reinforce and practice skills learned in individual, group, and family
therapy such as community integration skills, coping skills, family living and
health awareness skills, interpersonal skills, and stress management skills.
Combined treatment services may occur in group settings, in one-on-one
interactions, or in the home setting during a therapeutic pass. In addition to
the combined treatment services, the child or adolescent must also receive
psychotherapy services, care coordination, family-based discharge planning, and
locality-based transition activities. The child or adolescent shall receive
intensive family interventions at least twice per month, although it is recommended
that the intensive family interventions be provided at a frequency of one
family therapy session per week. Family involvement begins immediately upon
admission to therapeutic group home. If the minimum requirement cannot be met,
the reasons must be reported, and continued efforts to involve family members
must also be documented. Other family members or supportive adults may be
included as indicated in the plan of care.
(f) Less restrictive treatment options have been considered
but cannot yet meet the individual's treatment needs. There is sufficient
current clinical documentation or evidence to show that therapeutic group home
level of care continues to be the least restrictive level of care that can meet
the individual's mental health treatment needs.
(4) Discharge shall occur if any of the following applies:
(i) the level of functioning has improved with respect to the goals outlined in
the plan of care, and the individual can reasonably be expected to maintain
these gains at a lower level of treatment; (ii) the individual no longer
benefits from service as evidenced by absence of progress toward plan of care
goals for a period of 60 days; or (iii) other less intensive services may
achieve stabilization.
d. The following clinical activities shall be required for
each therapeutic group home resident:
(1) An assessment be performed by an LMHP, LMHP-R, LMHP-RP,
or LMHP-S.
(2) A face-to-face evaluation shall be performed by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days prior to admission with
a documented DSM-5 or ICD-10 diagnosis.
(3) A certificate of need shall be completed by an
independent certification team according to the requirements of subdivision D 4
of this section. Recertification shall occur at least every 60 calendar days by
an LMHP, LMHP-R, LMHP-RP, or LMHP-S acting within his scope of practice.
(4) An IPOC that is specific to the individual's unique
treatment needs and acuity levels. The IPOC shall be completed on the day of
admission by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be signed by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual and a family member or
legally authorized representative. The IPOC shall include all of the following:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Orders for medications, psychiatric, medical, dental,
and any special health care needs whether or not provided in the facilities,
treatments, restorative and rehabilitative services, activities, therapies,
therapeutic passes, social services, community integration, diet, and special
procedures recommended for the health and safety of the individual;
(f) Plans for continuing care, including review and
modification to the plan of care; and
(g) Plans for discharge.
(5) A CIPOC shall be completed no later than 14 calendar
days after admission. The CIPOC shall meet all of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and shall reflect the need
for therapeutic group home care;
(b) Be based on input from school, home, other health care
providers, FAPT if necessary, the individual, and the family or legal guardian;
(c) Shall state treatment objectives that include
measurable short-term and long-term goals and objectives, with target dates for
achievement;
(d) Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis; and
(e) Include a comprehensive discharge plan with necessary,
clinically appropriate community services to ensure continuity of care upon
discharge with the individual's family, school, and community.
(6) The CIPOC shall be reviewed, signed, and dated every 30
calendar days by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a
family member or primary caregiver. Updates shall be signed and dated by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a family member or
legally authorized representative. The review shall include all of the
following:
(a) The individual's response to the services provided;
(b) Recommended changes in the plan as indicated by the
individual's overall response to the CIPOC interventions; and
(c) Determinations regarding whether the services being
provided continue to be required.
(7) Crisis management, clinical assessment, and
individualized therapy shall be provided to address both behavioral health and
substance use disorder needs as indicated in the plan of care to address
intermittent crises and challenges within the therapeutic group home setting or
community settings as defined in the plan of care and to avoid a higher level
of care.
(8) Care coordination shall be provided with medical,
educational, and other behavioral health providers and other entities involved
in the care and discharge planning for the individual as included in the plan
of care.
(9) Weekly individual therapy shall be provided in the
therapeutic group home, or other settings as appropriate for the individual's
needs, by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which shall be documented in
progress notes in accordance with the requirements in 12VAC30-60-61.
(10) Weekly (or more frequently if clinically indicated)
group therapy shall be provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which
shall be documented in progress notes in accordance with the requirements in
12VAC30-60-61 and as planned and documented in the plan of care.
(11) Family treatment shall be provided as clinically
indicated, provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, and documented in
progress notes in accordance with the requirements in 12VAC30-60-61 and as
planned and documented in the plan of care.
(12) Family engagement activities shall be provided in
addition to family therapy or counseling. Family engagement activities shall be
provided at least weekly as outlined in the plan of care, and daily
communication with the family or legally authorized representative shall be
part of the family engagement strategies in the plan of care. For each
service authorization period when family engagement is not possible, the therapeutic
group home shall identify and document the specific barriers to the
individual's engagement with the individual's family or legally authorized
representatives. The therapeutic group home shall document on a weekly basis
the reasons why family engagement is not occurring as required. The therapeutic
group home shall document alternative family engagement strategies to be used
as part of the interventions in the plan of care and request approval of the
revised plan of care by DMAS. When family engagement is not possible, the
therapeutic group home shall collaborate with DMAS on a weekly basis to develop
individualized family engagement strategies and document the revised strategies
in the plan of care.
(13) Therapeutic passes shall be provided as clinically indicated
in the plan of care and as paired with facility-based and community-based
interventions to promote discharge planning, community integration, and family
engagement activities.
(a) The provider shall document how the family was prepared
for the therapeutic pass to include a review of the plan of care goals and
objectives being addressed by the planned interventions and the safety and
crisis plan in effect during the therapeutic pass.
(b) If a facility staff member does not accompany the
individual on the therapeutic pass and the therapeutic pass exceeds 24 hours,
the provider shall make daily contacts with the family and be available 24
hours per day to address concerns, incidents, or crises that may arise during
the pass.
(c) Contact with the family shall occur within seven
calendar days of the therapeutic pass to discuss the accomplishments and
challenges of the therapeutic pass along with an update on progress toward plan
of care goals and any necessary changes to the plan of care.
(d) Twenty-four therapeutic passes shall be permitted per
individual, per admission, without authorization as approved by the treating
LMHP and documented in the plan of care. Additional therapeutic passes shall
require service authorization. Any unauthorized therapeutic passes shall result
in retraction for those days of service.
(14) Discharge planning shall begin at admission and
continue throughout the individual's stay at the therapeutic group home. The
family or guardian, the community services board (CSB), the family assessment
and planning team (FAPT) case manager, and the DMAS contracted care manager
shall be involved in treatment planning and shall identify the anticipated
needs of the individual and family upon discharge and available services in the
community. Prior to discharge, the therapeutic group home shall submit an
active and viable discharge plan to the DMAS contractor for review. Once the
DMAS contractor approves the discharge plan, the provider shall begin actively
collaborating with the family or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The therapeutic
group home shall request permission from the parent or legally authorized
representative to share treatment information with these providers and shall
share information pursuant to a valid release. The therapeutic group home shall
request information from post-discharge providers to establish that the
planning of pending services and transition planning activities has begun,
shall establish that the individual has been enrolled in school, and shall
provide individualized education program recommendations to the school if
necessary. The therapeutic group home shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the therapeutic group home.
(15) Room and board costs shall not be reimbursed.
Facilities that only provide independent living services or nonclinical
services that do not meet the requirements of this subsection are not reimbursed
eligible for reimbursement. DMAS shall reimburse only for services
provided in facilities or programs with no more than 16 beds.
(4) These residential (16) Therapeutic group home
services providers must shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) under the Regulations
for Children's Residential Facilities (12VAC35-46).
(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include development or maintenance of daily living skills,
anger management, social skills, family living skills, communication skills,
and stress management. This service may be provided in a program setting or a
community-based group home.
(6) The individual must receive, at least weekly,
individual psychotherapy and, at least weekly, group psychotherapy that is
provided as part of the program.
(7) (17) Individuals shall be discharged from
this service when treatment goals are met or other less intensive
services may achieve stabilization.
(8) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. (18) Services that are based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs plans of care
shall be denied reimbursement. Requirements for intakes and ISPs are set out
in 12VAC30-60-61.
(9) These (19) Therapeutic group home services
may only be rendered by and within the scope of practice of an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH as
defined in 12VAC35-105-20.
(10) (20) The facility/group psychiatric
residential treatment facility or therapeutic group home shall coordinate
necessary services and discharge planning with other providers as
medically and clinically necessary. Documentation of this care coordination
shall be maintained by the facility/group facility or group home
in the individual's record. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted, and
recommended next steps.
(21) Failure to perform any of the items described in this
subsection shall result in a retraction of the per diem for each day of
noncompliance.
3. PRTF services are a 24-hour, supervised, clinically and
medically necessary out-of-home program designed to provide necessary support
and address mental health, behavioral, substance use, cognitive, or other
treatment needs of an individual younger than 21 years of age in order to
prevent or minimize the need for more inpatient treatment. Active treatment and
comprehensive discharge planning shall begin prior to admission. In order to be
covered for individuals younger than 21 years of age, these services shall (i)
meet DMAS-approved psychiatric medical necessity criteria or be approved as an
EPSDT service based upon a diagnosis made by an LMHP, LMHP-R, LMHP-RP, or
LMHP-S who is practicing within the scope of his license and (ii) be reflected
in provider records and on the provider's claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services.
a. PRTF services shall be covered for the purpose of
diagnosis and treatment of mental health and behavioral disorders when such
services are rendered by a psychiatric facility that is not a hospital and is
accredited by the Joint Commission on Accreditation of Healthcare
Organizations, the Commission on Accreditation of Rehabilitation Facilities,
the Council on Accreditation of Services for Families and Children, or by any
other accrediting organization with comparable standards that is recognized by
the state.
b. Providers of PRTF services shall be licensed by DBHDS.
c. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151 (a) and (b) and 42 CFR 441.152 through 42 CFR
441.156 and (ii) the Conditions of Participation in 42 CFR Part 483 Subpart G.
Each admission must be service authorized, and the treatment must meet DMAS
requirements for clinical necessity.
d. The PRTF benefit for individuals younger than 21 years
of age shall include services defined at 42 CFR 440.160 that are provided
under the direction of a physician pursuant to a certification of medical
necessity and plan of care developed by an interdisciplinary team of
professionals and shall involve active treatment designed to achieve the
child's discharge from PRTF services at the earliest possible time. The PRTF
services benefit shall include services provided under arrangement furnished by
Medicaid enrolled providers other than the PRTF, as long as the PRTF (i)
arranges for and oversees the provision of all services, (ii) maintains all
medical records of care furnished to the individual, and (iii) ensures that the
services are furnished under the direction of a physician. Services provided
under arrangement shall be documented by a written referral from the PRTF. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
e. PRTFs, as defined at 42 CFR 483.352, shall arrange for,
maintain records of, and ensure that physicians order these services: (i)
medical and psychological services, including those furnished by physicians,
licensed mental health professionals, and other licensed or certified health
professionals (i.e., nutritionists, podiatrists, respiratory therapists, and
substance abuse treatment practitioners); (ii) pharmacy services; (iii)
outpatient hospital services; (iv) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (v)
laboratory and radiology services; (vi) durable medical equipment; (vii) vision
services; (viii) dental, oral surgery, and orthodontic services; (ix)
nonemergency transportation services; and (x) emergency services.
f. PRTF services shall include assessment and
reassessment; room and board; daily supervision; combined treatment services;
individual, family, and group therapy; care coordination; interventions;
general or special education; medical treatment (including medication,
coordination of necessary medical services, and 24-hour onsite nursing);
specialty services; and discharge planning that meets the medical and clinical
needs of the individual.
g. Medical necessity criteria for admission to a PRTF. The
following requirements for severity of need and intensity and quality of
service shall be met to satisfy the medical necessity criteria for admission:
(1) Severity of need required for admission. The following
criteria shall be met to satisfy the criteria for severity of need:
(a) There is clinical evidence that the individual has a
DSM-5 disorder that is amenable to active psychiatric treatment.
(b) There is a high degree of potential of the condition
leading to acute psychiatric hospitalization in the absence of residential
treatment.
(c) Either (i) there is clinical evidence that the
individual would be a risk to self or others if the individual were not in a
PRTF or (ii) as a result of the individual's mental disorder, there is an
inability for the individual to adequately care for his own physical needs, and
caretakers, guardians, or family members are unable to safely fulfill these
needs, representing potential serious harm to self.
(d) The individual requires supervision seven days per
week, 24 hours per day to develop skills necessary for daily living; to assist
with planning and arranging access to a range of educational, therapeutic, and
aftercare services; and to develop the adaptive and functional behavior that
will allow the individual to live outside of a PRTF setting.
(e) The individual's current living environment does not
provide the support and access to therapeutic services needed.
(f) The individual is medically stable and does not require
the 24-hour medical or nursing monitoring or procedures provided in a hospital
level of care.
(2) Intensity and quality of service necessary for
admission. The following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The evaluation and assignment of a DSM-5 diagnosis must
result from a face-to-face psychiatric evaluation.
(b) The program provides supervision seven days per week,
24 hours per day to assist with the development of skills necessary for daily
living; to assist with planning and arranging access to a range of educational,
therapeutic, and aftercare services; and to assist with the development of the
adaptive and functional behavior that will allow the individual to live outside
of a PRTF setting.
(c) An individualized plan of active psychiatric treatment
and residential living support is provided in a timely manner. This treatment
must be medically monitored, with 24-hour medical availability and 24-hour
nursing services availability. This plan includes (i) at least once-a-week
psychiatric reassessments; (ii) intensive family or support system involvement
occurring at least once per week or valid reasons identified as to why such a
plan is not clinically appropriate or feasible; (iii) psychotropic medications,
when used, are to be used with specific target symptoms identified; (iv)
evaluation for current medical problems; (v) evaluation for concomitant
substance use issues; and (vi) linkage or coordination with the individual's
community resources, including the local school division and FAPT case manager,
as appropriate, with the goal of returning the individual to his regular social
environment as soon as possible, unless contraindicated. School contact should
address an individualized educational plan as appropriate.
(d) A urine drug screen is considered at the time of
admission, when progress is not occurring, when substance misuse is suspected,
or when substance use and medications may have a potential adverse interaction.
After a positive screen, additional random screens are considered and referral
to a substance use disorder provider is considered.
(3) Criteria for continued stay. The following criteria
shall be met to satisfy the criteria for continued stay:
(a) Despite reasonable therapeutic efforts, clinical
evidence indicates at least one of the following: (i) the persistence of
problems that caused the admission to a degree that continues to meet the
admission criteria (both severity of need and intensity of service needs); (ii)
the emergence of additional problems that meet the admission criteria (both
severity of need and intensity of service needs); or (iii) that disposition
planning or attempts at therapeutic reentry into the community have resulted in
or would result in exacerbation of the psychiatric illness to the degree that
would necessitate continued PRTF treatment. Subjective opinions without
objective clinical information or evidence are not sufficient to meet severity
of need based on justifying the expectation that there would be a
decompensation.
(b) There is evidence of objective, measurable, and
time-limited therapeutic clinical goals that must be met before the individual
can return to a new or previous living situation. There is evidence that
attempts are being made to secure timely access to treatment resources and
housing in anticipation of discharge, with alternative housing contingency
plans also being addressed.
(c) There is evidence that the plan of care is focused on
the alleviation of psychiatric symptoms and precipitating psychosocial
stressors that are interfering with the individual's ability to return to a
less-intensive level of care.
(d) The current or revised plan of care can be reasonably
expected to bring about significant improvement in the problems meeting the
criteria in subdivision 3 c (3) (a) of this subsection, and this is documented
in weekly progress notes written and signed by the provider.
(e) There is evidence of intensive family or support system
involvement occurring at least once per week, unless there is an identified
valid reason why it is not clinically appropriate or feasible.
(f) A discharge plan is formulated that is directly linked
to the behaviors or symptoms that resulted in admission and begins to identify
appropriate post-PRTF resources including the local school division and FAPT
case manager as appropriate.
(g) All applicable elements in admission-intensity and
quality of service criteria are applied as related to assessment and treatment
if clinically relevant and appropriate.
(4) Discharge criteria. Discharge shall occur if any of the
following applies: (i) the level of functioning has improved with respect to
the goals outlined in the plan of care, and the individual can reasonably be
expected to maintain these gains at a lower level of treatment; (ii) the
individual no longer benefits from service as evidenced by absence of progress
toward plan of care goals for a period of 30 days; or (iii) other less
intensive services may achieve stabilization.
h. The following clinical activities shall be required for
each PRTF resident:
(1) A face-to-face assessment shall be performed by an
LMHP, LMHP-R, LMHP-RS, or LMHP-S within 30 calendar days prior to admission and
weekly thereafter and shall document a DSM-5 or ICD-10 diagnosis.
(2) A certificate of need shall be completed by an independent
certification team according to the requirements of 12VAC30-50-130 D 4.
Recertification shall occur at least every 30 calendar days by a physician
acting within his scope of practice.
(3) The initial plan of care (IPOC) shall be completed
within 24 hours of admission by the treatment team. The IPOC shall
include:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Any orders for medications, psychiatric, medical,
dental, and any special health care needs, whether or not provided in the
facility; education or special education; treatments; interventions; and
restorative and rehabilitative services, activities, therapies, social
services, diet, and special procedures recommended for the health and safety of
the individual;
(f) Plans for continuing care, including review and
modification to the plan of care;
(g) Plans for discharge; and
(h) Signature and date by the individual, parent, or
legally authorized representative, a physician, and treatment team members.
(4) The CIPOC shall be completed and signed no later than
14 calendar days after admission by the treatment team. The PRTF shall request
authorizations from families to release confidential information to collect information
from medical and behavioral health treatment providers, schools, FAPT, social
services, court services, and other relevant parties. This information shall be
used when considering changes and updating the CIPOC. The CIPOC shall meet all
of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for PRTF care;
(b) Be developed by an interdisciplinary team of physicians
and other personnel specified in subdivision 3 d 4 of this subsection who are
employed by or provide services to the individual in the facility in
consultation with the individual, family member, or legally authorized representative,
or appropriate others into whose care the individual will be released after
discharge;
(c) Shall state treatment objectives that shall include
measurable, evidence-based, and short-term and long-term goals and objectives;
family engagement activities; and the design of community-based aftercare with
target dates for achievement;
(d) Prescribe an integrated program of therapies,
interventions, activities, and experiences designed to meet the treatment
objectives related to the individual and family treatment needs; and
(e) Describe comprehensive transition plans and
coordination of current care and post-discharge plans with related community
services to ensure continuity of care upon discharge with the recipient's
family, school, and community.
(5) The CIPOC shall be reviewed every 30 calendar days by
the team specified in subdivision 3 d 4 of this subsection to determine that
services being provided are or were required from a PRTF and to recommend
changes in the plan as indicated by the individual's overall adjustment during
the time away from home. The CIPOC shall include the signature and date from
the individual, parent, or legally authorized representative, a physician, and
treatment team members.
(6) Individual therapy shall be provided three times
per week (or more frequently based upon the individual's needs) provided by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of care
and progress notes in accordance with the requirements in this subsection and
12VAC30-60-61.
(7) Group therapy shall be provided as clinically indicated
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of
care and progress notes in accordance with the requirements in this subsection.
(8) Family therapy shall be provided as clinically
indicated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the
plan of care and progress notes in accordance with the individual and family or
legally authorized representative's goals and the requirements in this subsection.
(9) Family engagement shall be provided in addition to
family therapy or counseling. Family engagement shall be provided at least
weekly as outlined in the plan of care and daily communication with the
treatment team representative and the treatment team representative and the
family or legally authorized representative shall be part of the family
engagement strategies in the plan of care. For each service authorization
period when family engagement is not possible, the PRTF shall identify and
document the specific barriers to the individual's engagement with his family
or legally authorized representatives. The PRTF shall document on a weekly
basis the reasons that family engagement is not occurring as required. The PRTF
shall document alternate family engagement strategies to be used as part of the
interventions in the plan of care and request approval of the revised plan of
care by DMAS. When family engagement is not possible, the PRTF shall
collaborate with DMAS on a weekly basis to develop individualized family
engagement strategies and document the revised strategies in the plan of care.
(10) Three interventions shall be provided per 24-hour
period including nights and weekends. Family engagement activities are
considered to be an intervention and shall occur based on the treatment and
visitation goals and scheduling needs of the family or legally authorized
representative. Interventions shall be documented on a progress note and shall
be outlined in and aligned with the treatment goals and objectives in the plan
of care. Any deviation from the plan of care shall be documented along with a
clinical or medical justification for the deviation based on the needs of the
individual.
(11) Therapeutic passes shall be provided as clinically
indicated in the plan of care and as paired with community-based and
facility-based interventions to promote discharge planning, community
integration, and family engagement. Therapeutic passes include activities as
listed in subdivision 2 d (13) of this section. Twenty-four therapeutic passes
shall be permitted per individual, per admission, without authorization as
approved by the treating physician and documented in the plan of care.
Additional therapeutic passes shall require service authorization from DMAS.
Any unauthorized therapeutic passes not approved by the provider or DMAS shall
result in retraction for those days of service.
(12) Discharge planning shall begin at admission and
continue throughout the individual's placement at the PRTF. The parent or
legally authorized representative, the community services board (CSB), the
family assessment planning team (FAPT) case manager, if appropriate, and the
DMAS contracted care manager shall be involved in treatment planning and shall
identify the anticipated needs of the individual and family upon discharge and
identify the available services in the community. Prior to discharge, the PRTF
shall submit an active discharge plan to the DMAS contractor for review. Once
the DMAS contractor approves the discharge plan, the provider shall begin
collaborating with the parent or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The PRTF shall
request written permission from the parent or legally authorized representative
to share treatment information with these providers and shall share information
pursuant to a valid release. The PRTF shall request information from
post-discharge providers to establish that the planning of services and
activities has begun, shall establish that the individual has been enrolled in
school, and shall provide individualized education program recommendations to
the school if necessary. The PRTF shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the PRTF.
(13) Failure to perform any of the items as described in
subdivisions 3 h (1) through 3 h (12) of this subsection up until the discharge
of the individual shall result in a retraction of the per diem and all other
contracted and coordinated service payments for each day of noncompliance.
i. The team developing the CIPOC shall meet the following
requirements:
(1) At least one member of the team must have expertise in
pediatric behavioral health. Based on education and experience, preferably
including competence in child or adolescent psychiatry, the team must be
capable of all of the following: assessing the individual's immediate and
long-range therapeutic needs, developmental priorities, and personal strengths
and liabilities; assessing the potential resources of the individual's family
or legally authorized representative; setting treatment objectives; and
prescribing therapeutic modalities to achieve the CIPOC's objectives.
(2) The team shall include one of the following:
(a) A board-eligible or board-certified psychiatrist;
(b) A licensed clinical psychologist and a physician
licensed to practice medicine or osteopathy; or
(c) A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases and a licensed clinical psychologist.
(3) The team shall also include one of the following: an
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
4. Requirements for independent certification teams
applicable to both therapeutic group homes and PRTFs:
a. The independent certification team shall certify the
need for PRTF or therapeutic group home services and issue a certificate of
need document within the process and timeliness standards as approved by DMAS
under contractual agreement with the DMAS contractor.
b. The independent certification team shall be approved by
DMAS through a memorandum of understanding with a locality or be approved under
contractual agreement with the DMAS contractor. The team shall initiate and
coordinate referral to the family assessment and planning team (FAPT) as
defined in §§ 2.2-5207 and 2.2-5208 of the Code of Virginia to facilitate care
coordination and for consideration of educational coverage and other supports
not covered by DMAS.
c. The independent certification team shall assess the
individual's and family's strengths and needs in addition to diagnoses,
behaviors, and symptoms that indicate the need for behavioral health treatment
and also consider whether local resources and community-based care are
sufficient to meet the individual's treatment needs, as presented within the
previous 30 calendar days, within the least restrictive environment.
d. The LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP, as
part of the independent certification team, shall meet with an individual and
the individual's parent or legally authorized representative within two
business days from a request to assess the individual's needs and begin the
process to certify the need for an out-of-home placement.
e. The independent certification team shall meet with an
individual and the individual's parent or legally authorized representative
within 10 business days from a request to certify the need for an out-of-home
placement.
f. The independent certification team shall assess the
treatment needs of the individual to issue a certificate of need (CON) for the
most appropriate medically necessary services. The certification shall include
the dated signature and credentials for each of the team members who rendered
the certification. Referring or treatment providers shall not actively
participate during the certification process but may provide supporting
clinical documentation to the certification team.
g. The CON shall be effective for 30 calendar days prior to
admission.
h. The independent certification team shall provide the
completed CON to the facility within one calendar day of completing the CON.
i. The individual and the individual's parent or legally
authorized representative shall have the right to freedom of choice of service
providers.
j. If the individual or the individual's parent or legally
authorized representative disagrees with the independent certification team's
recommendation, the parent or legally authorized representative may appeal the
recommendation in accordance with 12VAC30-110.
k. If the LMHP, as part of the independent certification
team, determines that the individual is in immediate need of treatment, the
LMHP shall refer the individual to an appropriate Medicaid-enrolled crisis
intervention provider, crisis stabilization provider, or inpatient psychiatric
provider in accordance with 12VAC30-50-226 or shall refer the individual for
emergency admission to a PRTF or therapeutic group home under subdivision 4 m
of this subsection and shall also alert the individual's managed care organization.
l. For individuals who are already eligible for Medicaid at
the time of admission, the independent certification team shall be a
DMAS-authorized contractor with competence in the diagnosis and treatment of
mental illness, preferably in child psychiatry, and have knowledge of the
individual's situation and service availability in the individual's local
service area. The team shall be composed of at least one physician and one
LMHP, including LMHP-S, LMHP-R, and LMHP-RP. An individual's parent or legally
authorized representative shall be included in the certification process.
m. For emergency admissions, an assessment must be made by
the team responsible for the comprehensive individual plan of care (CIPOC).
Reimbursement shall only occur when a certificate of need is issued by the team
responsible for the CIPOC within 14 calendar days after admission. The
certification shall cover any period of time after admission and before claims
are made for reimbursement by Medicaid. After processing an emergency
admission, the therapeutic group home, PRTF, or institution for mental diseases
(IMD) shall notify the DMAS contractor within five calendar days of the
individual's status as being under the care of the facility.
n. For all individuals who apply and become eligible for
Medicaid while an inpatient in a facility or program, the certification team
shall refer the case to the DMAS contractor for referral to the local FAPT to
facilitate care coordination and consideration of educational coverage and
other supports not covered by DMAS.
o. For individuals who apply and become eligible for
Medicaid while an inpatient in the facility or program, the certification shall
be made by the team responsible for the CIPOC and shall cover any period of
time before the application for Medicaid eligibility for which claims are made
for reimbursement by Medicaid. Upon the individual's enrollment into the
Medicaid program, the therapeutic group home, PRTF, or IMD shall notify the
DMAS contractor of the individual's status as being under the care of the
facility within five calendar days of the individual becoming eligible for
Medicaid benefits.
5. Service authorization requirements applicable to both
therapeutic group homes and PRTFs:
a. Authorization shall be required and shall be conducted
by DMAS using medical necessity criteria specified in this subsection.
b. An individual shall have a valid psychiatric diagnosis
and meet the medical necessity criteria as defined in this subsection to
satisfy the criteria for admission. The diagnosis shall be current, as
documented within the past 12 months. If a current diagnosis is not available,
the individual will require a mental health evaluation prior to admission by an
LMHP affiliated with the independent certification team to establish a
diagnosis and recommend and coordinate referral to the available treatment
options.
c. At authorization, an initial length of stay shall be
agreed upon by the individual and parent or legally authorized representative
with the treating provider, and the treating provider shall be responsible for
evaluating and documenting evidence of treatment progress, assessing the need
for ongoing out-of-home placement, and obtaining authorization for continued
stay.
d. Information that is required to obtain authorization for
these services shall include:
(1) A completed state-designated uniform assessment
instrument approved by DMAS;
(2) A certificate of need completed by an independent
certification team specifying all of the following:
(a) The ambulatory care and Medicaid or FAPT-funded
services available in the community do not meet the specific treatment needs of
the individual;
(b) Alternative community-based care was not successful;
(c) Proper treatment of the individual's psychiatric
condition requires services in a 24-hour supervised setting under the direction
of a physician; and
(d) The services can reasonably be expected to improve the
individual's condition or prevent further regression so that a more intensive
level of care will not be needed;
(3) Diagnosis as defined in the DSM-5 and based on (i) an
evaluation by a psychiatrist or LMHP that has been completed within 30 calendar
days of admission or (ii) a diagnosis confirmed in writing by an LMHP after
review of a previous evaluation completed within one year of admission;
(4) A description of the individual's behavior during the
seven calendar days immediately prior to admission;
(5) A description of alternate placements and community
mental health and rehabilitation services and traditional behavioral health
services pursued and attempted and the outcomes of each service;
(6) The individual's level of functioning and clinical
stability;
(7) The level of family involvement and supports available;
and
(8) The initial plan of care (IPOC).
6. Continued stay criteria requirements applicable to both
therapeutic group homes and PRTFs. For a continued stay authorization or a
reauthorization to occur, the individual shall meet the medical necessity
criteria as defined in this subsection to satisfy the criteria for continuing
care. The length of the authorized stay shall be determined by DMAS. A current
plan of care and a current (within 30 calendar days) summary of progress
related to the goals and objectives of the plan of care shall be submitted to
DMAS for continuation of the service. The service provider shall also submit:
a. A state uniform assessment instrument, completed no more
than 30 business days prior to the date of submission;
b. Documentation that the required services have been
provided as defined in the plan of care;
c. Current (within the last 14 calendar days) information
on progress related to the achievement of all treatment and discharge-related
goals; and
d. A description of the individual's continued impairment
and treatment needs, problem behaviors, family engagement activities,
community-based discharge planning and care coordination, and need for a
residential level of care.
7. EPSDT services requirements applicable to therapeutic
group homes and PRTFs. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT. EPSDT services may involve
service modalities not available to other individuals, such as applied
behavioral analysis and neuro-rehabilitative services. Individualized services
to address specific clinical needs identified in an EPSDT screening shall
require authorization by a DMAS contractor. In unique EPSDT cases, DMAS may
authorize specialized services beyond the standard therapeutic group home or
PRTF medical necessity criteria and program requirements, as medically and
clinically indicated to ensure the most appropriate treatment is available to
each individual. Treating service providers authorized to deliver medically
necessary EPSDT services in therapeutic group homes and PRTFs on behalf of a
Medicaid-enrolled individual shall adhere to the individualized interventions
and evidence-based progress measurement criteria described in the plan of care
and approved for reimbursement by DMAS. All documentation, independent
certification team, family engagement activity, therapeutic pass, and discharge
planning requirements shall apply to cases approved as EPSDT PRTF or
therapeutic group home service.
8. Inpatient psychiatric services shall be covered for
individuals younger than 21 years of age for medically necessary stays in
inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2)
for the purpose of diagnosis and treatment of mental health and behavioral
disorders identified under EPSDT when such services meet the requirements set
forth in subdivision 7 of this subsection.
a. Inpatient psychiatric services shall be provided under
the direction of a physician.
b. Inpatient psychiatric services shall be provided by (i)
a psychiatric hospital that undergoes a state survey to determine whether the
hospital meets the requirements for participation in Medicare as a psychiatric
hospital as specified in 42 CFR 482.60 or is accredited by a national
organization whose psychiatric hospital accrediting program has been approved
by the Centers for Medicare and Medicaid Services (CMS); or (ii) a hospital
with an inpatient psychiatric program that undergoes a state survey to
determine whether the hospital meets the requirements for participation in
Medicare as a hospital, as specified in 42 CFR part 482 or is accredited by a
national accrediting organization whose hospital accrediting program has been
approved by CMS.
c. Inpatient psychiatric admissions at general acute care
hospitals and freestanding psychiatric hospitals shall also be subject to the
requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25.
d. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151(a) and 42 CFR 441.151 (b) and 42 CFR 441.152
through 42 CFR 441.156 and (ii) the Conditions of Participation in 42 CFR
Part 483 Subpart G. Each admission must be service authorized and the treatment
must meet DMAS requirements for clinical necessity.
e. The inpatient psychiatric benefit for individuals
younger than 21 years of age shall include services that are provided pursuant
to a certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the individual's discharge from inpatient status at the
earliest possible time. The inpatient psychiatric benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the individual,
and (iii) ensures that the services are furnished under the direction of a
physician. Services provided under arrangement shall be documented by a written
referral from the inpatient psychiatric facility. For purposes of pharmacy
services, a prescription ordered by an employee or contractor of the inpatient
psychiatric facility who is licensed to prescribe drugs shall be considered the
referral.
f. State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order pharmacy services
and emergency services. Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order the
following services: (i) medical and psychological services including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
outpatient hospital services; (iii) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) nonemergency transportation services;
and (viii) emergency services. (Emergency services means the same as is set
forth in 12VAC30-50-310 B.)
f. E. Mental health family support partners.
(1) 1. Mental health family support partners are
peer recovery support services and are nonclinical, peer-to-peer activities
that engage, educate, and support the caregiver and an individual's self-help
efforts to improve health recovery resiliency and wellness. Mental health
family support partners is a peer support service and is a strength-based,
individualized service provided to the caregiver of a Medicaid-eligible
individual younger than 21 years of age with a mental health disorder that is
the focus of support. The services provided to the caregiver and individual
must be directed exclusively toward the benefit of the Medicaid-eligible
individual. Services are expected to improve outcomes for individuals younger
than 21 years of age with complex needs who are involved with multiple systems
and increase the individual's and family's confidence and capacity to manage
their own services and supports while promoting recovery and healthy
relationships. These services are rendered by a PRS who is (i) a parent of a
minor or adult child with a similar mental health disorder or (ii) an adult
with personal experience with a family member with a similar mental health
disorder with experience navigating behavioral health care services. The PRS
shall perform the service within the scope of his knowledge, lived experience,
and education.
(2) 2. Under the clinical oversight of the LMHP
making the recommendation for mental health family support partners, the peer
recovery specialist in consultation with his direct supervisor shall develop a
recovery, resiliency, and wellness plan based on the LMHP's recommendation for
service, the individual's and the caregiver's perceived recovery needs, and any
clinical assessments or service specific provider intakes as defined in this
section within 30 calendar days of the initiation of service. Development of
the recovery, resiliency, and wellness plan shall include collaboration with
the individual and the individual's caregiver. Individualized goals and
strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.
(3) 3. Documentation of required activities
shall be required as set forth in 12VAC30-130-5200 A, C, and E through J.
(4) 4. Limitations and exclusions to service
delivery shall be the same as set forth in 12VAC30-130-5210.
(5) 5. Caregivers of individuals younger than 21
years of age who qualify to receive mental health family support partners shall
(i) care for an individual with a mental health disorder who requires recovery
assistance and (ii) meet two or more of the following:
(a) a. Individual and his caregiver need
peer-based recovery-oriented services for the maintenance of wellness and the
acquisition of skills needed to support the individual.
(b) b. Individual and his caregiver need
assistance to develop self-advocacy skills to assist the individual in
achieving self-management of the individual's health status.
(c) c. Individual and his caregiver need
assistance and support to prepare the individual for a successful work or
school experience.
(d) d. Individual and his caregiver need
assistance to help the individual and caregiver assume responsibility for
recovery.
(6) 6. Individuals 18 through, 19, and
20 years of age who meet the medical necessity criteria in 12VAC30-50-226 B 7
e, who would benefit from receiving peer supports directly and who choose to
receive mental health peer support services directly instead of through their
caregiver, shall be permitted to receive mental health peer support services by
an appropriate PRS.
(7) 7. To qualify for continued mental health family
support partners, medical necessity criteria shall continue to be met, and
progress notes shall document the status of progress relative to the goals
identified in the recovery, resiliency, and wellness plan.
(8) 8. Discharge criteria from mental health
family support partners shall be the same as set forth in 12VAC30-130-5180 E.
(9) 9. Mental health family support partners
services shall be rendered on an individual basis or in a group.
(10) 10. Prior to service initiation, a
documented recommendation for mental health family support partners services
shall be made by a licensed mental health professional (LMHP) who is acting
within his scope of practice under state law. The recommendation shall verify
that the individual meets the medical necessity criteria set forth in
subdivision 5 of this subsection. The recommendation shall be valid for no
longer than 30 calendar days.
(11) 11. Effective July 1, 2017, a peer recovery
specialist shall have the qualifications, education, experience, and
certification required by DBHDS in order to be eligible to register with the
Virginia Board of Counseling on or after July 1, 2018. Upon the promulgation of
regulations by the Board of Counseling, registration of peer recovery
specialists by the Board of Counseling shall be required. The PRS shall perform
mental health family support partners services under the oversight of the LMHP
making the recommendation for services and providing the clinical oversight of
the recovery, resiliency, and wellness plan.
(12) 12. The PRS shall be employed by or have a
contractual relationship with the enrolled provider licensed for one of the
following:
(a) a. Acute care general and emergency
department hospital services licensed by the Department of Health.
(b) b. Freestanding psychiatric hospital and
inpatient psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(c) c. Psychiatric residential treatment
facility licensed by the Department of Behavioral Health and Developmental
Services.
(d) d. Therapeutic group home licensed by the
Department of Behavioral Health and Developmental Services.
(e) e. Outpatient mental health clinic services
licensed by the Department of Behavioral Health and Developmental Services.
(f) f. Outpatient psychiatric services provider.
(g) g. A community mental health and
rehabilitative services provider licensed by the Department of Behavioral
Health and Developmental Services as a provider of one of the following
community mental health and rehabilitative services as defined in this section,
12VAC30-50-226, 12VAC30-50-420, or 12VAC30-50-430 for which the individual
younger than 21 years meets medical necessity criteria: (i) intensive in
home; (ii) therapeutic day treatment; (iii) day treatment or partial
hospitalization; (iv) crisis intervention; (v) crisis stabilization; (vi)
mental health skill building; or (vii) mental health case management.
(13) 13. Only the licensed and enrolled provider
as referenced in subdivision 5 f (12) 12 of this subsection shall
be eligible to bill and receive reimbursement from DMAS or its contractor
for mental health family support partner services. Payments shall not be
permitted to providers that fail to enter into an enrollment agreement with
DMAS or its contractor. Reimbursement shall be subject to retraction for
any billed service that is determined not to be in compliance with DMAS
requirements.
(14) 14. Supervision of the PRS shall meet the
requirements set forth in 12VAC30-50-226 B 7 l.
6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by: (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations or (ii) a
psychiatric facility that is accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.
a. The inpatient psychiatric services benefit for
individuals younger than 21 years of age shall include services defined at 42
CFR 440.160 that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active
treatment designed to achieve the child's discharge from inpatient status at
the earliest possible time. The inpatient psychiatric services benefit shall
include services provided under arrangement furnished by Medicaid enrolled
providers other than the inpatient psychiatric facility, as long as the
inpatient psychiatric facility (i) arranges for and oversees the provision of
all services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.
(1) State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order these services: (i)
pharmacy services and (ii) emergency services.
(2) Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order these
services: (i) medical and psychological services including those furnished by
physicians, licensed mental health professionals, and other licensed or
certified health professionals (i.e., nutritionists, podiatrists, respiratory
therapists, and substance abuse treatment practitioners); (ii) outpatient
hospital services; (iii) physical therapy, occupational therapy, and therapy
for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) transportation services; and (viii)
emergency services.
(3) Residential treatment facilities, as defined at 42 CFR
483.352, shall arrange for, maintain records of, and ensure that physicians
order these services: (i) medical and psychological services, including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
pharmacy services; (iii) outpatient hospital services; (iv) physical therapy,
occupational therapy, and therapy for individuals with speech, hearing, or
language disorders; (v) laboratory and radiology services; (vi) durable medical
equipment; (vii) vision services; (viii) dental, oral surgery, and orthodontic
services; (ix) transportation services; and (x) emergency services.
c. Inpatient psychiatric services are reimbursable only
when the treatment program is fully in compliance with (i) 42 CFR Part 441
Subpart D, specifically 42 CFR 441.151(a) and (b) and 42 CFR 441.152 through 42
CFR 441.156, and (ii) the conditions of participation in 42 CFR Part 483
Subpart G. Each admission must be preauthorized and the treatment must meet
DMAS requirements for clinical necessity.
d. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT.
7. F. Hearing aids shall be reimbursed for
individuals younger than 21 years of age according to medical necessity when
provided by practitioners licensed to engage in the practice of fitting or
dealing in hearing aids under the Code of Virginia.
8. G. Addiction and recovery treatment services
shall be covered under EPSDT consistent with 12VAC30-130-5000 et seq.
9. H. Services facilitators shall be required
for all consumer-directed personal care services consistent with the
requirements set out in 12VAC30-120-935.
10. I. Behavioral therapy services shall be
covered for individuals younger than 21 years of age.
a. 1. Definitions. The following words and terms
when used in this subsection shall have the following meanings unless the
context clearly indicates otherwise:
"Behavioral therapy" means systematic interventions
provided by licensed practitioners acting within the scope of practice defined
under a Virginia Department of Health Professions regulatory board and covered
as remedial care under 42 CFR 440.130(d) to individuals younger than 21 years
of age. Behavioral therapy includes applied behavioral analysis. Family
training related to the implementation of the behavioral therapy shall be
included as part of the behavioral therapy service. Behavioral therapy services
shall be subject to clinical reviews and determined as medically necessary.
Behavioral therapy may be provided in the individual's home and community
settings as deemed by DMAS or its contractor as medically necessary
treatment.
"Counseling" means a professional mental health
service that can only be provided by a person holding a license issued by a
health regulatory board at the Department of Health Professions, which includes
conducting assessments, making diagnoses of mental disorders and conditions,
establishing treatment plans, and determining treatment interventions.
"Individual" means the child or adolescent younger
than 21 years of age who is receiving behavioral therapy services.
"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.
b. 2. Behavioral therapy services shall be
designed to enhance communication skills and decrease maladaptive patterns of
behavior, which if left untreated, could lead to more complex problems and the
need for a greater or a more intensive level of care. The service goal shall be
to ensure the individual's family or caregiver is trained to effectively manage
the individual's behavior in the home using modification strategies. All
services shall be provided in accordance with the ISP and clinical assessment
summary.
c. 3. Behavioral therapy services shall be
covered when recommended by the individual's primary care provider or other
licensed physician, licensed physician assistant, or licensed nurse
practitioner and determined by DMAS or its contractor to be medically
necessary to correct or ameliorate significant impairments in major life
activities that have resulted from either developmental, behavioral, or mental
disabilities. Criteria for medical necessity are set out in 12VAC30-60-61 H
F. Service-specific provider intakes shall be required at the onset of
these services in order to receive authorization for reimbursement. Individual
service plans (ISPs) shall be required throughout the entire duration of
services. The services shall be provided in accordance with the individual
service plan and clinical assessment summary. These services shall be provided
in settings that are natural or normal for a child or adolescent without a
disability, such as the individual's home, unless there is justification in the
ISP, which has been authorized for reimbursement, to include service settings
that promote a generalization of behaviors across different settings to
maintain the targeted functioning outside of the treatment setting in the
individual's home and the larger community within which the individual resides.
Covered behavioral therapy services shall include:
(1) a. Initial and periodic service-specific
provider intake as defined in 12VAC30-60-61 H F;
(2) b. Development of initial and updated ISPs
as established in 12VAC30-60-61 H F;
(3) c. Clinical supervision activities. Requirements
for clinical supervision are set out in 12VAC30-60-61 H F;
(4) d. Behavioral training to increase the
individual's adaptive functioning and communication skills;
(5) e. Training a family member in behavioral
modification methods as established in 12VAC30-60-61 H F;
(6) f. Documentation and analysis of
quantifiable behavioral data related to the treatment objectives; and
(7) g. Care coordination.
C. J. School health services.
1. School health assistant services are repealed effective
July 1, 2006.
2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services, shall not be covered for school divisions. School divisions to
receive reimbursement for the screenings shall be enrolled with DMAS as clinic
providers.
a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.
b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act. These
services are necessary to correct or ameliorate defects of physical or mental
illnesses or conditions.
3. Providers shall be licensed under the applicable state
practice act or comparable licensing criteria by the Virginia Department of
Education, and shall meet applicable qualifications under 42 CFR Part 440.
Identification of defects, illnesses or conditions, and services
necessary to correct or ameliorate them shall be performed by practitioners
qualified to make those determinations within their licensed scope of practice,
either as a member of the IEP team or by a qualified practitioner outside the
IEP team.
a. Providers shall be employed by the school division or under
contract to the school division.
b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.
c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.
d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.
e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.
4. Covered services include:
a. Physical therapy, and occupational therapy
and services for individuals with speech, hearing, and language disorders,
performed by, or under the direction of, providers who meet the qualifications
set forth at 42 CFR 440.110. This coverage includes audiology services.
b. Skilled nursing services are covered under 42 CFR
440.60. These services are to be rendered in accordance to the licensing
standards and criteria of the Virginia Board of Nursing. Nursing services are
to be provided by licensed registered nurses or licensed practical nurses but
may be delegated by licensed registered nurses in accordance with the
regulations of the Virginia Board of Nursing, especially the section on
delegation of nursing tasks and procedures. The licensed practical nurse is
under the supervision of a registered nurse.
(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation, and evaluation) that is consistent with skilled nursing
services when performed by a licensed registered nurse or a licensed practical
nurse. These skilled nursing services shall include dressing changes,
maintaining patent airways, medication administration/monitoring administration
or monitoring, and urinary catheterizations.
(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant, or nurse practitioner for skilled nursing services. This
order shall be recertified on an annual basis.
c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient
services include individual medical psychotherapy, group medical psychotherapy
coverage, and family medical psychotherapy. Psychological and neuropsychological
testing are allowed when done for purposes other than educational diagnosis,
school admission, evaluation of an individual with intellectual or
developmental disability prior to admission to a nursing facility, or any
placement issue. These services are covered in the nonschool settings also.
School providers who may render these services when licensed by the state
include psychiatrists, licensed clinical psychologists, school psychologists,
licensed clinical social workers, professional counselors, psychiatric clinical
nurse specialists, marriage and family therapists, and school social workers.
d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner professional
develops a written plan for meeting the needs of the child individual,
which is implemented by the assistant. The assistant must have qualifications
comparable to those for other personal care aides recognized by the Virginia
Department of Medical Assistance Services. The assistant performs services such
as assisting with toileting, ambulation, and eating. The assistant may serve as
an aide on a specially adapted school vehicle that enables transportation to or
from the school or school contracted provider on days when the student is
receiving a Medicaid-covered service under the IEP. Children Individuals
requiring an aide during transportation on a specially adapted vehicle shall
have this stated in the IEP.
e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's an individual's
medical or other health related condition.
f. Transportation is covered as allowed under 42 CFR
431.53 and described at State Plan Attachment 3.1-D (12VAC30-50-530).
Transportation shall be rendered only by school division personnel or
contractors. Transportation is covered for a child an individual
who requires transportation on a specially adapted school vehicle that enables
transportation to or from the school or school contracted provider on days when
the student individual is receiving a Medicaid-covered service
under the IEP. Transportation shall be listed in the child's individual's
IEP. Children Individuals requiring an aide during transportation
on a specially adapted vehicle shall have this stated in the IEP.
g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's an individual's IEP and
shall be performed by any of the above licensed practitioners within the scope
of practice. Assessments and reassessments not tied to medical needs of the child
individual shall not be covered.
5. DMAS will ensure through quality management review that duplication
of services will be monitored. School divisions have a responsibility to ensure
that if a child an individual is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.
D. K. Family planning services and supplies for
individuals of child-bearing age.
1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing
arts.
2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.
3. Family planning services as established by § 1905(a)(4)(C)
of the Social Security Act include annual family planning exams; cervical
cancer screening for women; sexually transmitted infection (STI) testing; lab
services for family planning and STI testing; family planning education,
counseling, and preconception health; sterilization procedures; nonemergency
transportation to a family planning service; and U.S. Food and Drug Administration
approved prescription and over-the-counter contraceptives, subject to limits in
12VAC30-50-210.
12VAC30-50-226. Community mental health services.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:
"Activities of daily living" or "ADLs"
means personal care tasks such as bathing, dressing, toileting, transferring,
and eating or feeding. An individual's degree of independence in performing
these activities is a part of determining appropriate level of care and service
needs.
"Affiliated" means any entity or property in which
a provider or facility has a direct or indirect ownership interest of 5.0% or
more, or any management, partnership, or control of an entity.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS. DMAS' designated BHSA shall be
authorized to constitute, oversee, enroll, and train a provider network;
perform service authorization; adjudicate claims; process claims; gather and
maintain data; reimburse providers; perform quality assessment and improvement;
conduct member outreach and education; resolve member and provider issues; and
perform utilization management including care coordination for the provision of
Medicaid-covered behavioral health services. Such authority shall include
entering into or terminating contracts with providers in accordance with DMAS
authority pursuant to 42 CFR Part 1002 and § 32.1-325 D and E of the Code
of Virginia. DMAS shall retain authority for and oversight of the BHSA entity
or entities.
"Certified prescreener" means an employee of either
the local community services board/behavioral board or behavioral
health authority or its designee who is skilled in the assessment and treatment
of mental illness and who has completed a certification program approved by
DBHDS.
"Clinical experience" means, for the purpose of
rendering (i) mental health day treatment/partial hospitalization, (ii)
intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental
health skill building, (v) crisis stabilization, or (vi) crisis intervention
services, practical experience in providing direct services to individuals with
diagnoses of mental illness or intellectual disability or the provision of
direct geriatric services or special education services. Experience shall
include supervised internships, supervised practicums, or supervised field
experience. Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be
established by DBHDS in the document titled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Code" means the Code of Virginia.
"DBHDS" means the Department of Behavioral Health
and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.)
of Title 37.2 of the Code of Virginia.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined in
12VAC35-105-20 with at least two consecutive years of documented experience as
a QMHP, and who has documented completion of the DBHDS PRS supervisor training;
or (iii) shall be an LMHP who has documented completion of the DBHDS PRS
supervisor training who is acting within his scope of practice under state law.
An LMHP providing services before April 1, 2018, shall have until April 1,
2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractor or 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.
"Human services field" means the same as the term
is defined by DBHDS the Department of Health Professions in the
guidance document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013. Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual" means the patient, client, or
recipient of services described in this section.
"Individual service plan" or "ISP" means
a comprehensive and regularly updated treatment plan specific to the
individual's unique treatment needs as identified in the service-specific
provider intake. The ISP contains, but is not limited to, the individual's
treatment or training needs, the individual's goals and measurable objectives
to meet the identified needs, services to be provided with the recommended
frequency to accomplish the measurable goals and objectives, the estimated
timetable for achieving the goals and objectives, and an individualized
discharge plan that describes transition to other appropriate services. The
individual shall be included in the development of the ISP and the ISP shall be
signed by the individual. If the individual is a minor child, the ISP
shall also be signed by the individual's parent/legal parent or legal
guardian. Documentation shall be provided if the individual, who is a minor
child or an adult who lacks legal capacity, is unable or unwilling to sign the
ISP.
"Individualized training" means instruction and
practice in functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living skills,
and use of community resources; assistance with medical management; and
monitoring health, nutrition, and physical condition. The training shall be
rehabilitative and based on a variety of incremental (or cumulative) approaches
or tools to organize and guide the individual's life planning and shall reflect
what is important to the individual in addition to all other factors that
affect his the individual's functioning, including effects of the
disability and issues of health and safety.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the
same as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.
"LMHP-resident in psychology" or
"LMHP-RP" means the same as an individual in a residency, as that
term is defined in 18VAC125-20-10, program for clinical psychologists. An
LMHP-resident in psychology shall be in continuous compliance with the
regulatory requirements for supervised experience as found in 18VAC125-20-65
and shall not perform the functions of the LMHP-RP or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Psychology. For purposes of Medicaid reimbursement by supervisors for services
provided by such residents, they shall use the title "Resident in
Psychology" after their signatures to indicate such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" is defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered
a "supervisee" until the supervision for specific clinical duties at
a specific site is preapproved in writing by the Virginia Board of Social Work.
For purposes of Medicaid reimbursement to their supervisors for services
provided by supervisees, these persons shall use the title "Supervisee in
Social Work" after their signatures to indicate such status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Qualified mental health professional-adult" or
"QMHP-A" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-child" or
"QMHP-C" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20,
including a "QMHP-trainee" as defined by the Department of Health
Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as defined in 12VAC35-105-20.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Register" or "registration" means
notifying DMAS or its contractor that an individual will be receiving services
that do not require service authorization.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Review of ISP" means that the provider evaluates
and updates the individual's progress toward meeting the individualized service
plan objectives and documents the outcome of this review. For DMAS to determine
that these reviews are satisfactory and complete, the reviews shall (i) update
the goals, objectives, and strategies of the ISP to reflect any change in the
individual's progress and treatment needs as well as any newly identified
problems; (ii) be conducted in a manner that enables the individual to
participate in the process; and (iii) be documented in the individual's medical
record no later than 15 calendar days from the date of the review.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service authorization" means the process to
approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS
individual by a DMAS service authorization contractor prior to service delivery
and reimbursement in order to validate that the service requested is medically
necessary and meets DMAS and DMAS contractor criteria for reimbursement.
Service authorization does not guarantee payment for the service.
"Service-specific provider intake" means the same
as defined in 12VAC30-50-130 and also includes individuals who are older than
21 years of age.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
B. Mental health services. The following services, with their
definitions, shall be covered: day treatment/partial hospitalization,
psychosocial rehabilitation, crisis services, intensive community treatment
(ICT), and mental health skill building. Staff travel time shall not be
included in billable time for reimbursement. These services, in order to be
covered, shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and are reflected
in provider records and on providers' claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services. These services are intended to be delivered in a person-centered
person centered manner. The individuals who are receiving these services
shall be included in all service planning activities. All services which do not
require service authorization require registration. This registration shall
transmit service-specific information to DMAS or its contractor in accordance
with service authorization requirements.
1. Day treatment/partial hospitalization services shall be
provided in sessions of two or more consecutive hours per day, which may be
scheduled multiple times per week, to groups of individuals in a nonresidential
setting. These services, limited annually to 780 units, include the major
diagnostic, medical, psychiatric, psychosocial, and psychoeducational treatment
modalities designed for individuals who require coordinated, intensive,
comprehensive, and multidisciplinary treatment but who do not require inpatient
treatment. One unit of service shall be defined as a minimum of two but less
than four hours on a given day. Two units of service shall be defined as at
least four but less than seven hours in a given day. Three units of service
shall be defined as seven or more hours in a given day. Authorization is
required for Medicaid reimbursement.
a. Day treatment/partial hospitalization services shall be
time limited interventions that are more intensive than outpatient services and
are required to stabilize an individual's psychiatric condition. The services
are delivered when the individual is at risk of psychiatric hospitalization or
is transitioning from a psychiatric hospitalization to the community. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual is at risk of
psychiatric hospitalization or is transitioning from a psychiatric
hospitalization to the community.
b. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Individuals must meet at least two of the following criteria
on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
hospitalization or homelessness or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that the individual
requires repeated interventions or monitoring by the mental health, social
services, or judicial system that have been documented; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
c. Individuals shall be discharged from this service when they
are no longer in an acute psychiatric state and other less intensive services
may achieve psychiatric stabilization.
d. Admission and services for time periods longer than 90
calendar days must be authorized based upon a face-to-face evaluation by a
physician, psychiatrist, licensed clinical psychologist, licensed professional
counselor, licensed clinical social worker, or psychiatric clinical nurse
specialist.
e. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
2. Psychosocial rehabilitation shall be provided at least two
or more hours per day to groups of individuals in a nonresidential setting.
These services, limited annually to 936 units, include assessment, education to
teach the patient about the diagnosed mental illness and appropriate
medications to avoid complication and relapse, and opportunities to
learn and use independent living skills and to enhance social and interpersonal
skills within a supportive and normalizing program structure and environment.
One unit of service is defined as a minimum of two but less than four hours on
a given day. Two units are defined as at least four but less than seven hours
in a given day. Three units of service shall be defined as seven or more hours
in a given day. Authorization is required for Medicaid reimbursement. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Services are provided to individuals: (i) who without
these services would be unable to remain in the community or (ii) who meet at
least two of the following criteria on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that repeated
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
3. Crisis intervention shall provide immediate mental health
care, available 24 hours a day, seven days per week, to assist individuals who
are experiencing acute psychiatric dysfunction requiring immediate clinical attention.
This service's objectives shall be to prevent exacerbation of a condition, to
prevent injury to the client or others, and to provide treatment in the context
of the least restrictive setting. Crisis intervention activities shall include
assessing the crisis situation, providing short-term counseling designed to
stabilize the individual, providing access to further immediate assessment and
follow-up, and linking the individual and family with ongoing care to prevent
future crises. Crisis intervention services may include office visits, home
visits, preadmission screenings, telephone contacts, and other client-related
activities for the prevention of institutionalization. The service-specific
provider intake, as defined at 12VAC30-50-130, shall document the individual's
behavior and describe how the individual meets criteria for this service. The
provision of this service to an individual shall be registered with either DMAS,
DMAS contractors, or the BHSA within one business day or the completion of
the service-specific provider intake to avoid duplication of services and to
ensure informed care coordination.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a
psychiatric nature that puts the individual at risk of psychiatric
hospitalization. Individuals must meet at least two of the following criteria
at the time of admission to the service:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by mental health, social services, or the judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. The annual limit for crisis intervention is 720 units per
year. A unit shall equal 15 minutes.
c. These services may only be rendered by an LMHP, an
LMHP-supervisee, LMHP-resident, LMHP-RP, or a certified prescreener.
4. Intensive community treatment (ICT), initially covered for
a maximum of 26 weeks based on an initial service-specific provider intake and
may be reauthorized for up to an additional 26 weeks annually based on written
intake and certification of need by a licensed mental health provider (LMHP),
shall be defined by 12VAC35-105-20 or LMHP-S, LMHP-R, and LMHP-RP and shall
include medical psychotherapy, psychiatric assessment, medication management,
and care coordination activities offered to outpatients outside the clinic,
hospital, or office setting for individuals who are best served in the
community. Authorization is required for Medicaid reimbursement.
a. To qualify for ICT, the individual must meet at least one
of the following criteria:
(1) The individual must be at high risk for psychiatric
hospitalization or becoming or remaining homeless due to mental illness or
require intervention by the mental health or criminal justice system due to
inappropriate social behavior.
(2) The individual has a history (three months or more) of a
need for intensive mental health treatment or treatment for co-occurring
serious mental illness and substance use disorder and demonstrates a resistance
to seek out and utilize appropriate treatment options.
b. A written, service-specific provider intake, as defined at
12VAC30-50-130, that documents the individual's eligibility and the need for
this service must be completed prior to the initiation of services. This intake
must be maintained in the individual's records.
c. An individual service plan shall be initiated at the time
of admission and must be fully developed, as defined in this section, within 30
days of the initiation of services.
d. The annual unit limit shall be 130 units with a unit
equaling one hour.
e. These services may only be rendered by a team that meets
the requirements of 12VAC35-105-1370.
5. Crisis stabilization services for nonhospitalized
individuals shall provide direct mental health care to individuals experiencing
an acute psychiatric crisis which may jeopardize their current community living
situation. Services may be provided for up to a 15-day period per crisis
episode following a face-to-face service-specific provider intake by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP. Only one unit of service shall be
reimbursed for this intake. The provision of this service to an individual
shall be registered with either DMAS, DMAS contractors, or the BHSA
within one business day of the completion of the service-specific provider intake
to avoid duplication of services and to ensure informed care coordination.
a. The goals of crisis stabilization programs shall be to
avert hospitalization or rehospitalization, provide normative environments with
a high assurance of safety and security for crisis intervention, stabilize
individuals in psychiatric crisis, and mobilize the resources of the community
support system and family members and others for on-going maintenance and
rehabilitation. The services must be documented in the individual's records as
having been provided consistent with the ISP in order to receive Medicaid
reimbursement.
b. The crisis stabilization program shall provide to
individuals, as appropriate, psychiatric assessment including medication
evaluation, treatment planning, symptom and behavior management, and individual
and group counseling.
c. This service may be provided in any of the following
settings, but shall not be limited to: (i) the home of an individual who lives
with family or other primary caregiver; (ii) the home of an individual who
lives independently; or (iii) community-based programs licensed by DBHDS to
provide residential services but which are not institutions for mental disease
(IMDs).
d. This service shall not be reimbursed for (i) individuals with
medical conditions that require hospital care; (ii) individuals with a
primary diagnosis of substance abuse; or (iii) individuals with psychiatric
conditions that cannot be managed in the community (i.e., individuals who are
of imminent danger to themselves or others).
e. The maximum limit on this service is 60 days annually.
f. Services must be documented through daily progress notes
and a daily log of times spent in the delivery of services. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a psychiatric
nature that puts the individual at risk of psychiatric hospitalization.
Individuals must meet at least two of the following criteria at the time of
admission to the service:
(1) Experience difficulty in establishing and maintaining
normal interpersonal relationships to such a degree that the individual is at
risk of psychiatric hospitalization, homelessness, or isolation from social
supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that the
individual is unable to recognize personal danger or significantly
inappropriate social behavior.
g. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E or a certified
prescreener.
6. Mental health skill-building services (MHSS) shall be
defined as goal-directed training to enable individuals to achieve and maintain
community stability and independence in the most appropriate, least restrictive
environment. Authorization is required for Medicaid reimbursement. Services
that are rendered before the date of service authorization shall not be
reimbursed. These services may be authorized up to six consecutive months as long
as the individual meets the coverage criteria for this service. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. These services shall provide goal-directed training in the
following areas in order to be reimbursed by Medicaid or the BHSA DMAS
contractor: (i) functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living, and
use of community resources; (ii) assistance with medication management; and
(iii) monitoring of health, nutrition, and physical condition with goals
towards self-monitoring and self-regulation of all of these activities.
Providers shall be reimbursed only for training activities defined in the ISP
and only where services meet the service definition, eligibility, and service
provision criteria and this section. A review of MHSS services by an LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall be repeated for all individuals who have
received at least six months of MHSS to determine the continued need for this
service.
a. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Services are provided to individuals who
require individualized goal-directed training in order to achieve or maintain
stability and independence in the community.
b. Individuals ages 21 years of age and older
shall meet all of the following criteria in order to be eligible to receive
mental health skill-building services:
(1) The individual shall have one of the following as a
primary mental health diagnosis:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness; (ii)
results in severe and recurrent disability; (iii) produces functional
limitations in the individual's major life activities that are documented in the
individual's medical record; and (iv) requires individualized training for the
individual in order to achieve or maintain independent living in the community.
(2) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living
skills, such as symptom management; adherence to psychiatric and physical
health medication treatment plans; appropriate use of social skills and
personal support systems; skills to manage personal hygiene, food preparation,
and the maintenance of personal adequate nutrition; money management; and use
of community resources.
(3) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) (PRTF)
as a result of decompensation related to the individual's serious mental
illness; or (v) a temporary detention order (TDO) evaluation, pursuant to § 37.2-809
B of the Code of Virginia. This criterion shall be met in order to be initially
admitted to services and not for subsequent authorizations of service.
Discharge summaries from prior providers that clearly indicate (i) the type of
treatment provided, (ii) the dates of the treatment previously provided, and
(iii) the name of the treatment provider shall be sufficient to meet this
requirement. Family member statements shall not suffice to meet this
requirement.
(4) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications within the 12
months prior to the service-specific provider intake date. If a physician or
other practitioner who is authorized by his license to prescribe medications
indicates that antipsychotic, mood stabilizing, or antidepressant medications
are medically contraindicated for the individual, the provider shall obtain
medical records signed by the physician or other licensed prescriber detailing
the contraindication. This documentation shall be maintained in the
individual's mental health skill-building services record, and the provider
shall document and describe how the individual will be able to actively
participate in and benefit from services without the assistance of medication.
This criterion shall be met upon admission to services and shall not be
required for subsequent authorizations of service. Discharge summaries from prior
providers that clearly indicate (i) the type of treatment provided, (ii) the
dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
c. Individuals aged 18 to 21 years of age shall
meet all of the following criteria in order to be eligible to receive mental
health skill-building services:
(1) The individual shall not be living in a supervised setting
as described in § 63.2-905.1 of the Code of Virginia. If the individual is
transitioning into an independent living situation, MHSS shall only be
authorized for up to six months prior to the date of transition.
(2) The individual shall have at least one of the following as
a primary mental health diagnosis.:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness or serious
emotional disturbance; (ii) results in severe and recurrent disability; (iii)
produces functional limitations in the individual's major life activities that
are documented in the individual's medical record; and (iv) requires
individualized training for the individual in order to achieve or maintain
independent living in the community.
(3) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living skills
such as symptom management; adherence to psychiatric and physical health
medication treatment plans; appropriate use of social skills and personal
support systems; skills to manage personal hygiene, food preparation, and the
maintenance of personal adequate nutrition; money management; and use of
community resources.
(4) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) as a result
of decompensation related to the individual's serious mental illness; or (v)
temporary detention order (TDO) evaluation pursuant to § 37.2-809 B of the Code
of Virginia. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
(5) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications, within the 12
months prior to the assessment date. If a physician or other practitioner who
is authorized by his license to prescribe medications indicates that
antipsychotic, mood stabilizing, or antidepressant medications are medically
contraindicated for the individual, the provider shall obtain medical records
signed by the physician or other licensed prescriber detailing the
contraindication. This documentation of medication management shall be
maintained in the individual's mental health skill-building services record.
For individuals not prescribed antipsychotic, mood stabilizing, or
antidepressant medications, the provider shall have documentation from the
medication management physician describing how the individual will be able to
actively participate in and benefit from services without the assistance of
medication. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the
treatment provider shall be sufficient to meet this requirement. Family member
statements shall not suffice to meet this requirement.
(6) An independent clinical assessment, established in
12VAC30-130-3020, shall be completed for the individual.
d. Service-specific provider intakes shall be required at the
onset of services and individual service plans (ISPs) shall be required during
the entire duration of services. Services based upon incomplete, missing,
or outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in 12VAC30-50-130.
e. The yearly limit for mental health skill-building services
is 520 units. Only direct face-to-face contacts and services to the individual
shall be reimbursable. One unit is 1 to 2.99 hours per day, and two
units is 3 to 4.99 hours per day.
f. These services may only be rendered by an LMHP, LMHP-R,
LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or QPPMH.
g. The provider shall clearly document details of the services
provided during the entire amount of time billed.
h. The ISP shall not include activities that contradict or
duplicate those in the treatment plan established by the therapeutic
group home or assisted living facility. The provider shall coordinate mental
health skill-building services with the treatment plan established by the group
home or assisted living facility and shall document all coordination activities
in the medical record.
i. Limits and exclusions.
(1) Group Therapeutic group home (Level A or
B) and assisted living facility providers shall not serve as the mental
health skill-building services provider for individuals residing in the
provider's respective facility. Individuals residing in facilities may,
however, receive MHSS from another MHSS agency not affiliated with the owner of
the facility in which they reside.
(2) Mental health skill-building services shall not be
reimbursed for individuals who are receiving in-home residential services or
congregate residential services through the Intellectual Disability Waiver or
Individual and Family Developmental Disabilities Support Waiver.
(3) Mental health skill-building services shall not be
reimbursed for individuals who are also receiving services under the Department
of Social Services independent living program (22VAC40-151), independent living
services (22VAC40-131 and 22VAC40-151), or independent living arrangement
(22VAC40-131) or any Comprehensive Services Act-funded independent living
skills programs.
(4) Mental health skill-building services shall not be
available to individuals who are receiving treatment foster care
(12VAC30-130-900 et seq.).
(5) Mental health skill-building services shall not be
available to individuals who reside in intermediate care facilities for
individuals with intellectual disabilities or hospitals.
(6) Mental health skill-building services shall not be
available to individuals who reside in nursing facilities, except for up to 60
days prior to discharge. If the individual has not been discharged from the
nursing facility during the 60-day period of services, mental health
skill-building services shall be terminated and no further service
authorizations shall be available to the individual unless a provider can
demonstrate and document that mental health skill-building services are
necessary. Such documentation shall include facts demonstrating a change in the
individual's circumstances and a new plan for discharge requiring up to 60 days
of mental health skill-building services.
(7) Mental health skill-building services shall not be
available for residents of psychiatric residential treatment centers (Level
C facilities) except for the intake code H0032 (modifier U8) in the seven
days immediately prior to discharge.
(8) Mental health skill-building services shall not be
reimbursed if personal care services or attendant care services are being
received simultaneously, unless justification is provided why this is necessary
in the individual's mental health skill-building services record. Medical
record documentation shall fully substantiate the need for services when
personal care or attendant care services are being provided. This applies to
individuals who are receiving additional services through the Intellectual
Disability Waiver (12VAC30-120-1000 et seq.), Individual and Family
Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.), the
Elderly or Disabled with Consumer Direction Waiver (12VAC30-120-900 et seq.),
and EPSDT services (12VAC30-50-130).
(9) Mental health skill-building services shall not be
duplicative of other services. Providers shall be required to ensure that if an
individual is receiving additional therapeutic services that there will be
coordination of services by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A,
QMHP-C, QMHP-E, or QPPMH to avoid duplication of services.
(10) Individuals who have organic disorders, such as delirium,
dementia, or other cognitive disorders not elsewhere classified, will be
prohibited from receiving mental health skill-building services unless their
physicians issue signed and dated statements indicating that the individuals
can benefit from this service.
(11) Individuals who are not diagnosed with a serious mental
health disorder but who have personality disorders or other mental health
disorders, or both, that may lead to chronic disability shall not be excluded
from the mental health skill-building services eligibility criteria provided
that the individual has a primary mental health diagnosis from the list
included in subdivision B 6 b (1) or B 6 c (2) of this section and that the
provider can document and describe how the individual is expected to actively
participate in and benefit from mental health skill-building services.
7. Mental health peer support services.
a. Mental health peer support services are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support an individual's self-help efforts to improve health
recovery, resiliency, and wellness. Mental health peer support services for
adults is a person centered, strength-based, and recovery-oriented
rehabilitative service for individuals 21 years of age or older provided
by a peer recovery specialist successful in the recovery process with lived
experience with a mental health disorder, who is trained to offer support and
assistance in helping others in the recovery to reduce the disabling effects of
a mental health disorder that is the focus of support. Services assist the
individual with developing and maintaining a path to recovery, resiliency, and
wellness. Specific peer support service activities shall emphasize the
acquisition, development, and enhancement of recovery, resiliency, and
wellness. Services are designed to promote empowerment, self-determination,
understanding, and coping skills through mentoring and service coordination
supports, as well as to assist individuals in achieving positive coping
mechanisms for the stressors and barriers encountered when recovering from
their illnesses or disorders.
b. Under the clinical oversight of the LMHP making the
recommendation for mental health support services, the peer recovery specialist
in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's perceived recovery needs, and any clinical assessments or
service specific provider intakes as defined in this section within 30 calendar
days of the initiation of service. Development of the recovery, resiliency, and
wellness plan shall include collaboration with the individual. Individualized
goals and strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, and the individual
within 30 calendar days of the initiation of service. The PRS shall act as an
advocate for the individual, encouraging the individual to take a proactive
role in developing and updating goals and objectives in the individualized
recovery planning.
c. Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A, C, and E through J.
d. Limitations and exclusions to service delivery shall be the
same as set forth in 12VAC30-130-5210.
e. Individuals 21 years of age or older qualifying for
mental health peer support services shall meet the following requirements:
(1) Require recovery-oriented assistance and support services
for the acquisition of skills needed to engage in and maintain recovery; for the
development of self-advocacy skills to achieve a decreasing dependency on
formalized treatment systems; and to increase responsibilities, wellness
potential, and shared accountability for the individual's own recovery.
(2) Have a documented mental health disorder diagnosis.
(3) Demonstrate moderate to severe functional impairment
because of a diagnosis that interferes with or limits performance in at least
one of the following domains: educational (e.g., obtaining a high school or
college degree); social (e.g., developing a social support system); vocational
(e.g., obtaining part-time or full-time employment); self-maintenance (e.g.,
managing symptoms, understanding his illness, living more independently).
f. To qualify for continued mental health peer support
services, medical necessity criteria shall continue to be met, and progress
notes shall document the status of progress relative to the goals identified in
the recovery, resiliency, and wellness plan.
g. Discharge criteria from mental health peer support services
is the same as set forth in 12VAC30-130-5180 E.
h. Mental health peer support services shall be rendered
on an individual basis or in a group.
i. Prior to service initiation, a documented recommendation
for mental health peer support services shall be made by a licensed mental
health professional acting within the scope of practice under state law The
recommendation shall verify that the individual meets the medical necessity
criteria set forth in subdivision 7 e of this subsection. The recommendation
shall be valid for no longer than 30 calendar days.
j. Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification established
by DBHDS in order to be eligible to register with the Board of Counseling on or
after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health peer support
services under the oversight of the LMHP making the recommendation for services
and providing the clinical oversight of the recovery, resiliency, and wellness
plan. The PRS shall be employed by or have a contractual relationship with an
enrolled provider licensed for one of the following:
(1) Acute care general hospital licensed by the Department of
Health.
(2) Freestanding psychiatric hospital and inpatient
psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(3) Outpatient mental health clinic services licensed by the
Department of Behavioral Health and Developmental Services.
(4) Outpatient psychiatric services provider.
(5) Rural health clinics and federally qualified health
centers.
(6) Hospital emergency department services licensed by the
Department of Health.
(7) Community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services defined in this section or 12VAC30-50-420 for which the
individual meets medical necessity criteria:
(a) Day treatment or partial hospitalization;
(b) Psychosocial rehabilitation;
(c) Crisis intervention;
(d) Intensive community treatment;
(e) Crisis stabilization;
(f) Mental health skill building; or
(g) Mental health case management.
k. Only the licensed and enrolled provider referenced in
subdivision 7 j of this subsection shall be eligible to bill mental health peer
support services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor.
Reimbursement shall be subject to retraction for any billed service that is
determined to not to be in compliance with DMAS requirements.
l. Supervision of the PRS shall be required as set forth in
the definition of "supervision" in 12VAC30-130-5160. Supervision of
the PRS shall also meet the following requirements: the supervisor shall be
under the clinical oversight of the LMHP making the recommendation for
services, and the peer recovery specialist in consultation with his direct
supervisor shall conduct and document a review of the recovery, resiliency, and
wellness plan every 90 calendar days with the individual and the caregiver, as
applicable. The review shall be signed by the PRS and the individual and, as
applicable, the identified family member or caregiver. Review of the recovery,
resiliency, and wellness plan means the PRS evaluates and updates the
individual's progress every 90 days toward meeting the plan's goals and
documents the outcome of this review in the individual's medical record. For
DMAS to determine that these reviews are complete, the reviews shall (i) update
the goals and objectives as needed to reflect any change in the individual's
recovery as well as any newly identified needs, (ii) be conducted in a manner
that enables the individual to actively participate in the process, and (iii)
be documented by the PRS in the individual's medical record no later than 15 calendar
days from the date of the review.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, DSM-5, 2013, American Psychiatric Association
Length of Stay by Diagnosis and Operation, Southern Region,
1996, HCIA, Inc.
Guidelines for Perinatal Care, 4th Edition, August 1997,
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists
Virginia Supplemental Drug Rebate Agreement Contract and
Addenda
Office Reference Manual (Smiles for Children), prepared by
DMAS' Dental Benefits Administrator, copyright 2010, dated March 13, 2014 (http://www.dmas.virginia.gov/Content_atchs/dnt/VA_SFC_ORM_140313.pdf)
Patient Placement Criteria for the Treatment of
Substance-Related Disorders ASAM PPC-2R, Second Edition, copyright 2001,
American Society of Addiction Medicine
Human Services and Related Fields Approved
Degrees/Experience, Department of Behavioral Health and Developmental Services
(rev. 5/13)
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted on
November 3, 2017, revised on February 9, 2018
12VAC30-60-5. Applicability of utilization review requirements.
A. These utilization requirements shall apply to all Medicaid
covered services unless otherwise specified.
B. Some Medicaid covered services require an approved service
authorization prior to service delivery in order for reimbursement to occur.
1. To obtain service authorization, all providers' information
supplied to the Department of Medical Assistance Services (DMAS), service
authorization contractor, or the behavioral health service authorization
contractor or its contractor shall be fully substantiated throughout
individuals' medical records.
2. Providers shall be required to maintain documentation
detailing all relevant information about the Medicaid individuals who are in providers'
the provider's care. Such documentation shall fully disclose the extent
of services provided in order to support providers' the provider's
claims for reimbursement for services rendered. This documentation shall be
written, signed, and dated at the time the services are rendered unless
specified otherwise.
C. DMAS, or its designee contractor, shall
perform reviews of the utilization of all Medicaid covered services pursuant to
42 CFR 440.260 and 42 CFR Part 456.
D. DMAS shall recover expenditures made for covered services
when providers' documentation does not comport with standards specified in all
applicable regulations.
E. Providers who are determined not to be in compliance with
DMAS requirements shall be subject to 12VAC30-80-130 for the repayment of those
overpayments to DMAS.
F. Utilization review requirements specific to community
mental health services and residential treatment services, including
therapeutic group homes and psychiatric residential treatment facilities
(PRTFs), as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be as
follows:
1. To apply to be reimbursed as a Medicaid provider, the
required Department of Behavioral Health and Developmental Services (DBHDS)
license shall be either a full, annual, triennial, or conditional license.
Providers must be enrolled with DMAS or the BHSA its contractor
to be reimbursed. Once a health care entity has been enrolled as a provider, it
shall maintain, and update periodically as DMAS or its contractor
requires, a current Provider Enrollment Agreement for each Medicaid service
that the provider offers.
2. Health care entities with provisional licenses shall not be
reimbursed as Medicaid providers of community mental health services.
3. Payments shall not be permitted to health care entities
that either hold provisional licenses or fail to enter into a Medicaid
Provider Enrollment Agreement provider contract with DMAS or its
contractor for a service prior to rendering that service.
4. The behavioral health service authorization contractor
DMAS or its contractor shall apply a national standardized set of
medical necessity criteria in use in the industry, such as McKesson
InterQual Criteria, or an equivalent standard authorized in advance by
DMAS. Services that fail to meet medical necessity criteria shall be denied
service authorization.
5. For purposes of Medicaid reimbursement for services
provided by staff in residency, the following terms shall be used after their
signatures to indicate such status:
a. An LMHP-R shall use the term "Resident" after
his signature.
b. An LMHP-RP shall use the term "Resident in
Psychology" after his signature.
c. An LMHP-S shall use the term "Supervisee in Social
Work" after his signature.
12VAC30-60-50. Utilization control: Intermediate Care
Facilities care facilities for the Mentally Retarded (ICF/MR)
persons with intellectual and developmental disabilities and Institutions
institutions for Mental Disease (IMD) mental disease.
A. "Institution for mental disease" or
"IMD" means the same as that term is defined in § 1905(i) of the
Social Security Act.
B. With respect to each Medicaid-eligible resident in
an ICF/MR intermediate care facility for persons with intellectual
and developmental disabilities (ICF/ID) or an IMD in Virginia, a
written plan of care must be developed prior to admission to or authorization
of benefits in such facility, and a regular program of independent professional
review (including a medical evaluation) shall be completed periodically for
such services. The purpose of the review is to determine: the adequacy of the
services available to meet his the resident's current health
needs and promote his the resident's maximum physical well being;
the necessity and desirability of his the resident's continued
placement in the facility; and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Long-term care of residents in such facilities will
be provided in accordance with federal law that is based on the resident's
medical and social needs and requirements.
B. C. With respect to each ICF/MR ICF/ID
or IMD, periodic on-site onsite inspections of the care being
provided to each person receiving medical assistance, by one or more
independent professional review teams (composed of a physician or registered
nurse and other appropriate health and social service personnel), shall be
conducted. The review shall include, with respect to each recipient, a
determination of the adequacy of the services available to meet his the
resident's current health needs and promote his the resident's
maximum physical well-being, the necessity and desirability of continued
placement in the facility, and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Full reports shall be made to the state agency by
the review team of the findings of each inspection, together with any
recommendations.
C. D. In order for reimbursement to be made to
a facility for the mentally retarded persons with intellectual and
developmental disabilities, the resident must meet criteria for placement
in such facility as described in 12VAC30-60-360 and the facility must provide
active treatment for mental retardation intellectual or developmental
disabilities.
D. E. In each case for which payment for
nursing facility services for the mentally retarded persons with
intellectual or developmental disabilities or institution for mental
disease services is made under the State Plan:
1. A physician must certify for each applicant or recipient
that inpatient care is needed in a facility for the mentally retarded or an
institution for mental disease. A certificate of need shall be completed
by an independent certification team according to the requirements of
12VAC30-50-130 D 5. Recertification shall occur at least every 60 calendar days
by a physician, or by a physician assistant or nurse practitioner acting within
their scope of practice as defined by state law and under the supervision of a
physician. The certification must be made at the time of admission or, if an
individual applies for assistance while in the facility, before the Medicaid
agency authorizes payment; and
2. A physician, or physician assistant or nurse practitioner
acting within the scope of the practice as defined by state law and under the
supervision of a physician, must recertify for each applicant at least every 365
60 calendar days that services are needed in a facility for the
mentally retarded persons with intellectual and developmental
disabilities or an institution for mental disease.
E. F. When a resident no longer meets criteria
for facilities for the mentally retarded persons with intellectual
and developmental disabilities or for an institution for mental
disease, or no longer requires active treatment in a facility for the
mentally retarded persons with intellectual and developmental
disabilities then the resident must shall be discharged.
F. G. All services provided in an IMD and in
an ICF/MR ICF/ID shall be provided in accordance with guidelines
found in the Virginia Medicaid Nursing Home Manual.
H. All services provided in an IMD shall be provided with
the applicable provider agreement and all documents referenced therein.
I. Psychiatric services in IMDs shall only be covered for
eligible individuals younger than 21 years of age.
J. IMD services provided without service authorization
from DMAS or its contractor shall not be covered.
K. Absence of any of the required IMD documentation shall
result in denial or retraction of reimbursement.
L. In each case for which payment for IMD services is made
under the State Plan:
1. A physician shall certify at the time of admission, or
at the time the IMD is notified of an individual's retroactive eligibility status,
that the individual requires or required inpatient services in an IMD
consistent with 42 CFR 456.160.
2. The physician, or physician assistant or nurse
practitioner acting within the scope of practice as defined by state law and
under the supervision of a physician, shall recertify at least every 60
calendar days that the individual continues to require inpatient services in an
IMD.
3. Before admission to an IMD or before authorization
for payment, the attending physician or staff physician shall perform a medical
evaluation of the individual, and appropriate personnel shall complete a
psychiatric and social evaluation as described in 42 CFR 456.170.
4. Before admission to an IMD or before authorization for
payment, the attending physician or staff physician shall establish a written
plan of care for each individual as described in 42 CFR 441.155 and 42 CFR
456.180.
M. It shall be documented that the individual requiring
admission to an IMD who is younger than 21 years of age, that treatment is medically
necessary, and that the necessity was identified as a result of an independent
certification of need team review. Required documentation shall include the
following:
1. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition 2013, American Psychiatric
Association, and based on an evaluation by a psychiatrist completed within 30
calendar days of admission or if the diagnosis is confirmed, in writing, by a
previous evaluation completed within one year within admission.
2. A certification of the need for services as defined in
42 CFR 441.152 by an interdisciplinary team meeting the requirements of 42
CFR 441.153 or 42 CFR 441.156 and the Psychiatric Treatment of Minors Act (§
16.1-335 et seq. of the Code of Virginia).
N. The use of seclusion and restraint in an IMD shall be
in accordance with 42 CFR 483.350 through 42 CFR 483.376. Each use of a
seclusion or restraint, as defined in 42 CFR 483.350 through 42 CFR
483.376, shall be reported by the service provider to DMAS or its contractor
within one calendar day of the incident.
12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health and
behavioral therapy services for children.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:
"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian parent or
guardian is unable to manage the individual's mental, behavioral, or
emotional problems in the home and is actively, within the past two to four
weeks, seeking an out-of-home placement; (iii) a representative of either a
juvenile justice agency, a department of social services (either the state
agency or local agency), a community services board/behavioral health
authority, the Department of Education, or an LMHP, as defined in
12VAC35-105-20, and who is neither an employee of nor consultant to the
intensive in-home (IIH) services or therapeutic day treatment (TDT) provider,
has recommended an out-of-home placement absent an immediate change of
behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 calendar days; or
(v) the treatment team or family assessment planning team (FAPT) recommends IIH
services or TDT for an individual currently who is either: (a) transitioning
out of psychiatric residential treatment facility Level C (PRTF)
services, (b) transitioning out of a therapeutic group home Level A
or B services, (c) transitioning out of acute psychiatric hospitalization,
or (d) transitioning between foster homes, mental health case management,
crisis intervention, crisis stabilization, outpatient psychotherapy, or
outpatient substance abuse services.
"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the services did not treat or resolve the individual's mental
health or behavioral issues.
"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or and adolescents ages 12
through 20 years.
"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.
"Licensed behavior analyst" means a person who has
met the licensing requirements of 18VAC85-150 and holds a valid license issued
by the Department of Health Professions.
"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.
"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B therapeutic
group home; (ii) regular foster home if the individual is currently residing
with his the individual's biological family and, due to his
behavior problems, is at risk of being placed in the custody of the local
department of social services; (iii) treatment foster care if the individual is
currently residing with his the individual's biological family or
a regular foster care family and, due to the individual's behavioral problems,
is at risk of removal to a higher level of care; (iv) Level C psychiatric
residential treatment facility; (v) emergency shelter for the individual
only due either to his mental health or behavior or both; (vi) psychiatric
hospitalization; or (vii) juvenile justice system or incarceration.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized progress notes are part of the minimum documentation
requirements and shall convey the individual's status, staff interventions,
and, as appropriate, the individual's progress or lack of progress toward goals
and objectives in the plan of care. The progress notes shall also include, at a
minimum, the name of the service rendered, the date of the service rendered,
the signature and credentials of the person who rendered the service, the
setting in which the service was rendered, and the amount of time or units
required to deliver the service. The content of each progress note shall
corroborate the time or units billed. Progress notes shall be documented for
each service that is billed.
"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.
B. Utilization review requirements for all services in this
section.
1. The services described in this section shall be rendered
consistent with the definitions, service limits, and requirements described in
this section and in 12VAC30-50-130.
2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.
3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.
C. Utilization review of intensive in-home (IIH) services for
children and adolescents.
1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.
2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness that results in significant functional impairments in major life
activities. Individuals must meet at least two of the following criteria on a
continuing or intermittent basis to be authorized for these services:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.
4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian parent
or guardian within 30 calendar days of initiation of services. The
ISP shall meet all of the requirements as defined in 12VAC30-50-226.
5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.
6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered
in the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the
implementation of the ISP. For services provided outside of the home, there
shall be documentation reflecting therapeutic treatment as set forth in the ISP
provided for that date of service in the appropriately signed and dated
progress notes.
7. These services shall be provided when the clinical needs of
the individual put him the individual at risk for out-of-home
placement, as these terms are defined in this section:
a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,;
or
b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.
The service-specific provider intake shall describe how the
individual meets either subdivision 7 a or 7 b of this subdivision
7 subsection.
8. Services shall not be provided if the individual is no
longer a resident of the home.
9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual and
responsible parent/guardian parent or guardian shall be available
and in agreement to participate in the transition.
10. At least one parent/legal parent or legal
guardian or responsible adult with whom the individual is living must be
willing to participate in the intensive in-home services with the goal of
keeping the individual with the family. In the instance of this service, a
responsible adult shall be an adult who lives in the same household with the
child and is responsible for engaging in therapy and service-related activities
to benefit the individual.
11. The enrolled provider shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) as a provider of
intensive in-home services. The provider shall also have a provider enrollment
agreement with DMAS or its contractor in effect prior to the delivery of this
service that indicates that the provider will offer intensive in-home services.
12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.
13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family individual
or family per week in the initial phase of treatment. It is expected that
the pattern of service provision may show more intensive services and more
frequent contact with the individual and family initially with a lessening or
tapering off of intensity toward the latter weeks of service. Service plans
shall incorporate an individualized discharge plan that describes transition
from intensive in-home to less intensive or nonhome based services.
14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal members or legal
guardian or the individual with the provider, the provider shall discharge the
individual. If the individual continues to need services, then a new intake/admission
intake or admission shall be documented and a new service authorization
shall be required.
15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.
16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430,
the provider shall contact the case manager and provide notification of
the provision of services. In addition, the provider shall send monthly updates
to the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.
17. Emergency assistance shall be available 24 hours per day,
seven days a week.
18. Providers shall comply with DMAS marketing requirements at
12VAC30-130-2000. Providers that DMAS determines violate these marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him the primary care provider of the individual's receipt
of IIH services. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
D. Utilization review of therapeutic day treatment for
children and adolescents.
1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.
2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following criteria:
a. Children and adolescents who require year-round treatment
in order to sustain behavior or emotional gains.
b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:
(1) This programming during the school day; or
(2) This programming to supplement the school day or school
year.
c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.
d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; or (iv) are extremely depressed or marginally
connected with reality.
e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral emotional or
behavioral problems are so severe that they the children
cannot function in these programs without additional services.
3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.
4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.
5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian parent or guardian within 30 calendar
days of initiation of services and shall meet all requirements of an ISP as
defined in 12VAC30-50-226. Individual progress notes shall be required for each
contact with the individual and shall meet all of the requirements as defined
in 12VAC30-50-130 this section.
6. Such services shall not duplicate those services provided
by the school.
7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Individuals shall meet at least two of
the following criteria on a continuing or intermittent basis:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate social
behavior.
8. The enrolled provider of therapeutic day treatment for
child and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.
9. Services shall be provided by an LMHP, LMHP-supervisee,
LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E.
10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.
11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.
12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.
13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.
14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
the individual's parent or legal guardian, shall inform the primary care
provider of the child's the individual's receipt of community
mental health rehabilitative services. The documentation shall include who was
contacted, when the contact occurred, and what information was transmitted. The
parent/legal parent or legal guardian shall be required to give
written consent that this provider has permission to inform the primary care
provider of the child's or adolescent's receipt of community mental health
rehabilitative services.
16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission intake
or admission documentation shall be prepared and a new service
authorization shall be required.
E. Utilization review of community-based services for
children and adolescents younger than 21 years of age (Level A).
1. The staff ratio must be at least one to six during the
day and at least one to 10 between 11 p.m. and 7 a.m. The program
director supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E
(as defined in 12VAC35-105-20). The program director must be employed full
time.
2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.
3. Authorization is required for Medicaid reimbursement.
All community-based services for children and adolescents younger than 21
(Level A) require authorization prior to reimbursement for these services.
Reimbursement shall not be made for this service when other less intensive
services may achieve stabilization.
4. Services must be provided in accordance with an
individual service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.
5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.
6. Such service-specific provider intakes shall be
performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
7. If an individual receiving community-based services for
children and adolescents younger than 21 years of age (Level A) is also
receiving case management services, the provider shall collaborate with the
case manager by notifying the case manager of the provision of Level A services
and shall send monthly updates on the individual's progress. When the
individual is discharged from Level A services, a discharge summary shall be
sent to the case manager within 30 days of the service discontinuation
date. Providers and case managers who are using the same electronic health
record for the individual shall meet requirements for the delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
F. E. Utilization review of therapeutic behavioral
services group home for children and adolescents younger than 21
years of age (Level B).
1. The staff ratio must be at least one to four during the
day and at least one to eight between 11 p.m. and 7 a.m. approved
by the Office of Licensure at the Department of Behavioral Health and
Developmental Services. The clinical director must shall be a
licensed mental health professional. The caseload of the clinical director must
not exceed 16 individuals including all sites for which the same clinical
director is responsible.
2. The program director must shall be full time
and be a QMHP-C or QMHP-E with a bachelor's degree and at least one year's
clinical experience meet the requirements for a program director as
defined in 12VAC35-46-350.
3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the therapeutic group home shall
meet DBHDS paraprofessional staff qualified paraprofessional in
mental health (QPPMH) criteria, as defined in 12VAC35-105-20. The program/group
therapeutic group home must shall coordinate services with
other providers.
4. All therapeutic behavioral group home
services (Level B) shall be authorized prior to reimbursement for these
services. Services rendered without such prior authorization shall not be
covered.
5. Services must be provided in accordance with an ISP a
comprehensive individual plan of care as defined in 12VAC30-50-130, which
shall be fully completed within 30 calendar days of authorization for
Medicaid reimbursement.
6. Prior to admission, a service-specific provider intake
an assessment shall be performed using all elements specified by DMAS in
12VAC30-50-130.
7. Such service-specific provider intakes assessments
shall be performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
8. If an individual receiving therapeutic behavioral group
home services for children and adolescents younger than 21 years of age (Level
B) is also receiving case management services, the therapeutic behavioral
group home services provider must collaborate with the care
coordinator/case manager by notifying him of the provision of Level B therapeutic
group home services and the Level B therapeutic group home
services provider shall send monthly updates on the individual's treatment
status. When the individual is discharged from Level B services, a discharge
summary shall be sent to the care coordinator/case manager within 30 days of
the discontinuation date.
9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian parent or legally authorized representative, shall inform
the primary care provider of the individual's receipt of these Level B therapeutic
group home services. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted. If these
individuals are children or adolescents, then the parent/legal guardian parent
or legally authorized representative shall be required to give written
consent that this provider has permission to inform the primary care provider
of the individual's receipt of community mental health rehabilitative services.
G. Utilization review. Utilization reviews for
community-based services for children and adolescents younger than 21 years of
age (Level A) and therapeutic behavioral services for children and adolescents
younger than 21 years of age (Level B) shall include determinations whether
providers meet all DMAS requirements, including compliance with DMAS marketing
requirements. Providers that DMAS determines have violated the DMAS marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
H. F. Utilization review of behavioral therapy
services for children individuals younger than 21 years of age.
1. In order for Medicaid to cover behavioral therapy services,
the provider shall be enrolled with DMAS or its contractor as a Medicaid
provider. The provider enrollment agreement shall be in effect prior to the
delivery of services for Medicaid reimbursement.
2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.
3. Behavioral therapy services require service authorization.
Services shall be authorized only when eligibility and medical necessity
criteria are met.
4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), LMHP,
LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
behaviors targeted for treatment with their frequency, duration, and intensity)
and describing how service needs can best be met through behavioral therapy.
The service-specific provider intake shall be conducted face-to-face in the
individual's residence with the individual and parent or guardian.
5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP as defined in
12VAC30-50-130 shall be fully completed, signed, and dated by an LBA, LABA,
LMHP, LMHP-R, LMHP-RP, or LMHP-S. Every three months, the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall review the ISP, modify the ISP as appropriate,
and update the ISP, and all of these activities shall occur with the individual
in a manner in which the individual may participate in the process. The ISP
shall be rewritten at least annually.
6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.
7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision of unlicensed staff shall
occur at least weekly. As documented in the individual's medical record,
clinical supervision shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. Clinical supervision shall be documented by, at a
minimum, the contemporaneously dated signature of the clinical supervisor.
8. Family training involving the individual's family and
significant others to advance the treatment goals of the individual shall be
provided when (i) the training with the family member or significant other is
for the direct benefit of the individual, (ii) the training is not aimed at
addressing the treatment needs of the individual's family or significant
others, (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.
9. The following shall not be covered under this service:
a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.
b. Services other than the initial service-specific provider intake
that are provided but are not based upon the individual's ISP or linked to a
service in the ISP. Time not actively involved in providing services directed
by the ISP shall not be reimbursed.
c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.
d. Sessions that are conducted for family support, education,
recreational, or custodial purposes, including respite or child care.
e. Services that are provided by a provider but are rendered
primarily by a relative or guardian who is legally responsible for the
individual's care.
f. Services that are provided in a clinic or provider's office
without documented justification for the location in the ISP.
g. Services that are provided in the absence of the individual
or a parent or other authorized caregiver identified in the ISP with the
exception of treatment review processes described in subdivision 12 e of this
subsection, care coordination, and clinical supervision.
h. Services provided by a local education agency.
i. Provider travel time.
10. Behavioral therapy services shall not be reimbursed
concurrently with community mental health services described in 12VAC30-50-130 B
5 C or 12VAC30-50-226, or behavioral, psychological, or psychiatric
therapeutic consultation described in 12VAC30-120-756, 12VAC30-120-1000,
or 12VAC30-135-320.
11. If the individual is receiving targeted case management
services under the Medicaid state plan State Plan (defined in
12VAC30-50-410 through 12VAC30-50-491 12VAC30-50-491), the
provider shall notify the case manager of the provision of behavioral therapy
services unless the parent or guardian requests that the information not be
released. In addition, the provider shall send monthly updates to the case
manager on the individual's status pursuant to a valid release of information.
A discharge summary shall be sent to the case manager within 30 days of the
service discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.
12. Other standards to ensure quality of services:
a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.
b. Individual-specific services shall be directed toward the
treatment of the eligible individual and delivered in the family's residence
unless an alternative location is justified and documented in the ISP.
c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.
d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.
e. Billable time is permitted for the LBA, LABA, LMHP, LMHP-R,
LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision 12 c of this subsection.
13. Failure to comply with any of the requirements in
12VAC30-50-130 or in this section shall result in retraction.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)
Department of Medical Assistance Services Provider Manuals (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManuals):
Virginia Medicaid Nursing Home Manual
Virginia Medicaid Rehabilitation Manual
Virginia Medicaid Hospice Manual
Virginia Medicaid School Division Manual
Development of Special Criteria for the Purposes
of Pre-Admission Screening, Medicaid Memo, October 3, 2012, Department of
Medical Assistance Services
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association
Patient Placement Criteria for the Treatment of
Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001,
American Society on Addiction Medicine, Inc.
Medicaid Special Memo, Subject: New Service
Authorization Requirement for an Independent Clinical Assessment for Medicaid
and FAMIS Children's Community Mental Health Rehabilitative Services, dated
June 16, 2011, Department of Medical Assistance Services
Medicaid Special Memo, Subject: Changes to Children
Community Mental Health Rehabilitative Services - Children's Services, July 1,
2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Medicaid Special Memo, Subject: Changes to
Community Mental Health Rehabilitative Services - Adult-Oriented Services, July
1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018
Part XIV
Residential Psychiatric Treatment for Children and Adolescents (Repealed)
12VAC30-130-850. Definitions. (Repealed.)
The following words and terms when used in this part shall
have the following meanings, unless the context clearly indicates otherwise:
"Active treatment" means implementation of a
professionally developed and supervised individual plan of care that must be
designed to achieve the recipient's discharge from inpatient status at the
earliest possible time.
"Certification" means a statement signed by a
physician that inpatient services in a residential treatment facility are or
were needed. The certification must be made at the time of admission, or, if an
individual applies for assistance while in a mental hospital or residential
treatment facility, before the Medicaid agency authorizes payment.
"Comprehensive individual plan of care" or
"CIPOC" means a written plan developed for each recipient in
accordance with 12VAC30-130-890 to improve his condition to the extent that
inpatient care is no longer necessary.
"Emergency services" means a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.
"Individual" or "individuals" means a
child or adolescent younger than 21 years of age who is receiving a service
covered under this part of this chapter.
"Initial plan of care" means a plan of care established
at admission, signed by the attending physician or staff physician, that meets
the requirements in 12VAC30-130-890.
"Inpatient psychiatric facility" or
"IPF" means a private or state-run freestanding psychiatric hospital
or psychiatric residential treatment center.
"Recertification" means a certification for each
applicant or recipient that inpatient services in a residential treatment
facility are needed. Recertification must be made at least every 60 days by a
physician, or physician assistant or nurse practitioner acting within the scope
of practice as defined by state law and under the supervision of a physician.
"Recipient" or "recipients" means the
child or adolescent younger than 21 years of age receiving this covered
service.
"RTC-Level C" means a psychiatric residential
treatment facility (Level C).
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in an IPF that are billed by the arranged
practitioners separately from the IPF per diem.
12VAC30-130-860. Service coverage; eligible individuals;
service certification. (Repealed.)
A. Residential treatment programs (Level C) shall be
24-hour, supervised, medically necessary, out-of-home programs designed to
provide necessary support and address the special mental health and behavioral
needs of a child or adolescent in order to prevent or minimize the need for
more intensive inpatient treatment. Services must include, but shall not be
limited to, assessment and evaluation, medical treatment (including drugs),
individual and group counseling, and family therapy necessary to treat the child.
B. Residential treatment programs (Level C) shall provide
a total, 24 hours per day, specialized form of highly organized, intensive and
planned therapeutic interventions that shall be utilized to treat some of the
most severe mental, emotional, and behavioral disorders. Residential treatment
is a definitive therapeutic modality designed to deliver specified results for
a defined group of problems for children or adolescents for whom outpatient day
treatment or other less intrusive levels of care are not appropriate, and for
whom a protected, structured milieu is medically necessary for an extended
period of time.
C. Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B) and Community-Based Services for Children and
Adolescents under 21 (Level A) must be therapeutic services rendered in a
residential type setting such as a group home or program that provides
structure for daily activities, psychoeducation, therapeutic supervision and
mental health care to ensure the attainment of therapeutic mental health goals
as identified in the individual service plan (plan of care). The child or
adolescent must have a medical need for the service arising from a condition
due to mental, behavioral or emotional illness that results in significant functional
impairments in major life activities.
D. Active treatment shall be required. Residential
Treatment, Therapeutic Behavioral and Community-Based Services for Children and
Adolescents under age 21 shall be designed to serve the mental health needs of
children. In order to be reimbursed for Residential Treatment (Level C),
Therapeutic Behavioral Services for Children and Adolescents under 21 (Level
B), and Community-Based Services for Children and Adolescents under 21 (Level
A), the facility must provide active mental health treatment beginning at
admission and it must be related to the recipient's principle diagnosis and
admitting symptoms. To the extent that any recipient needs mental health
treatment and his needs meet the medical necessity criteria for the service, he
will be approved for these services. These services do not include
interventions and activities designed only to meet the supportive nonmental
health special needs, including but not limited to personal care, habilitation
or academic educational needs of the recipients.
E. An individual eligible for Residential Treatment
Services (Level C) is a recipient under the age of 21 years whose treatment
needs cannot be met by ambulatory care resources available in the community,
for whom proper treatment of his psychiatric condition requires services on an
inpatient basis under the direction of a physician.
An individual eligible for Therapeutic Behavioral Services
for Children and Adolescents under 21 (Level B) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a Licensed Mental Health Professional.
An individual eligible for Community-Based Services for
Children and Adolescents under 21 (Level A) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a qualified mental health professional. The services for all three
levels can reasonably be expected to improve the child's or adolescent's
condition or prevent regression so that the services will no longer be needed.
F. In order for Medicaid to reimburse for Residential
Treatment (Level C), Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B), and Community-Based Services for Children and
Adolescents under 21 (Level A), the need for the service must be certified
according to the standards and requirements set forth in subdivisions 1 and 2
of this subsection. At least one member of the independent certifying team must
have pediatric mental health expertise.
1. For an individual who is already a Medicaid recipient
when he is admitted to a facility or program, certification must:
a. Be made by an independent certifying team that includes
a licensed physician who:
(1) Has competence in diagnosis and treatment of pediatric
mental illness; and
(2) Has knowledge of the recipient's mental health history
and current situation.
b. Be signed and dated by a physician and the team.
2. For a recipient who applies for Medicaid while an
inpatient in the facility or program, the certification must:
a. Be made by the team responsible for the plan of care;
b. Cover any period of time before the application for
Medicaid eligibility for which claims for reimbursement by Medicaid are made;
and
c. Be signed and dated by a physician and the team.
12VAC30-130-870. Preauthorization. (Repealed.)
A. Authorization for Residential Treatment (Level C) shall
be required within 24 hours of admission and shall be conducted by DMAS or its
utilization management contractor using medical necessity criteria specified by
DMAS. At preauthorization, an initial length of stay shall be assigned and the
residential treatment provider shall be responsible for obtaining authorization
for continued stay.
B. DMAS will not pay for admission to or continued stay in
residential facilities (Level C) that were not authorized by DMAS.
C. Information that is required in order to obtain
admission preauthorization for Medicaid payment shall include:
1. A completed state-designated uniform assessment
instrument approved by the department.
2. A certification of the need for this service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the recipient;
b. Proper treatment of the recipient's psychiatric
condition requires services on an inpatient basis under the direction of a
physician; and
c. The services can reasonably be expected to improve the
recipient's condition or prevent further regression so that the services will
not be needed.
3. Additional required written documentation shall include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental Retardation,
Axis III (General Medical Conditions), Axis IV (Psychosocial and Environmental
Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the seven
days immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
D. Continued stay criteria for Residential Treatment
(Level C): information for continued stay authorization (Level C) for Medicaid
payment must include:
1. A state uniform assessment instrument, completed no more
than 90 days prior to the date of submission;
2. Documentation that the required services are provided as
indicated;
3. Current (within the last 30 days) information on
progress related to the achievement of treatment goals. The treatment goals
must address the reasons for admission, including a description of any new
symptoms amenable to treatment;
4. Description of continued impairment, problem behaviors,
and need for Residential Treatment level of care.
E. Denial of service may be appealed by the recipient
consistent with 12VAC30-110-10 et seq.; denial of reimbursement may be appealed
by the provider consistent with the Administrative Process Act (§ 2.2-4000 et
seq. of the Code of Virginia).
F. DMAS will not pay for services for Therapeutic
Behavioral Services for Children and Adolescents under 21 (Level B), and
Community-Based Services for Children and Adolescents under 21 (Level A) that
are not prior authorized by DMAS.
G. Authorization for Level A and Level B residential
treatment shall be required within three business days of admission.
Authorization for services shall be based upon the medical necessity criteria
described in 12VAC30-50-130. The authorized length of stay must not exceed six
months and may be reauthorized. The provider shall be responsible for documenting
the need for a continued stay and providing supporting documentation.
H. Information that is required in order to obtain
admission authorization for Medicaid payment must include:
1. A current completed state-designated uniform assessment
instrument approved by the department. The state designated uniform assessment
instrument must indicate at least two areas of moderate impairment for Level B
and two areas of moderate impairment for Level A. A moderate impairment is
evidenced by, but not limited to:
a. Frequent conflict in the family setting, for example,
credible threats of physical harm.
b. Frequent inability to accept age appropriate direction
and supervision from caretakers, family members, at school, or in the home or
community.
c. Severely limited involvement in social support; which
means significant avoidance of appropriate social interaction, deterioration of
existing relationships, or refusal to participate in therapeutic interventions.
d. Impaired ability to form a trusting relationship with at
least one caretaker in the home, school or community.
e. Limited ability to consider the effect of one's
inappropriate conduct on others, interactions consistently involving conflict,
which may include impulsive or abusive behaviors.
2. A certification of the need for the service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the child;
b. Proper treatment of the child's psychiatric condition
requires services in a community-based residential program; and
c. The services can reasonably be expected to improve the
child's condition or prevent regression so that the services will not be
needed.
3. Additional required written documentation must include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental
Retardation), Axis III (General Medical Conditions), Axis IV (Psychosocial and
Environmental Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the 30 days
immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
I. Denial of service may be appealed by the child
consistent with 12VAC30-110; denial of reimbursement may be appealed by the
provider consistent with the Administrative Process Act (§ 2.2-4000 et seq. of
the Code of Virginia).
J. Continued stay criteria for Levels A and B:
1. The length of the authorized stay shall be determined by
DMAS or its contractor.
2. A current Individual Service Plan (ISP) (plan of care)
and a current (within 30 days) summary of progress related to the goals and
objectives on the ISP (plan of care) must be submitted for continuation of the
service.
3. For reauthorization to occur, the desired outcome or
level of functioning has not been restored or improved, over the time frame
outlined in the child's ISP (plan of care) or the child continues to be at risk
for relapse based on history or the tenuous nature of the functional gains and
use of less intensive services will not achieve stabilization. Any one of the
following must apply:
a. The child has achieved initial service plan (plan of
care) goals but additional goals are indicated that cannot be met at a lower
level of care.
b. The child is making satisfactory progress toward meeting
goals but has not attained ISP goals, and the goals cannot be addressed at a
lower level of care.
c. The child is not making progress, and the service plan
(plan of care) has been modified to identify more effective interventions.
d. There are current indications that the child requires
this level of treatment to maintain level of functioning as evidenced by
failure to achieve goals identified for therapeutic visits or stays in a
nontreatment residential setting or in a lower level of residential treatment.
K. Discharge criteria for Levels A and B.
1. Reimbursement shall not be made for this level of care
if either of the following applies:
a. The level of functioning has improved with respect to
the goals outlined in the service plan (plan of care) and the child can reasonably
be expected to maintain these gains at a lower level of treatment; or
b. The child no longer benefits from service as evidenced
by absence of progress toward service plan goals for a period of 60 days.
12VAC30-130-880. Provider qualifications. (Repealed.)
A. Providers must provide all Residential Treatment
Services (Level C) as defined within this part and set forth in 42 CFR Part 441
Subpart D.
B. Providers of Residential Treatment Services (Level C)
must be:
1. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric hospital
accredited by the Joint Commission on Accreditation of Healthcare
Organizations;
2. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric unit of an
acute general hospital accredited by the Joint Commission on Accreditation of
Healthcare Organizations; or
3. A psychiatric facility that is (i) accredited by the
Joint Commission on Accreditation of Healthcare Organizations, the Commission
on Accreditation of Rehabilitation Facilities, the Council on Quality and
Leadership in Supports for People with Disabilities, or the Council on
Accreditation of Services for Families and Children and (ii) licensed by DMHMRSAS
as a residential treatment program for children and adolescents.
C. Providers of Community-Based Services for Children and
Adolescents under 21 (Level A) must be licensed by the Department of Social
Services, Department of Juvenile Justice, or Department of Education under the
Standards for Interdepartmental Regulation of Children's Residential Facilities
(22VAC42-10).
D. Providers of Therapeutic Behavioral Services (Level B)
must be licensed by the Department of Mental Health, Mental Retardation, and Substance
Abuse Services (DMHMRSAS) under the Standards for Interdepartmental Regulation
of Children's Residential Facilities (22VAC42-10).
12VAC30-130-890. Plans of care; review of plans of care.
(Repealed.)
A. All Medicaid services are subject to utilization review
and audit. The absence of any required documentation may result in denial or
retraction of any reimbursement.
B. For Residential Treatment Services (Level C) (RTS-Level
C), an initial plan of care must be completed at admission and a Comprehensive
Individual Plan of Care (CIPOC) must be completed no later than 14 days after
admission.
C. Initial plan of care (Level C) must include:
1. Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
2. A description of the functional level of the individual;
3. Treatment objectives with short-term and long-term
goals;
4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and
special procedures recommended for the health and safety of the individual and
a list of services provided under arrangement (see 12VAC30-50-130 for eligible
services provided under arrangement) that will be furnished to the individual
through the RTC-Level C's referral to an employed or a contracted provider of
services under arrangement, including the prescribed frequency of treatment and
the circumstances under which such treatment shall be sought;
5. Plans for continuing care, including review and modification
to the plan of care;
6. Plans for discharge; and
7. Signature and date by the physician.
D. The CIPOC for Level C must meet all of the following
criteria:
1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for inpatient psychiatric care;
2. Be developed by an interdisciplinary team of physicians
and other personnel specified under subsection G of this section, who are
employed by, or provide services to, patients in the facility in consultation
with the individual and his parents, legal guardians, or appropriate others in
whose care he will be released after discharge;
3. State treatment objectives that must include measurable
short-term and long-term goals and objectives, with target dates for
achievement;
4. Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis;
5. Include a list of services provided under arrangement
(described in 12VAC30-50-130) that will be furnished to the individual through
referral to an employee or a contracted provider of services under arrangement,
including the prescribed frequency of treatment and the circumstances under
which such treatment shall be sought; and
6. Describe comprehensive discharge plans and coordination
of inpatient services and post-discharge plans with related community services
to ensure continuity of care upon discharge with the individual's family,
school, and community.
E. Review of the CIPOC for Level C. The CIPOC must be
reviewed every 30 days by the team specified in subsection G of this section
to:
1. Determine that services being provided are or were
required on an inpatient basis; and
2. Recommend changes in the plan as indicated by the
individual's overall adjustment as an inpatient.
F. The development and review of the plan of care for
Level C as specified in this section satisfies the facility's utilization
control requirements for recertification and establishment and periodic review
of the plan of care, as required in 42 CFR 456.160 and 456.180.
G. Team developing the CIPOC for Level C. The following
requirements must be met:
1. At least one member of the team must have expertise in
pediatric mental health. Based on education and experience, preferably
including competence in child psychiatry, the team must be capable of all of
the following:
a. Assessing the individual's immediate and long-range therapeutic
needs, developmental priorities, and personal strengths and liabilities;
b. Assessing the potential resources of the individual's
family;
c. Setting treatment objectives; and
d. Prescribing therapeutic modalities to achieve the plan's
objectives.
2. The team must include, at a minimum, either:
a. A board-eligible or board-certified psychiatrist;
b. A clinical psychologist who has a doctoral degree and a
physician licensed to practice medicine or osteopathy; or
c. A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases, and a psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.
3. The team must also include one of the following:
a. A psychiatric social worker;
b. A registered nurse with specialized training or one
year's experience in treating mentally ill individuals;
c. An occupational therapist who is licensed, if required
by the state, and who has specialized training or one year of experience in
treating mentally ill individuals; or
d. A psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.
H. The RTC-Level C shall not receive a per diem
reimbursement for any day that:
1. The initial or comprehensive written plan of care fails
to include within three business days of the initiation of the service provided
under arrangement:
a. The prescribed frequency of treatment of such service,
or includes a frequency that was exceeded; or
b. All services that the individual needs while residing at
the RTC-Level C and that will be furnished to the individual through the
RTC-Level C referral to an employed or contracted provider of services under
arrangement;
2. The initial or comprehensive written plan of care fails
to list the circumstances under which the service provided under arrangement
shall be sought;
3. The referral to the service provided under arrangement
was not present in the individual's RTC-Level C record;
4. The service provided under arrangement was not supported
in that provider's records by a documented referral from the RTC-Level C;
5. The medical records from the provider of services under
arrangement (i.e., admission and discharge documents, treatment plans, progress
notes, treatment summaries, and documentation of medical results and findings)
(i) were not present in the individual's RTC-Level C record or had not been
requested in writing by the RTC-Level C within seven days of discharge from or
completion of the service or services provided under arrangement or (ii) had
been requested in writing within seven days of discharge from or completion of
the service or services provided under arrangement, but not received within 30
days of the request, and not re-requested;
6. The RTC-Level C did not have a fully executed contract
or employee relationship with an independent provider of services under
arrangement in advance of the provision of such services. For emergency
services, the RTC-Level C shall have a fully executed contract with the
emergency services provider prior to submission of the emergency service
provider's claim for payment;
7. A physician's order for the service under arrangement is
not present in the record; or
8. The service under arrangement is not included in the
individual's CIPOC within 30 calendar days of the physician's order.
I. The provider of services under arrangement shall be
required to reimburse DMAS for the cost of any such service provided under
arrangement that was (i) furnished prior to receiving a referral or (ii) in
excess of the amounts in the referral. Providers of services under arrangement
shall be required to reimburse DMAS for the cost of any such services provided
under arrangement that were rendered in the absence of an employment or
contractual relationship.
J. For therapeutic behavioral services for children and
adolescents under 21 (Level B), the initial plan of care must be completed at
admission by the licensed mental health professional (LMHP) and a CIPOC must be
completed by the LMHP no later than 30 days after admission. The assessment
must be signed and dated by the LMHP.
K. For community-based services for children and
adolescents under 21 (Level A), the initial plan of care must be completed at
admission by the QMHP and a CIPOC must be completed by the QMHP no later than
30 days after admission. The individualized plan of care must be signed and
dated by the program director.
L. Initial plan of care for Levels A and B must include:
1. Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
2. A description of the functional level of the individual;
3. Treatment objectives with short-term and long-term
goals;
4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and
special procedures recommended for the health and safety of the patient;
5. Plans for continuing care, including review and
modification to the plan of care; and
6. Plans for discharge.
M. The CIPOC for Levels A and B must meet all of the
following criteria:
1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for residential psychiatric care;
2. The CIPOC for both levels must be based on input from
school, home, other health care providers, the individual and family (or legal
guardian);
3. State treatment objectives that include measurable
short-term and long-term goals and objectives, with target dates for achievement;
4. Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis; and
5. Describe comprehensive discharge plans with related
community services to ensure continuity of care upon discharge with the
individual's family, school, and community.
N. Review of the CIPOC for Levels A and B. The CIPOC must
be reviewed, signed, and dated every 30 days by the QMHP for Level A and by the
LMHP for Level B. The review must include:
1. The response to services provided;
2. Recommended changes in the plan as indicated by the
individual's overall response to the plan of care interventions; and
3. Determinations regarding whether the services being
provided continue to be required.
Updates must be signed and dated by the service provider.
VA.R. Doc. No. R17-4495; Filed February 6, 2019, 2:45 p.m.
TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Proposed Regulation
Titles of Regulations: 12VAC30-10. State Plan under
Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-540).
12VAC30-50. Amount, Duration, and Scope of Medical and
Remedial Care Services (amending 12VAC30-50-20, 12VAC30-50-30,
12VAC30-50-60, 12VAC30-50-70, 12VAC30-50-130, 12VAC30-50-226).
12VAC30-60. Standards Established and Methods Used to Assure
High Quality Care (amending 12VAC30-60-5, 12VAC30-60-50,
12VAC30-60-61).
12VAC30-130. Amount, Duration and Scope of Selected Services (repealing 12VAC30-130-850, 12VAC30-130-860,
12VAC30-130-870, 12VAC30-130-880, 12VAC30-130-890).
Statutory Authority: § 32.1-325 of the Code of Virginia;
42 USC § 1396 et seq.
Public Hearing Information: No public hearings are
scheduled.
Public Comment Deadline: May 3, 2019.
Agency Contact: Emily McClellan, Regulatory Supervisor,
Policy Division, Department of Medical Assistance Services, 600 East Broad
Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)
786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants
to the Board of Medical Assistance Services the authority to administer and
amend the State Plan for Medical Assistance and promulgate regulations. Section
32.1-324 of the Code of Virginia authorizes the Director of the Department of
Medical Assistance Services (DMAS) to administer and amend the State Plan for
Medical Assistance according to the board's requirements and promulgate
regulations. The Medicaid authority as established by § 1902(a) of the Social
Security Act (42 USC § 1396a) provides governing authority for payments
for services.
The agency is proposing this regulatory action to comply with
Item 301 OO and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly. Items
301 PP states: "The Department of Medical Assistance Services shall make
programmatic changes in the provision of Residential Treatment Facility (Level
C) and Levels A and B residential services (group homes) for children with
serious emotional disturbances in order to ensure appropriate utilization and
cost efficiency. The department shall consider all available options including,
but not limited to, prior authorization, utilization review and provider
qualifications. The department shall have authority to promulgate regulations
to implement these changes within 280 days or less from the enactment date of
this act."
Purpose: This regulatory action is essential to protect
the health, safety, or welfare of Medicaid-covered individuals who require
behavioral health services and their families to ensure that families are well
informed about their family member's behavioral health condition about service
options prior to receiving these services, that the services are medically
necessary, and that the services are rendered by providers who use
evidence-based treatment approaches.
When residential treatment services were initially implemented
by DMAS, individuals did not have access to standardized methods of effective
care coordination upon entry into residential treatment due to placement
processes at the time and DMAS reimbursement limitations. This resulted in a
fragmented coordination approach for these individuals who were at risk for
high levels of care and remained at risk of repeated placements at this level
of care. Also, at the time of the appropriations act mandate, the process in
place for Medicaid enrolled children placed in residential settings yielded an
average stay of 260 days and had high readmission rates.
While residential treatment is not a service that should be
approved with great frequency for a large number of individuals, it is a
service that should be accessible to the families and individuals who require
that level of care. The service model had significant operational layers to be
navigated to access residential services. The processes involved coordination
of care by local family access and planning teams (FAPTs) who have, over time,
demonstrated some influence on determining an individual's eligibility for FAPT
funded services. The local influence on the programs administration caused
limitations on individualized freedom of provider choice and inconsistent
authorization of funding for persons deemed to need psychiatric care out of the
home setting. This local administration of the primary referral source for
residential treatment was outside the purview of DMAS, and this situation
produced outcomes that are inadequate to meet Centers for Medicare and Medicaid
Services (CMS) requirements on ensuring the individual freedom of choice of
providers.
Also, the state rules on FAPT composition were not consistent
with the federal Medicaid requirement for certifying a child for
Medicaid-funded residential treatment placement. Changes to the program were
necessary to address concerns that arose from the reliance upon the FAPT to
fulfill the role as the federally mandated independent team to certify
residential treatment.
The residential treatment model requires an enhanced care
coordination model to support the individuals who receive this level of service
to ensure an effective return to the family or caregiver home environment with
follow up services to facilitate ongoing treatment progress in the least
restrictive environment. The added coordination is required to navigate a very
complex service environment for the individual as the individual returns to a
community setting to establish an effective aftercare environment that involves
service providers who may be contracted with a variety of entities such as DMAS
contracted managed care organizations (MCOs), enrolled providers, the local
FAPT team, local school divisions, and the local community services board
(CSB). The proposed amendments allow DMAS to implement a contracted care
coordination team to focus on attaining specific clinical outcomes for all residential
care episodes and to provide a single liaison who will ensure coordination of
care in a complex service environment for individuals upon discharge from
residential treatment and prior to the time when they will enroll in an MCO.
During this transition period, the individual is very vulnerable to repeated
admissions to residential or inpatient care and must be supported in the
fee-for-service (FFS) environment with resources from the local CSB and
enrolled service providers and requires ongoing support and coordination to
receive post-discharge follow up and transition services.
DMAS has the goal that individuals receive the correct level of
service at the correct time for the treatment (service) needs related to the
individual's medical or psychiatric condition. Residential treatment services
consist of behavioral health interventions and are intended to provide high
intensity clinical treatment that should be provided for a short duration.
Stakeholder feedback supported observations by DMAS of lengthy durations of
stay for many individuals. Residential treatment services will benefit from
clarification of the service definition and eligibility requirements to ensure
that residential treatment does not evolve into a long-term level of support
instead of the high intensity psychiatric treatment modality that defines this
level of care.
Substance: The sections of the State Plan for Medical
Assistance that are affected by this action are: Inspection of Care in
Intermediate Care Facilities (12VAC30-10-540), Mandatory Coverage:
Categorically Needy and other required special groups (12VAC30-30-10), the
Amount, Duration, and Scope of Medical and Remedial Services Provided to
Categorically/Medically Needy Individuals-EPSDT Services (12VAC30-50-130);
Applicability of utilization review requirements (12VAC30-60-5), Utilization
control: Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and
Institutions for Mental Disease (IMD) (12VAC30-60-50) and Services related to
the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT);
community mental health services for children (12VAC30-60-61). The state-only
regulations that are affected by this action are Residential Psychiatric
Treatment for Children and Adolescents (plans of care; review of plans of care
(12VAC30-130-850 through 130-890).
The proposed regulatory action will serve to better clarify
policy interpretations that revise program standards to allow for more evidence
based service delivery, allow DMAS to implement more effective utilization
management in collaboration with the BHSA, enhance individualized coordination
of care, implement standardized coordination of individualized aftercare
resources by ensuring access to medical and behavioral health service providers
in the individual's home community, and support DMAS audit practices. The
proposed regulatory changes move toward a service model that will reduce
lengths of stay and facilitate an evidence based treatment approach to better
support the individual's discharge into their home environment. These changes
also align DMAS in meeting the requirements set forth by the Centers for
Medicare and Medicaid Services (CMS) in 42 CFR 441 Subpart D and 42 CFR
441.453.
The proposed regulatory action incorporates changes made in the
emergency regulation, including changes to the following areas: (i) provider
qualifications including acceptable licensing standards; (ii) preadmission
assessment requirements, (iii) program requirements; (iv) new discharge
planning and care coordination requirements; and (iv) language enhancements for
utilization review requirements to clarify program requirements, to ensure
adequate documentation of service delivery, and to help providers avoid payment
retractions. These changes are part of a review of the services to ensure that
services are effectively delivered and utilized for individuals who meet the
medical necessity criteria. For each individual seeking residential treatment
treatment needs are assessed with enhanced requirements by the current independent
certification teams who coordinate clinical assessment information and assess
local resources for each individual requesting residential care to determine an
appropriate level of care. The certification teams are also better able to
coordinate referrals for care to determine, in accordance with DOJ
requirements, whether or not the individual seeking services can be safely
served using community based services in the least restrictive setting.
Independent team certifications are conducted prior to the onset of specified
services, as required by CMS guidelines, by the DMAS behavioral health services
administrator.
The proposed regulatory action includes changes to program
requirements that ensure that effective levels of care coordination and
discharge planning occurs for each individual during the individual's
residential stay by enhancing program rules and utilization management
principles that facilitate effective discharge planning, family engagement and
establish community-based services prior to the individual's discharge from
residential care. The proposed regulatory action requires enhanced care
coordination to provide the necessary objective evaluations of treatment
progress and to facilitate evidence based practices during the treatment to
reduce the length of stay by ensuring that medical necessity indicates the
correct level of care and that appropriate and effective care is delivered in a
person centered manner. The proposed regulatory action requires that service
providers and local systems use standardized preadmission and discharge
processes to ensure effective services are delivered.
Issues: The primary advantages of the proposed
regulatory action to the Commonwealth and to Medicaid members are that the
proposed amendments (i) better clarify policy interpretations that revise
program standards to allow for more evidence based service delivery, (ii) allow
DMAS to implement more effective utilization management in collaboration with
the behavioral health services administrator, (iii) enhance individualized
coordination of care and implement standardized coordination of individualized
aftercare resources by ensuring access to medical and behavioral health service
providers in the individual's home community, (iv) support DMAS audit
practices, and (v) move toward a service model that will reduce lengths of stay
and facilitate an evidence based treatment approach to better support the
individual's discharge into their home environment. There are no disadvantages
to the Commonwealth or the public as a result of the proposed regulatory
action.
Department of Planning and Budget's Economic Impact
Analysis:
Summary of the Proposed Amendments to Regulation. Pursuant to
legislative mandates, the Board of Medical Assistance Services (Board) proposes
numerous changes to the provision of psychiatric residential treatment
services. These changes were already implemented under an emergency regulation
on July 1, 2017.1 The proposed regulation is a permanent replacement
for the emergency regulation.
Result of Analysis. The benefits likely exceed the costs for
the proposed amendments.
Estimated Economic Impact. Pursuant to Item 301 OO paragraphs 7
through 18 and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly, the
Board proposes to eliminate Level A group homes as they did not meet the
federal Centers for Medicare and Medicaid Services requirements and to change
the definition of "Level B" group homes to "Therapeutic Group
Homes." In response to the legislative mandates, the Board also proposes
changes to plan of care requirements, medical necessity requirements, discharge
planning, required clinical activities and documentation for Therapeutic Group
Homes (TGH); changes to Early and Periodic Screening, Diagnostic and Treatment
criteria, Independent Assessment, Certification and Coordination Team (IACCT)
provider requirements and required activities, admission practices, and plan of
care requirements for Psychiatric Residential Treatment Facilities (PRTF); and
changes to service authorization and continued stay requirements both for PRTF
and TGH.
According to DMAS, since 2001, when residential treatment
services were first implemented, individuals have not had access to
standardized methods of effective care coordination upon entry into residential
treatment due to locality influence and DMAS reimbursement limitations. This
has resulted in a fragmented coordination approach for these individuals who
are at risk for high level care and remain at risk of repeated placements at
this level of care. The residential treatment prior authorization and
utilization management structures require an enhanced care coordination model
to support the individuals who receive this level of service to ensure an
effective return to the family or caregiver home environment with follow up
services to facilitate ongoing treatment progress in the least restrictive
environment. The added coordination is required to navigate a very complex
service environment for the individual as they return to a community setting to
establish an effective aftercare environment that involves service providers
who may be contracted with a variety of entities such as managed care
organizations, enrolled providers, the local Family Assessment and Planning
Team (FAPT), local school divisions and the local Community Service Boards.
DMAS states that FAPT composition prior to the emergency
regulation was not consistent with the federal Medicaid requirement for
certifying a child for a Medicaid-funded residential treatment placement.
Changes to the program were necessary to address the concerns that arose from
the reliance upon the FAPT to fulfill the role as the federally mandated
independent team to certify residential treatment. The emergency regulation
implemented the IACCT approach to attain specific clinical outcomes for all
residential care episodes prior to managed care enrollment thorough discharge
from residential treatment. IACCT ensures meaningful communication across all
parts of the Children's Services Act providers, Department of Behavioral Health
and Developmental Services, Managed Care Organizations, and fee-for-servicer
systems to maximize efficiency of activities, eliminate duplicative and/or
conflicting efforts, and ensure established timelines are met. In addition, the
Virginia Independent Clinical Assessment Program (VICAP) process was originally
used to streamline high quality comprehensive assessments for services;
however, VICAP was sunset in order to use funds to pay for the IACCT.
These proposed changes are intended to ensure appropriate
utilization and cost efficiencies. Prior to the emergency regulation, the total
expenditures relating to the affected services were approximately $113 million.
In fiscal year 2018, the total expenditures decreased to $89.2 million. While
the precise total financial impact of these changes have not been quantified,
available data show that members utilizing PRTF have decreased from 1,104 in
the first quarter of 2016 to 887 in the third quarter of 2018 (a 20%
reduction); that members utilizing TGH have decreased from 349 in the first
quarter of 2016 to 311 in the third quarter of 2018 (an 11% reduction); that
members utilizing Level A group homes have decreased from 349 in the first
quarter of 2016 to 0 in the third quarter of 2018 (because it was completely
eliminated); that average length of stay in PRTF decreased from 215.2 days to
209 days (a 6.2-day reduction); and that average length of stay in TGH
decreased from 142.8 days to 120.9 days (a 21.9-day reduction).
Moreover, between September 2017 and August 2018, 3,231 IACCT
inquiries were received; 2,353 of these inquiries were referred for assessment.
Primary reasons for inquiries not leading to assessment included families not
returning calls, families deciding to continue with community services instead,
members being placed in juvenile detention, and families declining residential
services; 2,009 of the assessments recommended a residential placement (1,421
PRTF and 588 in a TGH). The remaining 344 individuals who received an
assessment but were not recommended for a residential placement, were
recommended for community services.
According to DMAS, the proposed changes are essential for
compliance with 42 CFR 441.153, which is prerequisite for federal match and for
members to receive services as appropriate.
Finally, this regulation has not been updated since 2001 when
psychiatric residential treatment services were first provided. Since then
major changes have occurred such as provision of behavioral health services
through Magellan, the Behavioral Health Service Administrator, implementation
of more evidence based service delivery systems, enhanced individualized
coordination of care, audit practices, etc. As a result, the proposed changes
also clarify provider qualifications including licensing standards; preadmission
assessment requirements, program requirements, discharge planning and care
coordination requirements in greater detail. Changes such as those are not
expected to create any significant economic impact upon promulgation of this
regulation. Added clarity of the regulatory requirements however would improve
compliance and produce a net benefit.
Businesses and Entities Affected. This regulation applies to 90
therapeutic group homes, 18 residential treatment facilities, 23 organizations
(including Community Service Boards, Comprehensive Services Act providers, and
private entities) providing Independent Assessment Certification and
Coordination services, and 128 Family Assessment and Planning Teams.
Localities Particularly Affected. No locality should be
affected any more than others.
Projected Impact on Employment. The proposed amendments were
implemented in July 2017. No impact on employment is expected upon promulgation
of the proposed amendments. However, the implementation of the emergency
regulations may have had a negative impact on group homes' and residential
treatment facilities' demand for labor to the extent it improved efficiencies
and eliminated duplicative and/or conflicting efforts. The establishment of the
IACCT approach should have added to demand for labor for them to perform their
functions.
Effects on the Use and Value of Private Property. No effects on
the use and value of private property is expected upon promulgation of the
proposed amendments.
Real Estate Development Costs. No impact on real estate
development costs is expected.
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 amendments do not impose
costs on small businesses; however, to the extent they improve efficiencies and
eliminate duplicative and/or conflicting efforts, they may reduce group homes
and residential treatment facility revenues.
Alternative Method that Minimizes Adverse Impact. There is no
known alternative method that would minimize the adverse impact while
accomplishing the same goals.
Adverse Impacts:
Businesses. The proposed amendments should not adversely affect
businesses upon promulgation.
Localities. The proposed amendments do not adversely affect
localities.
Other Entities. The proposed amendments do not adversely affect
other entities.
__________________________
1http://townhall.virginia.gov/L/viewstage.cfm?stageid=7424
Agency's Response to Economic Impact Analysis: The
agency has reviewed the economic impact analysis prepared by the Department of
Planning and Budget and raises no issues with this analysis.
Summary:
The proposed regulatory action implements Items 301 OO and
301 PP of Chapter 665 of the 2015 Acts of Assembly, which required the
department to develop and implement a care coordination model and make
programmatic changes in the provision of residential treatment for children.
The proposed action replaces emergency regulations published in 33:13 VA.R. 1436-1469 February 20, 2017,
and extended in 35:9 VA.R. 1130 December 24, 2018.
The proposed amendments clarify policy interpretations and
revise program standards to allow for more evidence-based service delivery,
allow the department to implement more effective utilization management in
collaboration with the behavioral health service administrator, enhance
individualized coordination of care, implement standardized coordination of
individualized aftercare resources by ensuring access to medical and behavioral
health service providers in the individual's home community, and support
department audit practices. The proposed action meets the requirements set
forth by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR
441 Subpart D and 42 CFR 441.453.
The proposed amendments include changes to the following
areas: (i) provider qualifications, including acceptable licensing standards;
(ii) preadmission assessment requirements; (iii) program requirements; (iv) new
discharge planning and care coordination requirements; and (v) language
enhancements for utilization review requirements to clarify program
requirements, ensure adequate documentation of service delivery, and help
providers avoid payment retractions.
The proposed action requires enhanced care coordination to
provide the necessary objective evaluations of treatment progress and to
facilitate evidence-based practices during the treatment to reduce the length
of stay by ensuring that medical necessity indicates the correct level of care,
that appropriate and effective care is delivered in a person centered manner,
and that service providers and local systems use standardized preadmission and
discharge processes to ensure effective services are delivered.
12VAC30-10-540. Inspection of care in intermediate care
facilities for the mentally retarded persons with intellectual and
developmental disabilities, facilities providing inpatient psychiatric
services for individuals under younger than 21 years of age,
and mental hospitals.
All applicable requirements of 42 CFR 456, Subpart I,
are met with respect to periodic inspections of care and services.*
Inpatient psychiatric services for individuals under age
21 are not provided under this plan.
*Inspection of Care (IOC) in Intermediate Care Facilities
for the Mentally Retarded and Institutions for Mental Diseases are Inspection
of care in intermediate care facilities for persons with intellectual and
developmental disabilities is completed through contractual arrangements
with the Virginia Department of Health.
12VAC30-50-20. Services provided to the categorically needy
without limitation.
The following services as described in Part III
(12VAC30-50-100 et seq.) of this chapter are provided to the categorically
needy without limitation:
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Services for individuals age 65 years of age
or over older in institutions for mental diseases: inpatient
hospital services; skilled nursing facility services; and services in an
intermediate care facility.
3. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined, in
accordance with § 1902(a)(31)(A) of the Social Security Act (the Act),
to be in need of such care, including such services in a public institution (or
distinct part thereof) for the mentally retarded or persons with intellectual
or developmental disability or related conditions.
4. Hospice care (in accordance with § 1905(o) of the Act).
5. Any other medical care and any type of remedial care recognized
under state law, specified by the U.S. Secretary of Health and Human
Services: care and services provided in religious nonmedical health care
institutions;, nursing facility services for patients under
younger than 21 years of age;, or emergency hospital
services.
6. Private health insurance premiums, coinsurance, and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
7. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for categorically needy individuals without limitation.
8. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21
years of age.
12VAC30-50-30. Services not provided to the categorically
needy.
The following services and devices are not provided to the
categorically needy:
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Other diagnostic and preventive services other than those
provided elsewhere in this plan: diagnostic services (see 12VAC30-50-95 et
seq.).
5. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
6. Special tuberculosis (TB) related services under § 1902(z)(2)(F)
of the Social Security Act (the Act).
7. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
8. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
9. Any other medical care and any type of remedial care
recognized under state law specified by the U.S. Secretary of Health
and Human Services: personal care services in recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12VAC30-50-60. Services provided to all medically needy groups
without limitations.
Services as described in Part III (12VAC30-50-100 et seq.) of
this chapter are provided to all medically needy groups without limitations.
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Early and periodic screening and diagnosis of individuals under
younger than 21 years of age, and treatment of conditions found.
3. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
4. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the
Act) to be in need of such care.
5. Hospice care (in accordance with § 1905(o) of the Act).
6. Any other medical care or any other type of remedial care
recognized under state law, specified by the secretary U.S. Secretary
of Health and Human Services, including: care and services provided in
religious nonmedical health care institutions;, skilled nursing
facility services for patients under younger than 21 years of age;,
and emergency hospital services.
7. Private health insurance premiums, coinsurance and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
8. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for medically needy individuals without limitation.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21 years
of age.
12VAC30-50-70. Services or devices not provided to the
medically needy.
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Diagnostic or preventive services other than those provided
elsewhere in the State Plan.
5. Inpatient hospital services, skilled nursing facility
services, and intermediate care facility services for individuals age 65
years of age or older in institutions for mental disease(s) diseases.
6. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the Act),
to be in need of such care in a public institution, or a distinct part thereof,
for the mentally retarded or persons with intellectual or
developmental disability or related conditions.
7. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
8. Special tuberculosis (TB) services under §
1902(z)(2)(F) of the Act.
9. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
10. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
11. Personal care services in a recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12. Home and community care for functionally disabled elderly
individuals, as defined, described and limited in 12VAC30-50-460 and
12VAC30-50-470.
13. Personal care services furnished to an individual who is
not an inpatient or resident of a hospital, nursing facility, intermediate care
facility for the mentally retarded intellectually or developmentally
disabled persons, or institution for mental disease that are (i) authorized
for the individual by a physician in accordance with a plan of treatment, (ii)
provided by an individual who is qualified to provide such services and who is
not a member of the individual's family, and (iii) furnished in a home.
12VAC30-50-130. Nursing facility services, EPSDT, including
school health services, and family planning.
A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or
performed within the scope of a license of the practitioner of the healing
arts.
B. Early General provisions for early and
periodic screening and, diagnosis, and treatment (EPSDT)
of individuals younger than 21 years of age, and treatment of conditions
found.
1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid
eligible, for medically necessary stays in acute care facilities,
and the accompanying attendant physician care, in excess of 21 days per
admission when such services are rendered for the purpose of diagnosis and
treatment of health conditions identified through a physical examination.
2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local departments
of social services departments on specific referral from those
departments.
3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department DMAS shall place appropriate
utilization controls upon this service.
4. Consistent with § 6403 of the Omnibus Budget
Reconciliation Act of 1989 § 6403, early and periodic screening,
diagnostic, and treatment services means the following services: screening
services, vision services, dental services, hearing services, and such other
necessary health care, diagnostic services, treatment, and other measures
described in Social Security Act § 1905(a) to correct or ameliorate defects and
physical and mental illnesses and conditions discovered by the screening
services and that are medically necessary, whether or not such services are
covered under the State Plan and notwithstanding the limitations, applicable to
recipients ages 21 years of age and older, provided for by §
1905(a) of the Social Security Act.
5. C. Community mental health services provided
through early and periodic screening diagnosis and treatment (EPSDT) for
individuals younger than 21 years of age. These services in order to be
covered (i) shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and (ii) are
shall be reflected in provider records and on providers' provider
claims for services by recognized diagnosis codes that support and are
consistent with the requested professional services.
a. 1. Definitions. The following words and terms
when used in this section shall have the following meanings unless the context
clearly indicates otherwise:
"Activities of daily living" means personal care
activities and includes bathing, dressing, transferring, toileting, feeding,
and eating.
"Adolescent or child" means the individual
receiving the services described in this section. For the purpose of the use of
these terms this term, adolescent means an individual 12 through
20 years of age; a child means an individual from birth up to 12 years of
age.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.
"Care coordination" means the collaboration
and sharing of information among health care providers, who are involved
with an individual's health care, to improve the care.
"Caregiver" means the same as defined
in 12VAC30-130-5160.
"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.
"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Child" means an individual ages birth through 11
years.
"DBHDS" means the Department of Behavioral Health
and Developmental Services.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined
in 12VAC35-105-20 with at least two consecutive years of documented
experience as a QMHP, and who has documented completion of the DBHDS PRS
supervisor training; or (iii) shall be an LMHP who has documented completion of
the DBHDS PRS supervisor training who is acting within his scope of practice
under state law. An LMHP providing services before April 1, 2018, shall have
until April 1, 2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractors.
"EPSDT" means early and periodic screening,
diagnosis, and treatment.
"Family support partners" means the same as defined
in 12VAC30-130-5170.
"Human services field" means the same as the term is
defined by DBHDS the Department of Health Professions in the
document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013 Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment practitioners.
An LMHP-resident shall be in continuous compliance with the regulatory
requirements of the applicable counseling profession for supervised practice
and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title "Resident"
in connection with the applicable profession after their signatures to indicate
such status.
"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the supervision
for specific clinical duties at a specific site has been preapproved in writing
by the Virginia Board of Psychology. For purposes of Medicaid reimbursement
by supervisors for services provided by such residents, they shall use the
title "Resident in Psychology" after their signatures to indicate
such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status,
staff interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.
"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.
"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.
"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590 including a
"QMHP-trainee" as defined by the Department of Health Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member as appropriate, about
the child's or adolescent's mental health status. It includes documented
history of the severity, intensity, and duration of mental health care problems
and issues and shall contain all of the following elements: (i) the presenting issue/reason
issue or reason for referral, (ii) mental health
history/hospitalizations, (iii) previous interventions by providers and
timeframes and response to treatment, (iv) medical profile, (v) developmental
history including history of abuse, if appropriate, (vi) educational/vocational
educational or vocational status, (vii) current living situation and
family history and relationships, (viii) legal status, (ix) drug and alcohol
profile, (x) resources and strengths, (xi) mental status exam and profile,
(xii) diagnosis, (xiii) professional summary and clinical formulation, (xiv)
recommended care and treatment goals, and (xv) the dated signature of the LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
"Services provided under arrangement" means the
same as defined in 12VAC30-130-850.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
b. 2. Intensive in-home services (IIH) to
children and adolescents younger than 21 years of age shall be time-limited
interventions provided in the individual's residence and when clinically
necessary in community settings. All interventions and the settings of the
intervention shall be defined in the Individual Service Plan. All IIH services
shall be designed to specifically improve family dynamics, and
provide modeling, and the clinically necessary interventions that
increase functional and therapeutic interpersonal relations between family
members in the home. IIH services are designed to promote psychoeducational
benefits of psychoeducation in the home setting of an individual who is
at risk of being moved into an out-of-home placement or who is being transitioned
to home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his the individual's parents or guardians, as appropriate, to
understand and practice appropriate problem solving, anger management, and
interpersonal interaction, etc.); care coordination with other required
services; and 24-hour emergency response.
(1) a. Service authorization shall be required
for Medicaid reimbursement prior to the onset of services. Services rendered
before the date of authorization shall not be reimbursed.
(2) b. Service-specific provider intakes shall
be required prior to the start of services at the onset of services and
ISPs shall be required during the entire duration of services. Services based
upon incomplete, missing, or outdated service-specific provider intakes or ISPs
shall be denied reimbursement. Requirements for service-specific provider
intakes and ISPs are set out in this section.
(3) c. These services may shall
only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C,
or a QMHP-E.
c. 3. Therapeutic day treatment (TDT) shall be
provided two or more hours per day in order to provide therapeutic
interventions (a unit is defined in 12VAC30-60-61 D 11). Day treatment
programs provide evaluation; medication education and management; opportunities
to learn and use daily living skills and to enhance social and interpersonal
skills (e.g., problem solving, anger management, community responsibility,
increased impulse control, and appropriate peer relations, etc.); and
individual, group, and family counseling.
(1) a. Service authorization shall be required
for Medicaid reimbursement.
(2) b. Service-specific provider intakes shall
be required at prior to the onset start of services,
and ISPs shall be required during the entire duration of services. Services
based upon incomplete, missing, or outdated service-specific provider intakes
or ISPs shall be denied reimbursement. Requirements for service-specific
provider intakes and ISPs are set out in this section.
(3) c. These services may shall be
rendered only by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or
a QMHP-E.
d. Community-based services for children and adolescents
younger than 21 years of age (Level A) pursuant to 42 CFR 440.031(d).
(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.
(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.
(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.
(5) Room and board costs shall not be reimbursed. DMAS
shall reimburse only for services provided in facilities or programs with no
more than 16 beds.
(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).
(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include development or maintenance of daily living skills, anger management,
social skills, family living skills, communication skills, stress management,
and any care coordination activities.
(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
(9) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.
(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.
D. Therapeutic group home services and psychiatric
residential treatment facility (PRTF) services for early and periodic screening
diagnosis and treatment (EPSDT) of individuals younger than 21 years of age.
1. Definitions. The following words and terms when used in
this subsection shall have the following meanings:
"Active treatment" means implementation of an
initial plan of care (IPOC) and comprehensive individual plan of care (CIPOC).
"Assessment" means the face-to-face interaction
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S to obtain information from the child or
adolescent and parent, guardian, or other family member, as appropriate,
utilizing a tool or series of tools to provide a comprehensive evaluation and review
of the child's or adolescent's mental health status. The assessment shall
include a documented history of the severity, intensity, and duration of mental
health problems and behavioral and emotional issues.
"Certificate of need" or "CON" means a
written statement by an independent certification team that services in a
therapeutic group home or PRTF are or were needed.
"Combined treatment services" means a structured,
therapeutic milieu and planned interventions that promote (i) the development
or restoration of adaptive functioning, self-care, and social skills; (ii)
community integrated activities and community living skills that each
individual requires to live in less restrictive environments; (iii) behavioral
consultation; (iv) individual and group therapy; (v) skills restoration, the
restoration of coping skills, family living and health awareness, interpersonal
skills, communication skills, and stress management skills; (vi) family
education and family therapy; and (vii) individualized treatment planning.
"Comprehensive individual plan of care" or
"CIPOC" means a person centered plan of care that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Crisis" means a deteriorating or unstable
situation that produces an acute, heightened emotional, mental, physical,
medical, or behavioral event.
"Crisis management" means immediately provided
activities and interventions designed to rapidly manage a crisis. The
activities and interventions include behavioral health care to provide
immediate assistance to individuals experiencing acute behavioral health
problems that require immediate intervention to stabilize and prevent harm and
higher level of acuity. Activities shall include assessment and short-term
counseling designed to stabilize the individual. Individuals are referred to
long-term services once the crisis has been stabilized.
"Daily supervision" means the supervision
provided in a PRTF through a resident-to-staff ratio approved by the Office of
Licensure at the Department of Behavioral Health and Developmental Services
with documented supervision checks every 15 minutes throughout a 24-hour
period.
"Discharge planning" means family and
locality-based care coordination that begins upon admission to a PRTF or
therapeutic group home with the goal of transitioning the individual out of the
PRTF or therapeutic group home to a less restrictive care setting with
continued, clinically-appropriate, and possibly intensive, services as soon as
possible upon discharge. Discharge plans shall be recommended by the treating
physician, psychiatrist, or treating LMHP responsible for the overall supervision
of the plan of care and shall be approved by the DMAS contractor.
"DSM-5" means the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric
Association.
"Emergency admissions" means those admissions that
are made when, pending a review for the certificate of need, it appears that
the individual is in need of an immediate admission to a therapeutic group home
or PRTF and likely does not meet the medical necessity criteria to receive
crisis intervention, crisis stabilization, or acute psychiatric inpatient
services.
"Emergency services" means unscheduled and
sometimes scheduled crisis intervention, stabilization, acute psychiatric
inpatient services, and referral assistance provided over the telephone or
face-to-face if indicated, and available 24 hours a day, seven days per week.
"Family engagement" means a family-centered and
strengths-based approach to partnering with families in making decisions,
setting goals, achieving desired outcomes, and promoting safety, permanency,
and well-being for children, adolescents, and families. Family engagement
requires ongoing opportunities for an individual to build and maintain
meaningful relationships with family members, for example, frequent,
unscheduled, and noncontingent telephone calls and visits between an individual
and family members. Family engagement may also include enhancing or
facilitating the development of the individual's relationship with other family
members and supportive adults responsible for the individual's care and
well-being upon discharge.
"Family engagement activity" means an
intervention consisting of family psychoeducational training or coaching,
transition planning with the family, family and independent living skills, and
training on accessing community supports as identified in the plan of care.
Family engagement activity does not include and is not the same as family
therapy.
"Family therapy" means counseling services
involving the individual's family and significant others to advance the
treatment goals when (i) the counseling with the family member and significant
others is for the direct benefit of the individual, (ii) the counseling is not
aimed at addressing treatment needs of the individual's family or significant
others, and (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals. Family therapy shall be aligned with the goals of
the individual's plan of care. All family therapy services furnished are for
the direct benefit of the individual, in accordance with the individual's needs
and treatment goals identified in the individual's plan of care, and for the
purpose of assisting in the individual's recovery.
"FAPT" means the family assessment and planning
team.
"ICD-10" means International Statistical
Classification of Diseases and Related Health Problems, 10th Revision,
published by the World Health Organization.
"Independent certification team" means a team
that has competence in diagnosis and treatment of mental illness, preferably in
child psychiatry; has knowledge of the individual's situation; and is composed
of at least one physician and one LMHP. The independent certification team
shall be a DMAS-authorized contractor with contractual or employment
relationships with the required team members.
"Individual" means the child or adolescent
younger than 21 years of age who is receiving therapeutic group home or PRTF
services.
"Individual and group therapy" means the
application of principles, standards, and methods of the counseling profession
in (i) conducting assessments and diagnosis for the purpose of establishing
treatment goals and objectives and (ii) planning, implementing, and evaluating
plans of care using treatment interventions to facilitate human development and
to identify and remediate mental, emotional, or behavioral disorders and
associated distresses that interfere with mental health.
"Initial plan of care" or "IPOC" means
a person centered plan of care established at admission that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Intervention" means scheduled therapeutic
treatment such as individual or group psychoeducation; skills restoration;
structured behavior support and training activities; recreation, art, and music
therapies; community integration activities that promote or assist in the
child's or adolescent's ability to acquire coping and functional or
self-regulating behavior skills; day and overnight passes; and family
engagement activities. Interventions shall not include individual, group, and
family therapy; medical or dental appointments; or physician services,
medication evaluation, or management provided by a licensed clinician or
physician and shall not include school attendance. Interventions shall be
provided in the therapeutic group home or PRTF and, when clinically necessary,
in a community setting or as part of a therapeutic pass. All interventions and
settings of the intervention shall be established in the plan of care.
"Plan of care" means the initial plan of care
(IPOC) and the comprehensive individual plan of care (CIPOC).
"Physician" means an individual licensed to
practice medicine or osteopathic medicine in Virginia, as defined in §
54.1-2900 of the Code of Virginia.
"Psychiatric residential treatment facility" or
"PRTF" means the same as defined in 42 CFR 483.352 and is a 24-hour,
supervised, clinically and medically necessary, out-of-home active treatment
program designed to provide necessary support and address mental health,
behavioral, substance abuse, cognitive, and training needs of an individual
younger than 21 years of age in order to prevent or minimize the need for more
intensive treatment.
"Recertification" means a certification for each
applicant or recipient for whom therapeutic group home or PRTF services are
needed.
"Room and board" means a component of the total
daily cost for placement in a licensed PRTF. Residential room and board costs
are maintenance costs associated with placement in a licensed PRTF and include
a semi-private room, three meals and two snacks per day, and personal care
items. Room and board costs are reimbursed only for PRTF settings.
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in a freestanding psychiatric hospital or PRTF that
are billed by the arranged practitioners separately from the freestanding
psychiatric hospital's or PRTF's per diem.
"Skills restoration" means a face-to-face service
to assist individuals in the restoration of lost skills that are necessary to
achieve the goals established in the beneficiary's plan of care. Services
include assisting the individual in restoring self-management, interpersonal,
communication, and problem solving skills through modeling, coaching, and
cueing.
"Therapeutic group home" means a congregate
residential service providing 24-hour supervision in a community-based home
having eight or fewer residents.
"Therapeutic pass" means time at home or
time with family consisting of partial or entire days of time away from the
therapeutic group home or psychiatric residential treatment facility as
clinically indicated in the plan of care and as paired with facility-based and
community-based interventions to promote discharge planning, community
integration, and family engagement activities. Therapeutic passes are not
recreational but are a therapeutic component of the plan of care and are
designed for the direct benefit of the individual.
"Treatment planning" means development of a
person centered plan of care that is specific to the individual's unique
treatment needs and acuity levels.
e. 2. Therapeutic behavioral group
home services (Level B) pursuant to 42 CFR 440.130(d).
(1) Such services must be therapeutic services rendered in
a residential setting. The residential services will provide structure for
daily activities, psychoeducation, therapeutic supervision, care coordination,
and psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual ® Criteria, or an equivalent standard authorized in advance by DMAS
shall be required for this service.
(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.
(3) a. Therapeutic group home services for children
and adolescents younger than 21 years of age shall provide therapeutic services
to restore or maintain appropriate skills necessary to promote prosocial
behavior and healthy living, including skills restoration, family living and
health awareness, interpersonal skills, communication skills, and stress
management skills. Therapeutic services shall also engage families and reflect
family-driven practices that correlate to sustained positive outcomes
post-discharge for youth and their family members. Each component of
therapeutic group home services is provided for the direct benefit of the
individual, in accordance with the individual's needs and treatment goals
identified in the individual's plan of care, and for the purpose of assisting
in the individual's recovery. These services are provided under 42 CFR
440.130(d) in accordance with the rehabilitative services benefit.
b. The plan of care shall include individualized
activities, including a minimum of one intervention per 24-hour period in
addition to individual, group, and family therapies. Daily interventions are
not required when there is documentation to justify clinical or medical reasons
for the individual's deviations from the plan of care. Interventions shall be
documented on a progress note and shall be outlined in and aligned with the
treatment goals and objectives in the IPOC and CIPOC. Any deviation from the
plan of care shall be documented along with a clinical or medical justification
for the deviation.
c. Medical necessity criteria for admission to a
therapeutic group home. The following requirements for severity of need and
intensity and quality of service shall be met to satisfy the medical necessity
criteria for admission.
(1) Severity of need required for admission. All of the
following criteria shall be met to satisfy the criteria for severity of need:
(a) The individual's behavioral health condition can only
be safely and effectively treated in a 24-hour therapeutic milieu with onsite
behavioral health therapy due to significant impairments in home, school, and
community functioning caused by current mental health symptoms consistent with
a DSM-5 diagnosis.
(b) The certificate of need must demonstrate all of the
following: (i) ambulatory care resources (all available modalities of treatment
less restrictive than inpatient treatment) available in the community do not
meet the treatment needs of the individual; (ii) proper treatment of the
individual's psychiatric condition requires services on an inpatient basis
under the direction of a physician; and (iii) the services can reasonably be
expected to improve the individual's condition or prevent further regression so
that the services will no longer be needed.
(c) The state uniform assessment tool shall be completed.
The assessment shall demonstrate at least two areas of moderate impairment in
major life activities. A moderate impairment is defined as a major or
persistent disruption in major life activities. A moderate impairment is
evidenced by, but not limited to (i) frequent conflict in the family setting
such as credible threats of physical harm, where "frequent" means
more than expected for the individual's age and developmental level; (ii)
frequent inability to accept age-appropriate direction and supervision from
caretakers, from family members, at school, or in the home or community; (iii)
severely limited involvement in social support, which means significant
avoidance of appropriate social interaction, deterioration of existing
relationships, or refusal to participate in therapeutic interventions; (iv)
impaired ability to form a trusting relationship with at least one caretaker in
the home, school, or community; (v) limited ability to consider the effect of
one's inappropriate conduct on others; and (vi) interactions consistently
involving conflict, which may include impulsive or abusive behaviors.
(d) Less restrictive community-based services have been
given a fully adequate trial and were unsuccessful or, if not attempted, have
been considered, but in either situation were determined to be unable to meet
the individual's treatment needs and the reasons for that are discussed in the
certificate of need.
(e) The individual's symptoms, or the need for treatment in
a 24 hours a day, seven days a week level of care (LOC), are not primarily due
to any of the following: (i) intellectual disability, developmental disability,
or autistic spectrum disorder; (ii) organic mental disorders, traumatic brain
injury, or other medical condition; or (iii) the individual does not require a
more intensive level of care.
(f) The individual does not require primary medical or
surgical treatment.
(2) Intensity and quality of service necessary for admission.
All of the following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The therapeutic group home service has been prescribed
by a psychiatrist, psychologist, or other LMHP who has documented that a
residential setting is the least restrictive clinically appropriate service
that can meet the specifically identified treatment needs of the individual.
(b) The therapeutic group home is not being used for
clinically inappropriate reasons, including (i) an alternative to incarceration
or preventative detention; (ii) an alternative to a parent's, guardian's, or
agency's capacity to provide a place of residence for the individual; or (iii)
a treatment intervention when other less restrictive alternatives are available.
(c) The individual's treatment goals are included in the
service specific provider intake and include behaviorally defined objectives
that require and can reasonably be achieved within a therapeutic group home
setting.
(d) The therapeutic group home is required to coordinate
with the individual's community resources, including schools and FAPT as
appropriate, with the goal of transitioning the individual out of the program
to a less restrictive care setting for continued, sometimes intensive, services
as soon as possible and appropriate.
(e) The therapeutic group home program must incorporate
nationally established, evidence-based, trauma-informed services and supports
that promote recovery and resiliency.
(f) Discharge planning begins upon admission, with concrete
plans for the individual to transition back into the community beginning within
the first week of admission, with clear action steps and target dates outlined
in the plan of care.
(3) Continued stay criteria. The following criteria shall
be met in order to satisfy the criteria for continued stay:
(a) All of the admission guidelines continue to be met and
continue to be supported by the written clinical documentation.
(b) The individual shall meet one of the following
criteria: (i) the desired outcome or level of functioning has not been restored
or improved in the timeframe outlined in the individual's plan of care or the
individual continues to be at risk for relapse based on history or (ii) the
nature of the functional gains is tenuous and use of less intensive services
will not achieve stabilization.
(c) The individual shall meet one of the following
criteria: (i) the individual has achieved initial CIPOC goals, but additional
goals are indicated that cannot be met at a lower level of care; (ii) the
individual is making satisfactory progress toward meeting goals but has not
attained plan of care goals, and the goals cannot be addressed at a lower level
of care; (iii) the individual is not making progress, and the plan of care has
been modified to identify more effective interventions; or (iv) there are
current indications that the individual requires this level of treatment to
maintain level of functioning as evidenced by failure to achieve goals
identified for therapeutic visits or stays in a nontreatment residential
setting or in a lower level of residential treatment.
(d) There is a written, up-to-date discharge plan that (i)
identifies the custodial parent or custodial caregiver at discharge; (ii)
identifies the school the individual will attend at discharge, if applicable;
(iii) includes individualized education program (IEP) and FAPT recommendations,
if necessary; (iv) outlines the aftercare treatment plan (discharge to another
residential level of care is not an acceptable discharge goal); and (v) lists
barriers to community reintegration and progress made on resolving these
barriers since last review.
(e) The active plan of care includes structure for combined
treatment services and activities to ensure the attainment of therapeutic
mental health goals as identified in the plan of care. Combined treatment
services reinforce and practice skills learned in individual, group, and family
therapy such as community integration skills, coping skills, family living and
health awareness skills, interpersonal skills, and stress management skills.
Combined treatment services may occur in group settings, in one-on-one
interactions, or in the home setting during a therapeutic pass. In addition to
the combined treatment services, the child or adolescent must also receive
psychotherapy services, care coordination, family-based discharge planning, and
locality-based transition activities. The child or adolescent shall receive
intensive family interventions at least twice per month, although it is recommended
that the intensive family interventions be provided at a frequency of one
family therapy session per week. Family involvement begins immediately upon
admission to therapeutic group home. If the minimum requirement cannot be met,
the reasons must be reported, and continued efforts to involve family members
must also be documented. Other family members or supportive adults may be
included as indicated in the plan of care.
(f) Less restrictive treatment options have been considered
but cannot yet meet the individual's treatment needs. There is sufficient
current clinical documentation or evidence to show that therapeutic group home
level of care continues to be the least restrictive level of care that can meet
the individual's mental health treatment needs.
(4) Discharge shall occur if any of the following applies:
(i) the level of functioning has improved with respect to the goals outlined in
the plan of care, and the individual can reasonably be expected to maintain
these gains at a lower level of treatment; (ii) the individual no longer
benefits from service as evidenced by absence of progress toward plan of care
goals for a period of 60 days; or (iii) other less intensive services may
achieve stabilization.
d. The following clinical activities shall be required for
each therapeutic group home resident:
(1) An assessment be performed by an LMHP, LMHP-R, LMHP-RP,
or LMHP-S.
(2) A face-to-face evaluation shall be performed by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days prior to admission with
a documented DSM-5 or ICD-10 diagnosis.
(3) A certificate of need shall be completed by an
independent certification team according to the requirements of subdivision D 4
of this section. Recertification shall occur at least every 60 calendar days by
an LMHP, LMHP-R, LMHP-RP, or LMHP-S acting within his scope of practice.
(4) An IPOC that is specific to the individual's unique
treatment needs and acuity levels. The IPOC shall be completed on the day of
admission by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be signed by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual and a family member or
legally authorized representative. The IPOC shall include all of the following:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Orders for medications, psychiatric, medical, dental,
and any special health care needs whether or not provided in the facilities,
treatments, restorative and rehabilitative services, activities, therapies,
therapeutic passes, social services, community integration, diet, and special
procedures recommended for the health and safety of the individual;
(f) Plans for continuing care, including review and
modification to the plan of care; and
(g) Plans for discharge.
(5) A CIPOC shall be completed no later than 14 calendar
days after admission. The CIPOC shall meet all of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and shall reflect the need
for therapeutic group home care;
(b) Be based on input from school, home, other health care
providers, FAPT if necessary, the individual, and the family or legal guardian;
(c) Shall state treatment objectives that include
measurable short-term and long-term goals and objectives, with target dates for
achievement;
(d) Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis; and
(e) Include a comprehensive discharge plan with necessary,
clinically appropriate community services to ensure continuity of care upon
discharge with the individual's family, school, and community.
(6) The CIPOC shall be reviewed, signed, and dated every 30
calendar days by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a
family member or primary caregiver. Updates shall be signed and dated by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a family member or
legally authorized representative. The review shall include all of the
following:
(a) The individual's response to the services provided;
(b) Recommended changes in the plan as indicated by the
individual's overall response to the CIPOC interventions; and
(c) Determinations regarding whether the services being
provided continue to be required.
(7) Crisis management, clinical assessment, and
individualized therapy shall be provided to address both behavioral health and
substance use disorder needs as indicated in the plan of care to address
intermittent crises and challenges within the therapeutic group home setting or
community settings as defined in the plan of care and to avoid a higher level
of care.
(8) Care coordination shall be provided with medical,
educational, and other behavioral health providers and other entities involved
in the care and discharge planning for the individual as included in the plan
of care.
(9) Weekly individual therapy shall be provided in the
therapeutic group home, or other settings as appropriate for the individual's
needs, by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which shall be documented in
progress notes in accordance with the requirements in 12VAC30-60-61.
(10) Weekly (or more frequently if clinically indicated)
group therapy shall be provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which
shall be documented in progress notes in accordance with the requirements in
12VAC30-60-61 and as planned and documented in the plan of care.
(11) Family treatment shall be provided as clinically
indicated, provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, and documented in
progress notes in accordance with the requirements in 12VAC30-60-61 and as
planned and documented in the plan of care.
(12) Family engagement activities shall be provided in
addition to family therapy or counseling. Family engagement activities shall be
provided at least weekly as outlined in the plan of care, and daily
communication with the family or legally authorized representative shall be
part of the family engagement strategies in the plan of care. For each
service authorization period when family engagement is not possible, the therapeutic
group home shall identify and document the specific barriers to the
individual's engagement with the individual's family or legally authorized
representatives. The therapeutic group home shall document on a weekly basis
the reasons why family engagement is not occurring as required. The therapeutic
group home shall document alternative family engagement strategies to be used
as part of the interventions in the plan of care and request approval of the
revised plan of care by DMAS. When family engagement is not possible, the
therapeutic group home shall collaborate with DMAS on a weekly basis to develop
individualized family engagement strategies and document the revised strategies
in the plan of care.
(13) Therapeutic passes shall be provided as clinically indicated
in the plan of care and as paired with facility-based and community-based
interventions to promote discharge planning, community integration, and family
engagement activities.
(a) The provider shall document how the family was prepared
for the therapeutic pass to include a review of the plan of care goals and
objectives being addressed by the planned interventions and the safety and
crisis plan in effect during the therapeutic pass.
(b) If a facility staff member does not accompany the
individual on the therapeutic pass and the therapeutic pass exceeds 24 hours,
the provider shall make daily contacts with the family and be available 24
hours per day to address concerns, incidents, or crises that may arise during
the pass.
(c) Contact with the family shall occur within seven
calendar days of the therapeutic pass to discuss the accomplishments and
challenges of the therapeutic pass along with an update on progress toward plan
of care goals and any necessary changes to the plan of care.
(d) Twenty-four therapeutic passes shall be permitted per
individual, per admission, without authorization as approved by the treating
LMHP and documented in the plan of care. Additional therapeutic passes shall
require service authorization. Any unauthorized therapeutic passes shall result
in retraction for those days of service.
(14) Discharge planning shall begin at admission and
continue throughout the individual's stay at the therapeutic group home. The
family or guardian, the community services board (CSB), the family assessment
and planning team (FAPT) case manager, and the DMAS contracted care manager
shall be involved in treatment planning and shall identify the anticipated
needs of the individual and family upon discharge and available services in the
community. Prior to discharge, the therapeutic group home shall submit an
active and viable discharge plan to the DMAS contractor for review. Once the
DMAS contractor approves the discharge plan, the provider shall begin actively
collaborating with the family or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The therapeutic
group home shall request permission from the parent or legally authorized
representative to share treatment information with these providers and shall
share information pursuant to a valid release. The therapeutic group home shall
request information from post-discharge providers to establish that the
planning of pending services and transition planning activities has begun,
shall establish that the individual has been enrolled in school, and shall
provide individualized education program recommendations to the school if
necessary. The therapeutic group home shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the therapeutic group home.
(15) Room and board costs shall not be reimbursed.
Facilities that only provide independent living services or nonclinical
services that do not meet the requirements of this subsection are not reimbursed
eligible for reimbursement. DMAS shall reimburse only for services
provided in facilities or programs with no more than 16 beds.
(4) These residential (16) Therapeutic group home
services providers must shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) under the Regulations
for Children's Residential Facilities (12VAC35-46).
(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include development or maintenance of daily living skills,
anger management, social skills, family living skills, communication skills,
and stress management. This service may be provided in a program setting or a
community-based group home.
(6) The individual must receive, at least weekly,
individual psychotherapy and, at least weekly, group psychotherapy that is
provided as part of the program.
(7) (17) Individuals shall be discharged from
this service when treatment goals are met or other less intensive
services may achieve stabilization.
(8) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. (18) Services that are based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs plans of care
shall be denied reimbursement. Requirements for intakes and ISPs are set out
in 12VAC30-60-61.
(9) These (19) Therapeutic group home services
may only be rendered by and within the scope of practice of an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH as
defined in 12VAC35-105-20.
(10) (20) The facility/group psychiatric
residential treatment facility or therapeutic group home shall coordinate
necessary services and discharge planning with other providers as
medically and clinically necessary. Documentation of this care coordination
shall be maintained by the facility/group facility or group home
in the individual's record. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted, and
recommended next steps.
(21) Failure to perform any of the items described in this
subsection shall result in a retraction of the per diem for each day of
noncompliance.
3. PRTF services are a 24-hour, supervised, clinically and
medically necessary out-of-home program designed to provide necessary support
and address mental health, behavioral, substance use, cognitive, or other
treatment needs of an individual younger than 21 years of age in order to
prevent or minimize the need for more inpatient treatment. Active treatment and
comprehensive discharge planning shall begin prior to admission. In order to be
covered for individuals younger than 21 years of age, these services shall (i)
meet DMAS-approved psychiatric medical necessity criteria or be approved as an
EPSDT service based upon a diagnosis made by an LMHP, LMHP-R, LMHP-RP, or
LMHP-S who is practicing within the scope of his license and (ii) be reflected
in provider records and on the provider's claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services.
a. PRTF services shall be covered for the purpose of
diagnosis and treatment of mental health and behavioral disorders when such
services are rendered by a psychiatric facility that is not a hospital and is
accredited by the Joint Commission on Accreditation of Healthcare
Organizations, the Commission on Accreditation of Rehabilitation Facilities,
the Council on Accreditation of Services for Families and Children, or by any
other accrediting organization with comparable standards that is recognized by
the state.
b. Providers of PRTF services shall be licensed by DBHDS.
c. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151 (a) and (b) and 42 CFR 441.152 through 42 CFR
441.156 and (ii) the Conditions of Participation in 42 CFR Part 483 Subpart G.
Each admission must be service authorized, and the treatment must meet DMAS
requirements for clinical necessity.
d. The PRTF benefit for individuals younger than 21 years
of age shall include services defined at 42 CFR 440.160 that are provided
under the direction of a physician pursuant to a certification of medical
necessity and plan of care developed by an interdisciplinary team of
professionals and shall involve active treatment designed to achieve the
child's discharge from PRTF services at the earliest possible time. The PRTF
services benefit shall include services provided under arrangement furnished by
Medicaid enrolled providers other than the PRTF, as long as the PRTF (i)
arranges for and oversees the provision of all services, (ii) maintains all
medical records of care furnished to the individual, and (iii) ensures that the
services are furnished under the direction of a physician. Services provided
under arrangement shall be documented by a written referral from the PRTF. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
e. PRTFs, as defined at 42 CFR 483.352, shall arrange for,
maintain records of, and ensure that physicians order these services: (i)
medical and psychological services, including those furnished by physicians,
licensed mental health professionals, and other licensed or certified health
professionals (i.e., nutritionists, podiatrists, respiratory therapists, and
substance abuse treatment practitioners); (ii) pharmacy services; (iii)
outpatient hospital services; (iv) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (v)
laboratory and radiology services; (vi) durable medical equipment; (vii) vision
services; (viii) dental, oral surgery, and orthodontic services; (ix)
nonemergency transportation services; and (x) emergency services.
f. PRTF services shall include assessment and
reassessment; room and board; daily supervision; combined treatment services;
individual, family, and group therapy; care coordination; interventions;
general or special education; medical treatment (including medication,
coordination of necessary medical services, and 24-hour onsite nursing);
specialty services; and discharge planning that meets the medical and clinical
needs of the individual.
g. Medical necessity criteria for admission to a PRTF. The
following requirements for severity of need and intensity and quality of
service shall be met to satisfy the medical necessity criteria for admission:
(1) Severity of need required for admission. The following
criteria shall be met to satisfy the criteria for severity of need:
(a) There is clinical evidence that the individual has a
DSM-5 disorder that is amenable to active psychiatric treatment.
(b) There is a high degree of potential of the condition
leading to acute psychiatric hospitalization in the absence of residential
treatment.
(c) Either (i) there is clinical evidence that the
individual would be a risk to self or others if the individual were not in a
PRTF or (ii) as a result of the individual's mental disorder, there is an
inability for the individual to adequately care for his own physical needs, and
caretakers, guardians, or family members are unable to safely fulfill these
needs, representing potential serious harm to self.
(d) The individual requires supervision seven days per
week, 24 hours per day to develop skills necessary for daily living; to assist
with planning and arranging access to a range of educational, therapeutic, and
aftercare services; and to develop the adaptive and functional behavior that
will allow the individual to live outside of a PRTF setting.
(e) The individual's current living environment does not
provide the support and access to therapeutic services needed.
(f) The individual is medically stable and does not require
the 24-hour medical or nursing monitoring or procedures provided in a hospital
level of care.
(2) Intensity and quality of service necessary for
admission. The following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The evaluation and assignment of a DSM-5 diagnosis must
result from a face-to-face psychiatric evaluation.
(b) The program provides supervision seven days per week,
24 hours per day to assist with the development of skills necessary for daily
living; to assist with planning and arranging access to a range of educational,
therapeutic, and aftercare services; and to assist with the development of the
adaptive and functional behavior that will allow the individual to live outside
of a PRTF setting.
(c) An individualized plan of active psychiatric treatment
and residential living support is provided in a timely manner. This treatment
must be medically monitored, with 24-hour medical availability and 24-hour
nursing services availability. This plan includes (i) at least once-a-week
psychiatric reassessments; (ii) intensive family or support system involvement
occurring at least once per week or valid reasons identified as to why such a
plan is not clinically appropriate or feasible; (iii) psychotropic medications,
when used, are to be used with specific target symptoms identified; (iv)
evaluation for current medical problems; (v) evaluation for concomitant
substance use issues; and (vi) linkage or coordination with the individual's
community resources, including the local school division and FAPT case manager,
as appropriate, with the goal of returning the individual to his regular social
environment as soon as possible, unless contraindicated. School contact should
address an individualized educational plan as appropriate.
(d) A urine drug screen is considered at the time of
admission, when progress is not occurring, when substance misuse is suspected,
or when substance use and medications may have a potential adverse interaction.
After a positive screen, additional random screens are considered and referral
to a substance use disorder provider is considered.
(3) Criteria for continued stay. The following criteria
shall be met to satisfy the criteria for continued stay:
(a) Despite reasonable therapeutic efforts, clinical
evidence indicates at least one of the following: (i) the persistence of
problems that caused the admission to a degree that continues to meet the
admission criteria (both severity of need and intensity of service needs); (ii)
the emergence of additional problems that meet the admission criteria (both
severity of need and intensity of service needs); or (iii) that disposition
planning or attempts at therapeutic reentry into the community have resulted in
or would result in exacerbation of the psychiatric illness to the degree that
would necessitate continued PRTF treatment. Subjective opinions without
objective clinical information or evidence are not sufficient to meet severity
of need based on justifying the expectation that there would be a
decompensation.
(b) There is evidence of objective, measurable, and
time-limited therapeutic clinical goals that must be met before the individual
can return to a new or previous living situation. There is evidence that
attempts are being made to secure timely access to treatment resources and
housing in anticipation of discharge, with alternative housing contingency
plans also being addressed.
(c) There is evidence that the plan of care is focused on
the alleviation of psychiatric symptoms and precipitating psychosocial
stressors that are interfering with the individual's ability to return to a
less-intensive level of care.
(d) The current or revised plan of care can be reasonably
expected to bring about significant improvement in the problems meeting the
criteria in subdivision 3 c (3) (a) of this subsection, and this is documented
in weekly progress notes written and signed by the provider.
(e) There is evidence of intensive family or support system
involvement occurring at least once per week, unless there is an identified
valid reason why it is not clinically appropriate or feasible.
(f) A discharge plan is formulated that is directly linked
to the behaviors or symptoms that resulted in admission and begins to identify
appropriate post-PRTF resources including the local school division and FAPT
case manager as appropriate.
(g) All applicable elements in admission-intensity and
quality of service criteria are applied as related to assessment and treatment
if clinically relevant and appropriate.
(4) Discharge criteria. Discharge shall occur if any of the
following applies: (i) the level of functioning has improved with respect to
the goals outlined in the plan of care, and the individual can reasonably be
expected to maintain these gains at a lower level of treatment; (ii) the
individual no longer benefits from service as evidenced by absence of progress
toward plan of care goals for a period of 30 days; or (iii) other less
intensive services may achieve stabilization.
h. The following clinical activities shall be required for
each PRTF resident:
(1) A face-to-face assessment shall be performed by an
LMHP, LMHP-R, LMHP-RS, or LMHP-S within 30 calendar days prior to admission and
weekly thereafter and shall document a DSM-5 or ICD-10 diagnosis.
(2) A certificate of need shall be completed by an independent
certification team according to the requirements of 12VAC30-50-130 D 4.
Recertification shall occur at least every 30 calendar days by a physician
acting within his scope of practice.
(3) The initial plan of care (IPOC) shall be completed
within 24 hours of admission by the treatment team. The IPOC shall
include:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Any orders for medications, psychiatric, medical,
dental, and any special health care needs, whether or not provided in the
facility; education or special education; treatments; interventions; and
restorative and rehabilitative services, activities, therapies, social
services, diet, and special procedures recommended for the health and safety of
the individual;
(f) Plans for continuing care, including review and
modification to the plan of care;
(g) Plans for discharge; and
(h) Signature and date by the individual, parent, or
legally authorized representative, a physician, and treatment team members.
(4) The CIPOC shall be completed and signed no later than
14 calendar days after admission by the treatment team. The PRTF shall request
authorizations from families to release confidential information to collect information
from medical and behavioral health treatment providers, schools, FAPT, social
services, court services, and other relevant parties. This information shall be
used when considering changes and updating the CIPOC. The CIPOC shall meet all
of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for PRTF care;
(b) Be developed by an interdisciplinary team of physicians
and other personnel specified in subdivision 3 d 4 of this subsection who are
employed by or provide services to the individual in the facility in
consultation with the individual, family member, or legally authorized representative,
or appropriate others into whose care the individual will be released after
discharge;
(c) Shall state treatment objectives that shall include
measurable, evidence-based, and short-term and long-term goals and objectives;
family engagement activities; and the design of community-based aftercare with
target dates for achievement;
(d) Prescribe an integrated program of therapies,
interventions, activities, and experiences designed to meet the treatment
objectives related to the individual and family treatment needs; and
(e) Describe comprehensive transition plans and
coordination of current care and post-discharge plans with related community
services to ensure continuity of care upon discharge with the recipient's
family, school, and community.
(5) The CIPOC shall be reviewed every 30 calendar days by
the team specified in subdivision 3 d 4 of this subsection to determine that
services being provided are or were required from a PRTF and to recommend
changes in the plan as indicated by the individual's overall adjustment during
the time away from home. The CIPOC shall include the signature and date from
the individual, parent, or legally authorized representative, a physician, and
treatment team members.
(6) Individual therapy shall be provided three times
per week (or more frequently based upon the individual's needs) provided by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of care
and progress notes in accordance with the requirements in this subsection and
12VAC30-60-61.
(7) Group therapy shall be provided as clinically indicated
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of
care and progress notes in accordance with the requirements in this subsection.
(8) Family therapy shall be provided as clinically
indicated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the
plan of care and progress notes in accordance with the individual and family or
legally authorized representative's goals and the requirements in this subsection.
(9) Family engagement shall be provided in addition to
family therapy or counseling. Family engagement shall be provided at least
weekly as outlined in the plan of care and daily communication with the
treatment team representative and the treatment team representative and the
family or legally authorized representative shall be part of the family
engagement strategies in the plan of care. For each service authorization
period when family engagement is not possible, the PRTF shall identify and
document the specific barriers to the individual's engagement with his family
or legally authorized representatives. The PRTF shall document on a weekly
basis the reasons that family engagement is not occurring as required. The PRTF
shall document alternate family engagement strategies to be used as part of the
interventions in the plan of care and request approval of the revised plan of
care by DMAS. When family engagement is not possible, the PRTF shall
collaborate with DMAS on a weekly basis to develop individualized family
engagement strategies and document the revised strategies in the plan of care.
(10) Three interventions shall be provided per 24-hour
period including nights and weekends. Family engagement activities are
considered to be an intervention and shall occur based on the treatment and
visitation goals and scheduling needs of the family or legally authorized
representative. Interventions shall be documented on a progress note and shall
be outlined in and aligned with the treatment goals and objectives in the plan
of care. Any deviation from the plan of care shall be documented along with a
clinical or medical justification for the deviation based on the needs of the
individual.
(11) Therapeutic passes shall be provided as clinically
indicated in the plan of care and as paired with community-based and
facility-based interventions to promote discharge planning, community
integration, and family engagement. Therapeutic passes include activities as
listed in subdivision 2 d (13) of this section. Twenty-four therapeutic passes
shall be permitted per individual, per admission, without authorization as
approved by the treating physician and documented in the plan of care.
Additional therapeutic passes shall require service authorization from DMAS.
Any unauthorized therapeutic passes not approved by the provider or DMAS shall
result in retraction for those days of service.
(12) Discharge planning shall begin at admission and
continue throughout the individual's placement at the PRTF. The parent or
legally authorized representative, the community services board (CSB), the
family assessment planning team (FAPT) case manager, if appropriate, and the
DMAS contracted care manager shall be involved in treatment planning and shall
identify the anticipated needs of the individual and family upon discharge and
identify the available services in the community. Prior to discharge, the PRTF
shall submit an active discharge plan to the DMAS contractor for review. Once
the DMAS contractor approves the discharge plan, the provider shall begin
collaborating with the parent or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The PRTF shall
request written permission from the parent or legally authorized representative
to share treatment information with these providers and shall share information
pursuant to a valid release. The PRTF shall request information from
post-discharge providers to establish that the planning of services and
activities has begun, shall establish that the individual has been enrolled in
school, and shall provide individualized education program recommendations to
the school if necessary. The PRTF shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the PRTF.
(13) Failure to perform any of the items as described in
subdivisions 3 h (1) through 3 h (12) of this subsection up until the discharge
of the individual shall result in a retraction of the per diem and all other
contracted and coordinated service payments for each day of noncompliance.
i. The team developing the CIPOC shall meet the following
requirements:
(1) At least one member of the team must have expertise in
pediatric behavioral health. Based on education and experience, preferably
including competence in child or adolescent psychiatry, the team must be
capable of all of the following: assessing the individual's immediate and
long-range therapeutic needs, developmental priorities, and personal strengths
and liabilities; assessing the potential resources of the individual's family
or legally authorized representative; setting treatment objectives; and
prescribing therapeutic modalities to achieve the CIPOC's objectives.
(2) The team shall include one of the following:
(a) A board-eligible or board-certified psychiatrist;
(b) A licensed clinical psychologist and a physician
licensed to practice medicine or osteopathy; or
(c) A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases and a licensed clinical psychologist.
(3) The team shall also include one of the following: an
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
4. Requirements for independent certification teams
applicable to both therapeutic group homes and PRTFs:
a. The independent certification team shall certify the
need for PRTF or therapeutic group home services and issue a certificate of
need document within the process and timeliness standards as approved by DMAS
under contractual agreement with the DMAS contractor.
b. The independent certification team shall be approved by
DMAS through a memorandum of understanding with a locality or be approved under
contractual agreement with the DMAS contractor. The team shall initiate and
coordinate referral to the family assessment and planning team (FAPT) as
defined in §§ 2.2-5207 and 2.2-5208 of the Code of Virginia to facilitate care
coordination and for consideration of educational coverage and other supports
not covered by DMAS.
c. The independent certification team shall assess the
individual's and family's strengths and needs in addition to diagnoses,
behaviors, and symptoms that indicate the need for behavioral health treatment
and also consider whether local resources and community-based care are
sufficient to meet the individual's treatment needs, as presented within the
previous 30 calendar days, within the least restrictive environment.
d. The LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP, as
part of the independent certification team, shall meet with an individual and
the individual's parent or legally authorized representative within two
business days from a request to assess the individual's needs and begin the
process to certify the need for an out-of-home placement.
e. The independent certification team shall meet with an
individual and the individual's parent or legally authorized representative
within 10 business days from a request to certify the need for an out-of-home
placement.
f. The independent certification team shall assess the
treatment needs of the individual to issue a certificate of need (CON) for the
most appropriate medically necessary services. The certification shall include
the dated signature and credentials for each of the team members who rendered
the certification. Referring or treatment providers shall not actively
participate during the certification process but may provide supporting
clinical documentation to the certification team.
g. The CON shall be effective for 30 calendar days prior to
admission.
h. The independent certification team shall provide the
completed CON to the facility within one calendar day of completing the CON.
i. The individual and the individual's parent or legally
authorized representative shall have the right to freedom of choice of service
providers.
j. If the individual or the individual's parent or legally
authorized representative disagrees with the independent certification team's
recommendation, the parent or legally authorized representative may appeal the
recommendation in accordance with 12VAC30-110.
k. If the LMHP, as part of the independent certification
team, determines that the individual is in immediate need of treatment, the
LMHP shall refer the individual to an appropriate Medicaid-enrolled crisis
intervention provider, crisis stabilization provider, or inpatient psychiatric
provider in accordance with 12VAC30-50-226 or shall refer the individual for
emergency admission to a PRTF or therapeutic group home under subdivision 4 m
of this subsection and shall also alert the individual's managed care organization.
l. For individuals who are already eligible for Medicaid at
the time of admission, the independent certification team shall be a
DMAS-authorized contractor with competence in the diagnosis and treatment of
mental illness, preferably in child psychiatry, and have knowledge of the
individual's situation and service availability in the individual's local
service area. The team shall be composed of at least one physician and one
LMHP, including LMHP-S, LMHP-R, and LMHP-RP. An individual's parent or legally
authorized representative shall be included in the certification process.
m. For emergency admissions, an assessment must be made by
the team responsible for the comprehensive individual plan of care (CIPOC).
Reimbursement shall only occur when a certificate of need is issued by the team
responsible for the CIPOC within 14 calendar days after admission. The
certification shall cover any period of time after admission and before claims
are made for reimbursement by Medicaid. After processing an emergency
admission, the therapeutic group home, PRTF, or institution for mental diseases
(IMD) shall notify the DMAS contractor within five calendar days of the
individual's status as being under the care of the facility.
n. For all individuals who apply and become eligible for
Medicaid while an inpatient in a facility or program, the certification team
shall refer the case to the DMAS contractor for referral to the local FAPT to
facilitate care coordination and consideration of educational coverage and
other supports not covered by DMAS.
o. For individuals who apply and become eligible for
Medicaid while an inpatient in the facility or program, the certification shall
be made by the team responsible for the CIPOC and shall cover any period of
time before the application for Medicaid eligibility for which claims are made
for reimbursement by Medicaid. Upon the individual's enrollment into the
Medicaid program, the therapeutic group home, PRTF, or IMD shall notify the
DMAS contractor of the individual's status as being under the care of the
facility within five calendar days of the individual becoming eligible for
Medicaid benefits.
5. Service authorization requirements applicable to both
therapeutic group homes and PRTFs:
a. Authorization shall be required and shall be conducted
by DMAS using medical necessity criteria specified in this subsection.
b. An individual shall have a valid psychiatric diagnosis
and meet the medical necessity criteria as defined in this subsection to
satisfy the criteria for admission. The diagnosis shall be current, as
documented within the past 12 months. If a current diagnosis is not available,
the individual will require a mental health evaluation prior to admission by an
LMHP affiliated with the independent certification team to establish a
diagnosis and recommend and coordinate referral to the available treatment
options.
c. At authorization, an initial length of stay shall be
agreed upon by the individual and parent or legally authorized representative
with the treating provider, and the treating provider shall be responsible for
evaluating and documenting evidence of treatment progress, assessing the need
for ongoing out-of-home placement, and obtaining authorization for continued
stay.
d. Information that is required to obtain authorization for
these services shall include:
(1) A completed state-designated uniform assessment
instrument approved by DMAS;
(2) A certificate of need completed by an independent
certification team specifying all of the following:
(a) The ambulatory care and Medicaid or FAPT-funded
services available in the community do not meet the specific treatment needs of
the individual;
(b) Alternative community-based care was not successful;
(c) Proper treatment of the individual's psychiatric
condition requires services in a 24-hour supervised setting under the direction
of a physician; and
(d) The services can reasonably be expected to improve the
individual's condition or prevent further regression so that a more intensive
level of care will not be needed;
(3) Diagnosis as defined in the DSM-5 and based on (i) an
evaluation by a psychiatrist or LMHP that has been completed within 30 calendar
days of admission or (ii) a diagnosis confirmed in writing by an LMHP after
review of a previous evaluation completed within one year of admission;
(4) A description of the individual's behavior during the
seven calendar days immediately prior to admission;
(5) A description of alternate placements and community
mental health and rehabilitation services and traditional behavioral health
services pursued and attempted and the outcomes of each service;
(6) The individual's level of functioning and clinical
stability;
(7) The level of family involvement and supports available;
and
(8) The initial plan of care (IPOC).
6. Continued stay criteria requirements applicable to both
therapeutic group homes and PRTFs. For a continued stay authorization or a
reauthorization to occur, the individual shall meet the medical necessity
criteria as defined in this subsection to satisfy the criteria for continuing
care. The length of the authorized stay shall be determined by DMAS. A current
plan of care and a current (within 30 calendar days) summary of progress
related to the goals and objectives of the plan of care shall be submitted to
DMAS for continuation of the service. The service provider shall also submit:
a. A state uniform assessment instrument, completed no more
than 30 business days prior to the date of submission;
b. Documentation that the required services have been
provided as defined in the plan of care;
c. Current (within the last 14 calendar days) information
on progress related to the achievement of all treatment and discharge-related
goals; and
d. A description of the individual's continued impairment
and treatment needs, problem behaviors, family engagement activities,
community-based discharge planning and care coordination, and need for a
residential level of care.
7. EPSDT services requirements applicable to therapeutic
group homes and PRTFs. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT. EPSDT services may involve
service modalities not available to other individuals, such as applied
behavioral analysis and neuro-rehabilitative services. Individualized services
to address specific clinical needs identified in an EPSDT screening shall
require authorization by a DMAS contractor. In unique EPSDT cases, DMAS may
authorize specialized services beyond the standard therapeutic group home or
PRTF medical necessity criteria and program requirements, as medically and
clinically indicated to ensure the most appropriate treatment is available to
each individual. Treating service providers authorized to deliver medically
necessary EPSDT services in therapeutic group homes and PRTFs on behalf of a
Medicaid-enrolled individual shall adhere to the individualized interventions
and evidence-based progress measurement criteria described in the plan of care
and approved for reimbursement by DMAS. All documentation, independent
certification team, family engagement activity, therapeutic pass, and discharge
planning requirements shall apply to cases approved as EPSDT PRTF or
therapeutic group home service.
8. Inpatient psychiatric services shall be covered for
individuals younger than 21 years of age for medically necessary stays in
inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2)
for the purpose of diagnosis and treatment of mental health and behavioral
disorders identified under EPSDT when such services meet the requirements set
forth in subdivision 7 of this subsection.
a. Inpatient psychiatric services shall be provided under
the direction of a physician.
b. Inpatient psychiatric services shall be provided by (i)
a psychiatric hospital that undergoes a state survey to determine whether the
hospital meets the requirements for participation in Medicare as a psychiatric
hospital as specified in 42 CFR 482.60 or is accredited by a national
organization whose psychiatric hospital accrediting program has been approved
by the Centers for Medicare and Medicaid Services (CMS); or (ii) a hospital
with an inpatient psychiatric program that undergoes a state survey to
determine whether the hospital meets the requirements for participation in
Medicare as a hospital, as specified in 42 CFR part 482 or is accredited by a
national accrediting organization whose hospital accrediting program has been
approved by CMS.
c. Inpatient psychiatric admissions at general acute care
hospitals and freestanding psychiatric hospitals shall also be subject to the
requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25.
d. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151(a) and 42 CFR 441.151 (b) and 42 CFR 441.152
through 42 CFR 441.156 and (ii) the Conditions of Participation in 42 CFR
Part 483 Subpart G. Each admission must be service authorized and the treatment
must meet DMAS requirements for clinical necessity.
e. The inpatient psychiatric benefit for individuals
younger than 21 years of age shall include services that are provided pursuant
to a certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the individual's discharge from inpatient status at the
earliest possible time. The inpatient psychiatric benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the individual,
and (iii) ensures that the services are furnished under the direction of a
physician. Services provided under arrangement shall be documented by a written
referral from the inpatient psychiatric facility. For purposes of pharmacy
services, a prescription ordered by an employee or contractor of the inpatient
psychiatric facility who is licensed to prescribe drugs shall be considered the
referral.
f. State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order pharmacy services
and emergency services. Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order the
following services: (i) medical and psychological services including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
outpatient hospital services; (iii) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) nonemergency transportation services;
and (viii) emergency services. (Emergency services means the same as is set
forth in 12VAC30-50-310 B.)
f. E. Mental health family support partners.
(1) 1. Mental health family support partners are
peer recovery support services and are nonclinical, peer-to-peer activities
that engage, educate, and support the caregiver and an individual's self-help
efforts to improve health recovery resiliency and wellness. Mental health
family support partners is a peer support service and is a strength-based,
individualized service provided to the caregiver of a Medicaid-eligible
individual younger than 21 years of age with a mental health disorder that is
the focus of support. The services provided to the caregiver and individual
must be directed exclusively toward the benefit of the Medicaid-eligible
individual. Services are expected to improve outcomes for individuals younger
than 21 years of age with complex needs who are involved with multiple systems
and increase the individual's and family's confidence and capacity to manage
their own services and supports while promoting recovery and healthy
relationships. These services are rendered by a PRS who is (i) a parent of a
minor or adult child with a similar mental health disorder or (ii) an adult
with personal experience with a family member with a similar mental health
disorder with experience navigating behavioral health care services. The PRS
shall perform the service within the scope of his knowledge, lived experience,
and education.
(2) 2. Under the clinical oversight of the LMHP
making the recommendation for mental health family support partners, the peer
recovery specialist in consultation with his direct supervisor shall develop a
recovery, resiliency, and wellness plan based on the LMHP's recommendation for
service, the individual's and the caregiver's perceived recovery needs, and any
clinical assessments or service specific provider intakes as defined in this
section within 30 calendar days of the initiation of service. Development of
the recovery, resiliency, and wellness plan shall include collaboration with
the individual and the individual's caregiver. Individualized goals and
strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.
(3) 3. Documentation of required activities
shall be required as set forth in 12VAC30-130-5200 A, C, and E through J.
(4) 4. Limitations and exclusions to service
delivery shall be the same as set forth in 12VAC30-130-5210.
(5) 5. Caregivers of individuals younger than 21
years of age who qualify to receive mental health family support partners shall
(i) care for an individual with a mental health disorder who requires recovery
assistance and (ii) meet two or more of the following:
(a) a. Individual and his caregiver need
peer-based recovery-oriented services for the maintenance of wellness and the
acquisition of skills needed to support the individual.
(b) b. Individual and his caregiver need
assistance to develop self-advocacy skills to assist the individual in
achieving self-management of the individual's health status.
(c) c. Individual and his caregiver need
assistance and support to prepare the individual for a successful work or
school experience.
(d) d. Individual and his caregiver need
assistance to help the individual and caregiver assume responsibility for
recovery.
(6) 6. Individuals 18 through, 19, and
20 years of age who meet the medical necessity criteria in 12VAC30-50-226 B 7
e, who would benefit from receiving peer supports directly and who choose to
receive mental health peer support services directly instead of through their
caregiver, shall be permitted to receive mental health peer support services by
an appropriate PRS.
(7) 7. To qualify for continued mental health family
support partners, medical necessity criteria shall continue to be met, and
progress notes shall document the status of progress relative to the goals
identified in the recovery, resiliency, and wellness plan.
(8) 8. Discharge criteria from mental health
family support partners shall be the same as set forth in 12VAC30-130-5180 E.
(9) 9. Mental health family support partners
services shall be rendered on an individual basis or in a group.
(10) 10. Prior to service initiation, a
documented recommendation for mental health family support partners services
shall be made by a licensed mental health professional (LMHP) who is acting
within his scope of practice under state law. The recommendation shall verify
that the individual meets the medical necessity criteria set forth in
subdivision 5 of this subsection. The recommendation shall be valid for no
longer than 30 calendar days.
(11) 11. Effective July 1, 2017, a peer recovery
specialist shall have the qualifications, education, experience, and
certification required by DBHDS in order to be eligible to register with the
Virginia Board of Counseling on or after July 1, 2018. Upon the promulgation of
regulations by the Board of Counseling, registration of peer recovery
specialists by the Board of Counseling shall be required. The PRS shall perform
mental health family support partners services under the oversight of the LMHP
making the recommendation for services and providing the clinical oversight of
the recovery, resiliency, and wellness plan.
(12) 12. The PRS shall be employed by or have a
contractual relationship with the enrolled provider licensed for one of the
following:
(a) a. Acute care general and emergency
department hospital services licensed by the Department of Health.
(b) b. Freestanding psychiatric hospital and
inpatient psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(c) c. Psychiatric residential treatment
facility licensed by the Department of Behavioral Health and Developmental
Services.
(d) d. Therapeutic group home licensed by the
Department of Behavioral Health and Developmental Services.
(e) e. Outpatient mental health clinic services
licensed by the Department of Behavioral Health and Developmental Services.
(f) f. Outpatient psychiatric services provider.
(g) g. A community mental health and
rehabilitative services provider licensed by the Department of Behavioral
Health and Developmental Services as a provider of one of the following
community mental health and rehabilitative services as defined in this section,
12VAC30-50-226, 12VAC30-50-420, or 12VAC30-50-430 for which the individual
younger than 21 years meets medical necessity criteria: (i) intensive in
home; (ii) therapeutic day treatment; (iii) day treatment or partial
hospitalization; (iv) crisis intervention; (v) crisis stabilization; (vi)
mental health skill building; or (vii) mental health case management.
(13) 13. Only the licensed and enrolled provider
as referenced in subdivision 5 f (12) 12 of this subsection shall
be eligible to bill and receive reimbursement from DMAS or its contractor
for mental health family support partner services. Payments shall not be
permitted to providers that fail to enter into an enrollment agreement with
DMAS or its contractor. Reimbursement shall be subject to retraction for
any billed service that is determined not to be in compliance with DMAS
requirements.
(14) 14. Supervision of the PRS shall meet the
requirements set forth in 12VAC30-50-226 B 7 l.
6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by: (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations or (ii) a
psychiatric facility that is accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.
a. The inpatient psychiatric services benefit for
individuals younger than 21 years of age shall include services defined at 42
CFR 440.160 that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active
treatment designed to achieve the child's discharge from inpatient status at
the earliest possible time. The inpatient psychiatric services benefit shall
include services provided under arrangement furnished by Medicaid enrolled
providers other than the inpatient psychiatric facility, as long as the
inpatient psychiatric facility (i) arranges for and oversees the provision of
all services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.
(1) State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order these services: (i)
pharmacy services and (ii) emergency services.
(2) Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order these
services: (i) medical and psychological services including those furnished by
physicians, licensed mental health professionals, and other licensed or
certified health professionals (i.e., nutritionists, podiatrists, respiratory
therapists, and substance abuse treatment practitioners); (ii) outpatient
hospital services; (iii) physical therapy, occupational therapy, and therapy
for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) transportation services; and (viii)
emergency services.
(3) Residential treatment facilities, as defined at 42 CFR
483.352, shall arrange for, maintain records of, and ensure that physicians
order these services: (i) medical and psychological services, including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
pharmacy services; (iii) outpatient hospital services; (iv) physical therapy,
occupational therapy, and therapy for individuals with speech, hearing, or
language disorders; (v) laboratory and radiology services; (vi) durable medical
equipment; (vii) vision services; (viii) dental, oral surgery, and orthodontic
services; (ix) transportation services; and (x) emergency services.
c. Inpatient psychiatric services are reimbursable only
when the treatment program is fully in compliance with (i) 42 CFR Part 441
Subpart D, specifically 42 CFR 441.151(a) and (b) and 42 CFR 441.152 through 42
CFR 441.156, and (ii) the conditions of participation in 42 CFR Part 483
Subpart G. Each admission must be preauthorized and the treatment must meet
DMAS requirements for clinical necessity.
d. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT.
7. F. Hearing aids shall be reimbursed for
individuals younger than 21 years of age according to medical necessity when
provided by practitioners licensed to engage in the practice of fitting or
dealing in hearing aids under the Code of Virginia.
8. G. Addiction and recovery treatment services
shall be covered under EPSDT consistent with 12VAC30-130-5000 et seq.
9. H. Services facilitators shall be required
for all consumer-directed personal care services consistent with the
requirements set out in 12VAC30-120-935.
10. I. Behavioral therapy services shall be
covered for individuals younger than 21 years of age.
a. 1. Definitions. The following words and terms
when used in this subsection shall have the following meanings unless the
context clearly indicates otherwise:
"Behavioral therapy" means systematic interventions
provided by licensed practitioners acting within the scope of practice defined
under a Virginia Department of Health Professions regulatory board and covered
as remedial care under 42 CFR 440.130(d) to individuals younger than 21 years
of age. Behavioral therapy includes applied behavioral analysis. Family
training related to the implementation of the behavioral therapy shall be
included as part of the behavioral therapy service. Behavioral therapy services
shall be subject to clinical reviews and determined as medically necessary.
Behavioral therapy may be provided in the individual's home and community
settings as deemed by DMAS or its contractor as medically necessary
treatment.
"Counseling" means a professional mental health
service that can only be provided by a person holding a license issued by a
health regulatory board at the Department of Health Professions, which includes
conducting assessments, making diagnoses of mental disorders and conditions,
establishing treatment plans, and determining treatment interventions.
"Individual" means the child or adolescent younger
than 21 years of age who is receiving behavioral therapy services.
"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.
b. 2. Behavioral therapy services shall be
designed to enhance communication skills and decrease maladaptive patterns of
behavior, which if left untreated, could lead to more complex problems and the
need for a greater or a more intensive level of care. The service goal shall be
to ensure the individual's family or caregiver is trained to effectively manage
the individual's behavior in the home using modification strategies. All
services shall be provided in accordance with the ISP and clinical assessment
summary.
c. 3. Behavioral therapy services shall be
covered when recommended by the individual's primary care provider or other
licensed physician, licensed physician assistant, or licensed nurse
practitioner and determined by DMAS or its contractor to be medically
necessary to correct or ameliorate significant impairments in major life
activities that have resulted from either developmental, behavioral, or mental
disabilities. Criteria for medical necessity are set out in 12VAC30-60-61 H
F. Service-specific provider intakes shall be required at the onset of
these services in order to receive authorization for reimbursement. Individual
service plans (ISPs) shall be required throughout the entire duration of
services. The services shall be provided in accordance with the individual
service plan and clinical assessment summary. These services shall be provided
in settings that are natural or normal for a child or adolescent without a
disability, such as the individual's home, unless there is justification in the
ISP, which has been authorized for reimbursement, to include service settings
that promote a generalization of behaviors across different settings to
maintain the targeted functioning outside of the treatment setting in the
individual's home and the larger community within which the individual resides.
Covered behavioral therapy services shall include:
(1) a. Initial and periodic service-specific
provider intake as defined in 12VAC30-60-61 H F;
(2) b. Development of initial and updated ISPs
as established in 12VAC30-60-61 H F;
(3) c. Clinical supervision activities. Requirements
for clinical supervision are set out in 12VAC30-60-61 H F;
(4) d. Behavioral training to increase the
individual's adaptive functioning and communication skills;
(5) e. Training a family member in behavioral
modification methods as established in 12VAC30-60-61 H F;
(6) f. Documentation and analysis of
quantifiable behavioral data related to the treatment objectives; and
(7) g. Care coordination.
C. J. School health services.
1. School health assistant services are repealed effective
July 1, 2006.
2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services, shall not be covered for school divisions. School divisions to
receive reimbursement for the screenings shall be enrolled with DMAS as clinic
providers.
a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.
b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act. These
services are necessary to correct or ameliorate defects of physical or mental
illnesses or conditions.
3. Providers shall be licensed under the applicable state
practice act or comparable licensing criteria by the Virginia Department of
Education, and shall meet applicable qualifications under 42 CFR Part 440.
Identification of defects, illnesses or conditions, and services
necessary to correct or ameliorate them shall be performed by practitioners
qualified to make those determinations within their licensed scope of practice,
either as a member of the IEP team or by a qualified practitioner outside the
IEP team.
a. Providers shall be employed by the school division or under
contract to the school division.
b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.
c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.
d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.
e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.
4. Covered services include:
a. Physical therapy, and occupational therapy
and services for individuals with speech, hearing, and language disorders,
performed by, or under the direction of, providers who meet the qualifications
set forth at 42 CFR 440.110. This coverage includes audiology services.
b. Skilled nursing services are covered under 42 CFR
440.60. These services are to be rendered in accordance to the licensing
standards and criteria of the Virginia Board of Nursing. Nursing services are
to be provided by licensed registered nurses or licensed practical nurses but
may be delegated by licensed registered nurses in accordance with the
regulations of the Virginia Board of Nursing, especially the section on
delegation of nursing tasks and procedures. The licensed practical nurse is
under the supervision of a registered nurse.
(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation, and evaluation) that is consistent with skilled nursing
services when performed by a licensed registered nurse or a licensed practical
nurse. These skilled nursing services shall include dressing changes,
maintaining patent airways, medication administration/monitoring administration
or monitoring, and urinary catheterizations.
(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant, or nurse practitioner for skilled nursing services. This
order shall be recertified on an annual basis.
c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient
services include individual medical psychotherapy, group medical psychotherapy
coverage, and family medical psychotherapy. Psychological and neuropsychological
testing are allowed when done for purposes other than educational diagnosis,
school admission, evaluation of an individual with intellectual or
developmental disability prior to admission to a nursing facility, or any
placement issue. These services are covered in the nonschool settings also.
School providers who may render these services when licensed by the state
include psychiatrists, licensed clinical psychologists, school psychologists,
licensed clinical social workers, professional counselors, psychiatric clinical
nurse specialists, marriage and family therapists, and school social workers.
d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner professional
develops a written plan for meeting the needs of the child individual,
which is implemented by the assistant. The assistant must have qualifications
comparable to those for other personal care aides recognized by the Virginia
Department of Medical Assistance Services. The assistant performs services such
as assisting with toileting, ambulation, and eating. The assistant may serve as
an aide on a specially adapted school vehicle that enables transportation to or
from the school or school contracted provider on days when the student is
receiving a Medicaid-covered service under the IEP. Children Individuals
requiring an aide during transportation on a specially adapted vehicle shall
have this stated in the IEP.
e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's an individual's
medical or other health related condition.
f. Transportation is covered as allowed under 42 CFR
431.53 and described at State Plan Attachment 3.1-D (12VAC30-50-530).
Transportation shall be rendered only by school division personnel or
contractors. Transportation is covered for a child an individual
who requires transportation on a specially adapted school vehicle that enables
transportation to or from the school or school contracted provider on days when
the student individual is receiving a Medicaid-covered service
under the IEP. Transportation shall be listed in the child's individual's
IEP. Children Individuals requiring an aide during transportation
on a specially adapted vehicle shall have this stated in the IEP.
g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's an individual's IEP and
shall be performed by any of the above licensed practitioners within the scope
of practice. Assessments and reassessments not tied to medical needs of the child
individual shall not be covered.
5. DMAS will ensure through quality management review that duplication
of services will be monitored. School divisions have a responsibility to ensure
that if a child an individual is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.
D. K. Family planning services and supplies for
individuals of child-bearing age.
1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing
arts.
2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.
3. Family planning services as established by § 1905(a)(4)(C)
of the Social Security Act include annual family planning exams; cervical
cancer screening for women; sexually transmitted infection (STI) testing; lab
services for family planning and STI testing; family planning education,
counseling, and preconception health; sterilization procedures; nonemergency
transportation to a family planning service; and U.S. Food and Drug Administration
approved prescription and over-the-counter contraceptives, subject to limits in
12VAC30-50-210.
12VAC30-50-226. Community mental health services.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:
"Activities of daily living" or "ADLs"
means personal care tasks such as bathing, dressing, toileting, transferring,
and eating or feeding. An individual's degree of independence in performing
these activities is a part of determining appropriate level of care and service
needs.
"Affiliated" means any entity or property in which
a provider or facility has a direct or indirect ownership interest of 5.0% or
more, or any management, partnership, or control of an entity.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS. DMAS' designated BHSA shall be
authorized to constitute, oversee, enroll, and train a provider network;
perform service authorization; adjudicate claims; process claims; gather and
maintain data; reimburse providers; perform quality assessment and improvement;
conduct member outreach and education; resolve member and provider issues; and
perform utilization management including care coordination for the provision of
Medicaid-covered behavioral health services. Such authority shall include
entering into or terminating contracts with providers in accordance with DMAS
authority pursuant to 42 CFR Part 1002 and § 32.1-325 D and E of the Code
of Virginia. DMAS shall retain authority for and oversight of the BHSA entity
or entities.
"Certified prescreener" means an employee of either
the local community services board/behavioral board or behavioral
health authority or its designee who is skilled in the assessment and treatment
of mental illness and who has completed a certification program approved by
DBHDS.
"Clinical experience" means, for the purpose of
rendering (i) mental health day treatment/partial hospitalization, (ii)
intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental
health skill building, (v) crisis stabilization, or (vi) crisis intervention
services, practical experience in providing direct services to individuals with
diagnoses of mental illness or intellectual disability or the provision of
direct geriatric services or special education services. Experience shall
include supervised internships, supervised practicums, or supervised field
experience. Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be
established by DBHDS in the document titled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Code" means the Code of Virginia.
"DBHDS" means the Department of Behavioral Health
and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.)
of Title 37.2 of the Code of Virginia.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined in
12VAC35-105-20 with at least two consecutive years of documented experience as
a QMHP, and who has documented completion of the DBHDS PRS supervisor training;
or (iii) shall be an LMHP who has documented completion of the DBHDS PRS
supervisor training who is acting within his scope of practice under state law.
An LMHP providing services before April 1, 2018, shall have until April 1,
2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractor or 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.
"Human services field" means the same as the term
is defined by DBHDS the Department of Health Professions in the
guidance document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013. Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual" means the patient, client, or
recipient of services described in this section.
"Individual service plan" or "ISP" means
a comprehensive and regularly updated treatment plan specific to the
individual's unique treatment needs as identified in the service-specific
provider intake. The ISP contains, but is not limited to, the individual's
treatment or training needs, the individual's goals and measurable objectives
to meet the identified needs, services to be provided with the recommended
frequency to accomplish the measurable goals and objectives, the estimated
timetable for achieving the goals and objectives, and an individualized
discharge plan that describes transition to other appropriate services. The
individual shall be included in the development of the ISP and the ISP shall be
signed by the individual. If the individual is a minor child, the ISP
shall also be signed by the individual's parent/legal parent or legal
guardian. Documentation shall be provided if the individual, who is a minor
child or an adult who lacks legal capacity, is unable or unwilling to sign the
ISP.
"Individualized training" means instruction and
practice in functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living skills,
and use of community resources; assistance with medical management; and
monitoring health, nutrition, and physical condition. The training shall be
rehabilitative and based on a variety of incremental (or cumulative) approaches
or tools to organize and guide the individual's life planning and shall reflect
what is important to the individual in addition to all other factors that
affect his the individual's functioning, including effects of the
disability and issues of health and safety.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the
same as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.
"LMHP-resident in psychology" or
"LMHP-RP" means the same as an individual in a residency, as that
term is defined in 18VAC125-20-10, program for clinical psychologists. An
LMHP-resident in psychology shall be in continuous compliance with the
regulatory requirements for supervised experience as found in 18VAC125-20-65
and shall not perform the functions of the LMHP-RP or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Psychology. For purposes of Medicaid reimbursement by supervisors for services
provided by such residents, they shall use the title "Resident in
Psychology" after their signatures to indicate such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" is defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered
a "supervisee" until the supervision for specific clinical duties at
a specific site is preapproved in writing by the Virginia Board of Social Work.
For purposes of Medicaid reimbursement to their supervisors for services
provided by supervisees, these persons shall use the title "Supervisee in
Social Work" after their signatures to indicate such status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Qualified mental health professional-adult" or
"QMHP-A" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-child" or
"QMHP-C" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20,
including a "QMHP-trainee" as defined by the Department of Health
Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as defined in 12VAC35-105-20.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Register" or "registration" means
notifying DMAS or its contractor that an individual will be receiving services
that do not require service authorization.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Review of ISP" means that the provider evaluates
and updates the individual's progress toward meeting the individualized service
plan objectives and documents the outcome of this review. For DMAS to determine
that these reviews are satisfactory and complete, the reviews shall (i) update
the goals, objectives, and strategies of the ISP to reflect any change in the
individual's progress and treatment needs as well as any newly identified
problems; (ii) be conducted in a manner that enables the individual to
participate in the process; and (iii) be documented in the individual's medical
record no later than 15 calendar days from the date of the review.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service authorization" means the process to
approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS
individual by a DMAS service authorization contractor prior to service delivery
and reimbursement in order to validate that the service requested is medically
necessary and meets DMAS and DMAS contractor criteria for reimbursement.
Service authorization does not guarantee payment for the service.
"Service-specific provider intake" means the same
as defined in 12VAC30-50-130 and also includes individuals who are older than
21 years of age.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
B. Mental health services. The following services, with their
definitions, shall be covered: day treatment/partial hospitalization,
psychosocial rehabilitation, crisis services, intensive community treatment
(ICT), and mental health skill building. Staff travel time shall not be
included in billable time for reimbursement. These services, in order to be
covered, shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and are reflected
in provider records and on providers' claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services. These services are intended to be delivered in a person-centered
person centered manner. The individuals who are receiving these services
shall be included in all service planning activities. All services which do not
require service authorization require registration. This registration shall
transmit service-specific information to DMAS or its contractor in accordance
with service authorization requirements.
1. Day treatment/partial hospitalization services shall be
provided in sessions of two or more consecutive hours per day, which may be
scheduled multiple times per week, to groups of individuals in a nonresidential
setting. These services, limited annually to 780 units, include the major
diagnostic, medical, psychiatric, psychosocial, and psychoeducational treatment
modalities designed for individuals who require coordinated, intensive,
comprehensive, and multidisciplinary treatment but who do not require inpatient
treatment. One unit of service shall be defined as a minimum of two but less
than four hours on a given day. Two units of service shall be defined as at
least four but less than seven hours in a given day. Three units of service
shall be defined as seven or more hours in a given day. Authorization is
required for Medicaid reimbursement.
a. Day treatment/partial hospitalization services shall be
time limited interventions that are more intensive than outpatient services and
are required to stabilize an individual's psychiatric condition. The services
are delivered when the individual is at risk of psychiatric hospitalization or
is transitioning from a psychiatric hospitalization to the community. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual is at risk of
psychiatric hospitalization or is transitioning from a psychiatric
hospitalization to the community.
b. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Individuals must meet at least two of the following criteria
on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
hospitalization or homelessness or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that the individual
requires repeated interventions or monitoring by the mental health, social
services, or judicial system that have been documented; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
c. Individuals shall be discharged from this service when they
are no longer in an acute psychiatric state and other less intensive services
may achieve psychiatric stabilization.
d. Admission and services for time periods longer than 90
calendar days must be authorized based upon a face-to-face evaluation by a
physician, psychiatrist, licensed clinical psychologist, licensed professional
counselor, licensed clinical social worker, or psychiatric clinical nurse
specialist.
e. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
2. Psychosocial rehabilitation shall be provided at least two
or more hours per day to groups of individuals in a nonresidential setting.
These services, limited annually to 936 units, include assessment, education to
teach the patient about the diagnosed mental illness and appropriate
medications to avoid complication and relapse, and opportunities to
learn and use independent living skills and to enhance social and interpersonal
skills within a supportive and normalizing program structure and environment.
One unit of service is defined as a minimum of two but less than four hours on
a given day. Two units are defined as at least four but less than seven hours
in a given day. Three units of service shall be defined as seven or more hours
in a given day. Authorization is required for Medicaid reimbursement. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Services are provided to individuals: (i) who without
these services would be unable to remain in the community or (ii) who meet at
least two of the following criteria on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that repeated
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
3. Crisis intervention shall provide immediate mental health
care, available 24 hours a day, seven days per week, to assist individuals who
are experiencing acute psychiatric dysfunction requiring immediate clinical attention.
This service's objectives shall be to prevent exacerbation of a condition, to
prevent injury to the client or others, and to provide treatment in the context
of the least restrictive setting. Crisis intervention activities shall include
assessing the crisis situation, providing short-term counseling designed to
stabilize the individual, providing access to further immediate assessment and
follow-up, and linking the individual and family with ongoing care to prevent
future crises. Crisis intervention services may include office visits, home
visits, preadmission screenings, telephone contacts, and other client-related
activities for the prevention of institutionalization. The service-specific
provider intake, as defined at 12VAC30-50-130, shall document the individual's
behavior and describe how the individual meets criteria for this service. The
provision of this service to an individual shall be registered with either DMAS,
DMAS contractors, or the BHSA within one business day or the completion of
the service-specific provider intake to avoid duplication of services and to
ensure informed care coordination.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a
psychiatric nature that puts the individual at risk of psychiatric
hospitalization. Individuals must meet at least two of the following criteria
at the time of admission to the service:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by mental health, social services, or the judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. The annual limit for crisis intervention is 720 units per
year. A unit shall equal 15 minutes.
c. These services may only be rendered by an LMHP, an
LMHP-supervisee, LMHP-resident, LMHP-RP, or a certified prescreener.
4. Intensive community treatment (ICT), initially covered for
a maximum of 26 weeks based on an initial service-specific provider intake and
may be reauthorized for up to an additional 26 weeks annually based on written
intake and certification of need by a licensed mental health provider (LMHP),
shall be defined by 12VAC35-105-20 or LMHP-S, LMHP-R, and LMHP-RP and shall
include medical psychotherapy, psychiatric assessment, medication management,
and care coordination activities offered to outpatients outside the clinic,
hospital, or office setting for individuals who are best served in the
community. Authorization is required for Medicaid reimbursement.
a. To qualify for ICT, the individual must meet at least one
of the following criteria:
(1) The individual must be at high risk for psychiatric
hospitalization or becoming or remaining homeless due to mental illness or
require intervention by the mental health or criminal justice system due to
inappropriate social behavior.
(2) The individual has a history (three months or more) of a
need for intensive mental health treatment or treatment for co-occurring
serious mental illness and substance use disorder and demonstrates a resistance
to seek out and utilize appropriate treatment options.
b. A written, service-specific provider intake, as defined at
12VAC30-50-130, that documents the individual's eligibility and the need for
this service must be completed prior to the initiation of services. This intake
must be maintained in the individual's records.
c. An individual service plan shall be initiated at the time
of admission and must be fully developed, as defined in this section, within 30
days of the initiation of services.
d. The annual unit limit shall be 130 units with a unit
equaling one hour.
e. These services may only be rendered by a team that meets
the requirements of 12VAC35-105-1370.
5. Crisis stabilization services for nonhospitalized
individuals shall provide direct mental health care to individuals experiencing
an acute psychiatric crisis which may jeopardize their current community living
situation. Services may be provided for up to a 15-day period per crisis
episode following a face-to-face service-specific provider intake by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP. Only one unit of service shall be
reimbursed for this intake. The provision of this service to an individual
shall be registered with either DMAS, DMAS contractors, or the BHSA
within one business day of the completion of the service-specific provider intake
to avoid duplication of services and to ensure informed care coordination.
a. The goals of crisis stabilization programs shall be to
avert hospitalization or rehospitalization, provide normative environments with
a high assurance of safety and security for crisis intervention, stabilize
individuals in psychiatric crisis, and mobilize the resources of the community
support system and family members and others for on-going maintenance and
rehabilitation. The services must be documented in the individual's records as
having been provided consistent with the ISP in order to receive Medicaid
reimbursement.
b. The crisis stabilization program shall provide to
individuals, as appropriate, psychiatric assessment including medication
evaluation, treatment planning, symptom and behavior management, and individual
and group counseling.
c. This service may be provided in any of the following
settings, but shall not be limited to: (i) the home of an individual who lives
with family or other primary caregiver; (ii) the home of an individual who
lives independently; or (iii) community-based programs licensed by DBHDS to
provide residential services but which are not institutions for mental disease
(IMDs).
d. This service shall not be reimbursed for (i) individuals with
medical conditions that require hospital care; (ii) individuals with a
primary diagnosis of substance abuse; or (iii) individuals with psychiatric
conditions that cannot be managed in the community (i.e., individuals who are
of imminent danger to themselves or others).
e. The maximum limit on this service is 60 days annually.
f. Services must be documented through daily progress notes
and a daily log of times spent in the delivery of services. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a psychiatric
nature that puts the individual at risk of psychiatric hospitalization.
Individuals must meet at least two of the following criteria at the time of
admission to the service:
(1) Experience difficulty in establishing and maintaining
normal interpersonal relationships to such a degree that the individual is at
risk of psychiatric hospitalization, homelessness, or isolation from social
supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that the
individual is unable to recognize personal danger or significantly
inappropriate social behavior.
g. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E or a certified
prescreener.
6. Mental health skill-building services (MHSS) shall be
defined as goal-directed training to enable individuals to achieve and maintain
community stability and independence in the most appropriate, least restrictive
environment. Authorization is required for Medicaid reimbursement. Services
that are rendered before the date of service authorization shall not be
reimbursed. These services may be authorized up to six consecutive months as long
as the individual meets the coverage criteria for this service. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. These services shall provide goal-directed training in the
following areas in order to be reimbursed by Medicaid or the BHSA DMAS
contractor: (i) functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living, and
use of community resources; (ii) assistance with medication management; and
(iii) monitoring of health, nutrition, and physical condition with goals
towards self-monitoring and self-regulation of all of these activities.
Providers shall be reimbursed only for training activities defined in the ISP
and only where services meet the service definition, eligibility, and service
provision criteria and this section. A review of MHSS services by an LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall be repeated for all individuals who have
received at least six months of MHSS to determine the continued need for this
service.
a. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Services are provided to individuals who
require individualized goal-directed training in order to achieve or maintain
stability and independence in the community.
b. Individuals ages 21 years of age and older
shall meet all of the following criteria in order to be eligible to receive
mental health skill-building services:
(1) The individual shall have one of the following as a
primary mental health diagnosis:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness; (ii)
results in severe and recurrent disability; (iii) produces functional
limitations in the individual's major life activities that are documented in the
individual's medical record; and (iv) requires individualized training for the
individual in order to achieve or maintain independent living in the community.
(2) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living
skills, such as symptom management; adherence to psychiatric and physical
health medication treatment plans; appropriate use of social skills and
personal support systems; skills to manage personal hygiene, food preparation,
and the maintenance of personal adequate nutrition; money management; and use
of community resources.
(3) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) (PRTF)
as a result of decompensation related to the individual's serious mental
illness; or (v) a temporary detention order (TDO) evaluation, pursuant to § 37.2-809
B of the Code of Virginia. This criterion shall be met in order to be initially
admitted to services and not for subsequent authorizations of service.
Discharge summaries from prior providers that clearly indicate (i) the type of
treatment provided, (ii) the dates of the treatment previously provided, and
(iii) the name of the treatment provider shall be sufficient to meet this
requirement. Family member statements shall not suffice to meet this
requirement.
(4) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications within the 12
months prior to the service-specific provider intake date. If a physician or
other practitioner who is authorized by his license to prescribe medications
indicates that antipsychotic, mood stabilizing, or antidepressant medications
are medically contraindicated for the individual, the provider shall obtain
medical records signed by the physician or other licensed prescriber detailing
the contraindication. This documentation shall be maintained in the
individual's mental health skill-building services record, and the provider
shall document and describe how the individual will be able to actively
participate in and benefit from services without the assistance of medication.
This criterion shall be met upon admission to services and shall not be
required for subsequent authorizations of service. Discharge summaries from prior
providers that clearly indicate (i) the type of treatment provided, (ii) the
dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
c. Individuals aged 18 to 21 years of age shall
meet all of the following criteria in order to be eligible to receive mental
health skill-building services:
(1) The individual shall not be living in a supervised setting
as described in § 63.2-905.1 of the Code of Virginia. If the individual is
transitioning into an independent living situation, MHSS shall only be
authorized for up to six months prior to the date of transition.
(2) The individual shall have at least one of the following as
a primary mental health diagnosis.:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness or serious
emotional disturbance; (ii) results in severe and recurrent disability; (iii)
produces functional limitations in the individual's major life activities that
are documented in the individual's medical record; and (iv) requires
individualized training for the individual in order to achieve or maintain
independent living in the community.
(3) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living skills
such as symptom management; adherence to psychiatric and physical health
medication treatment plans; appropriate use of social skills and personal
support systems; skills to manage personal hygiene, food preparation, and the
maintenance of personal adequate nutrition; money management; and use of
community resources.
(4) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) as a result
of decompensation related to the individual's serious mental illness; or (v)
temporary detention order (TDO) evaluation pursuant to § 37.2-809 B of the Code
of Virginia. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
(5) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications, within the 12
months prior to the assessment date. If a physician or other practitioner who
is authorized by his license to prescribe medications indicates that
antipsychotic, mood stabilizing, or antidepressant medications are medically
contraindicated for the individual, the provider shall obtain medical records
signed by the physician or other licensed prescriber detailing the
contraindication. This documentation of medication management shall be
maintained in the individual's mental health skill-building services record.
For individuals not prescribed antipsychotic, mood stabilizing, or
antidepressant medications, the provider shall have documentation from the
medication management physician describing how the individual will be able to
actively participate in and benefit from services without the assistance of
medication. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the
treatment provider shall be sufficient to meet this requirement. Family member
statements shall not suffice to meet this requirement.
(6) An independent clinical assessment, established in
12VAC30-130-3020, shall be completed for the individual.
d. Service-specific provider intakes shall be required at the
onset of services and individual service plans (ISPs) shall be required during
the entire duration of services. Services based upon incomplete, missing,
or outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in 12VAC30-50-130.
e. The yearly limit for mental health skill-building services
is 520 units. Only direct face-to-face contacts and services to the individual
shall be reimbursable. One unit is 1 to 2.99 hours per day, and two
units is 3 to 4.99 hours per day.
f. These services may only be rendered by an LMHP, LMHP-R,
LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or QPPMH.
g. The provider shall clearly document details of the services
provided during the entire amount of time billed.
h. The ISP shall not include activities that contradict or
duplicate those in the treatment plan established by the therapeutic
group home or assisted living facility. The provider shall coordinate mental
health skill-building services with the treatment plan established by the group
home or assisted living facility and shall document all coordination activities
in the medical record.
i. Limits and exclusions.
(1) Group Therapeutic group home (Level A or
B) and assisted living facility providers shall not serve as the mental
health skill-building services provider for individuals residing in the
provider's respective facility. Individuals residing in facilities may,
however, receive MHSS from another MHSS agency not affiliated with the owner of
the facility in which they reside.
(2) Mental health skill-building services shall not be
reimbursed for individuals who are receiving in-home residential services or
congregate residential services through the Intellectual Disability Waiver or
Individual and Family Developmental Disabilities Support Waiver.
(3) Mental health skill-building services shall not be
reimbursed for individuals who are also receiving services under the Department
of Social Services independent living program (22VAC40-151), independent living
services (22VAC40-131 and 22VAC40-151), or independent living arrangement
(22VAC40-131) or any Comprehensive Services Act-funded independent living
skills programs.
(4) Mental health skill-building services shall not be
available to individuals who are receiving treatment foster care
(12VAC30-130-900 et seq.).
(5) Mental health skill-building services shall not be
available to individuals who reside in intermediate care facilities for
individuals with intellectual disabilities or hospitals.
(6) Mental health skill-building services shall not be
available to individuals who reside in nursing facilities, except for up to 60
days prior to discharge. If the individual has not been discharged from the
nursing facility during the 60-day period of services, mental health
skill-building services shall be terminated and no further service
authorizations shall be available to the individual unless a provider can
demonstrate and document that mental health skill-building services are
necessary. Such documentation shall include facts demonstrating a change in the
individual's circumstances and a new plan for discharge requiring up to 60 days
of mental health skill-building services.
(7) Mental health skill-building services shall not be
available for residents of psychiatric residential treatment centers (Level
C facilities) except for the intake code H0032 (modifier U8) in the seven
days immediately prior to discharge.
(8) Mental health skill-building services shall not be
reimbursed if personal care services or attendant care services are being
received simultaneously, unless justification is provided why this is necessary
in the individual's mental health skill-building services record. Medical
record documentation shall fully substantiate the need for services when
personal care or attendant care services are being provided. This applies to
individuals who are receiving additional services through the Intellectual
Disability Waiver (12VAC30-120-1000 et seq.), Individual and Family
Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.), the
Elderly or Disabled with Consumer Direction Waiver (12VAC30-120-900 et seq.),
and EPSDT services (12VAC30-50-130).
(9) Mental health skill-building services shall not be
duplicative of other services. Providers shall be required to ensure that if an
individual is receiving additional therapeutic services that there will be
coordination of services by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A,
QMHP-C, QMHP-E, or QPPMH to avoid duplication of services.
(10) Individuals who have organic disorders, such as delirium,
dementia, or other cognitive disorders not elsewhere classified, will be
prohibited from receiving mental health skill-building services unless their
physicians issue signed and dated statements indicating that the individuals
can benefit from this service.
(11) Individuals who are not diagnosed with a serious mental
health disorder but who have personality disorders or other mental health
disorders, or both, that may lead to chronic disability shall not be excluded
from the mental health skill-building services eligibility criteria provided
that the individual has a primary mental health diagnosis from the list
included in subdivision B 6 b (1) or B 6 c (2) of this section and that the
provider can document and describe how the individual is expected to actively
participate in and benefit from mental health skill-building services.
7. Mental health peer support services.
a. Mental health peer support services are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support an individual's self-help efforts to improve health
recovery, resiliency, and wellness. Mental health peer support services for
adults is a person centered, strength-based, and recovery-oriented
rehabilitative service for individuals 21 years of age or older provided
by a peer recovery specialist successful in the recovery process with lived
experience with a mental health disorder, who is trained to offer support and
assistance in helping others in the recovery to reduce the disabling effects of
a mental health disorder that is the focus of support. Services assist the
individual with developing and maintaining a path to recovery, resiliency, and
wellness. Specific peer support service activities shall emphasize the
acquisition, development, and enhancement of recovery, resiliency, and
wellness. Services are designed to promote empowerment, self-determination,
understanding, and coping skills through mentoring and service coordination
supports, as well as to assist individuals in achieving positive coping
mechanisms for the stressors and barriers encountered when recovering from
their illnesses or disorders.
b. Under the clinical oversight of the LMHP making the
recommendation for mental health support services, the peer recovery specialist
in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's perceived recovery needs, and any clinical assessments or
service specific provider intakes as defined in this section within 30 calendar
days of the initiation of service. Development of the recovery, resiliency, and
wellness plan shall include collaboration with the individual. Individualized
goals and strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, and the individual
within 30 calendar days of the initiation of service. The PRS shall act as an
advocate for the individual, encouraging the individual to take a proactive
role in developing and updating goals and objectives in the individualized
recovery planning.
c. Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A, C, and E through J.
d. Limitations and exclusions to service delivery shall be the
same as set forth in 12VAC30-130-5210.
e. Individuals 21 years of age or older qualifying for
mental health peer support services shall meet the following requirements:
(1) Require recovery-oriented assistance and support services
for the acquisition of skills needed to engage in and maintain recovery; for the
development of self-advocacy skills to achieve a decreasing dependency on
formalized treatment systems; and to increase responsibilities, wellness
potential, and shared accountability for the individual's own recovery.
(2) Have a documented mental health disorder diagnosis.
(3) Demonstrate moderate to severe functional impairment
because of a diagnosis that interferes with or limits performance in at least
one of the following domains: educational (e.g., obtaining a high school or
college degree); social (e.g., developing a social support system); vocational
(e.g., obtaining part-time or full-time employment); self-maintenance (e.g.,
managing symptoms, understanding his illness, living more independently).
f. To qualify for continued mental health peer support
services, medical necessity criteria shall continue to be met, and progress
notes shall document the status of progress relative to the goals identified in
the recovery, resiliency, and wellness plan.
g. Discharge criteria from mental health peer support services
is the same as set forth in 12VAC30-130-5180 E.
h. Mental health peer support services shall be rendered
on an individual basis or in a group.
i. Prior to service initiation, a documented recommendation
for mental health peer support services shall be made by a licensed mental
health professional acting within the scope of practice under state law The
recommendation shall verify that the individual meets the medical necessity
criteria set forth in subdivision 7 e of this subsection. The recommendation
shall be valid for no longer than 30 calendar days.
j. Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification established
by DBHDS in order to be eligible to register with the Board of Counseling on or
after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health peer support
services under the oversight of the LMHP making the recommendation for services
and providing the clinical oversight of the recovery, resiliency, and wellness
plan. The PRS shall be employed by or have a contractual relationship with an
enrolled provider licensed for one of the following:
(1) Acute care general hospital licensed by the Department of
Health.
(2) Freestanding psychiatric hospital and inpatient
psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(3) Outpatient mental health clinic services licensed by the
Department of Behavioral Health and Developmental Services.
(4) Outpatient psychiatric services provider.
(5) Rural health clinics and federally qualified health
centers.
(6) Hospital emergency department services licensed by the
Department of Health.
(7) Community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services defined in this section or 12VAC30-50-420 for which the
individual meets medical necessity criteria:
(a) Day treatment or partial hospitalization;
(b) Psychosocial rehabilitation;
(c) Crisis intervention;
(d) Intensive community treatment;
(e) Crisis stabilization;
(f) Mental health skill building; or
(g) Mental health case management.
k. Only the licensed and enrolled provider referenced in
subdivision 7 j of this subsection shall be eligible to bill mental health peer
support services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor.
Reimbursement shall be subject to retraction for any billed service that is
determined to not to be in compliance with DMAS requirements.
l. Supervision of the PRS shall be required as set forth in
the definition of "supervision" in 12VAC30-130-5160. Supervision of
the PRS shall also meet the following requirements: the supervisor shall be
under the clinical oversight of the LMHP making the recommendation for
services, and the peer recovery specialist in consultation with his direct
supervisor shall conduct and document a review of the recovery, resiliency, and
wellness plan every 90 calendar days with the individual and the caregiver, as
applicable. The review shall be signed by the PRS and the individual and, as
applicable, the identified family member or caregiver. Review of the recovery,
resiliency, and wellness plan means the PRS evaluates and updates the
individual's progress every 90 days toward meeting the plan's goals and
documents the outcome of this review in the individual's medical record. For
DMAS to determine that these reviews are complete, the reviews shall (i) update
the goals and objectives as needed to reflect any change in the individual's
recovery as well as any newly identified needs, (ii) be conducted in a manner
that enables the individual to actively participate in the process, and (iii)
be documented by the PRS in the individual's medical record no later than 15 calendar
days from the date of the review.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, DSM-5, 2013, American Psychiatric Association
Length of Stay by Diagnosis and Operation, Southern Region,
1996, HCIA, Inc.
Guidelines for Perinatal Care, 4th Edition, August 1997,
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists
Virginia Supplemental Drug Rebate Agreement Contract and
Addenda
Office Reference Manual (Smiles for Children), prepared by
DMAS' Dental Benefits Administrator, copyright 2010, dated March 13, 2014 (http://www.dmas.virginia.gov/Content_atchs/dnt/VA_SFC_ORM_140313.pdf)
Patient Placement Criteria for the Treatment of
Substance-Related Disorders ASAM PPC-2R, Second Edition, copyright 2001,
American Society of Addiction Medicine
Human Services and Related Fields Approved
Degrees/Experience, Department of Behavioral Health and Developmental Services
(rev. 5/13)
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted on
November 3, 2017, revised on February 9, 2018
12VAC30-60-5. Applicability of utilization review requirements.
A. These utilization requirements shall apply to all Medicaid
covered services unless otherwise specified.
B. Some Medicaid covered services require an approved service
authorization prior to service delivery in order for reimbursement to occur.
1. To obtain service authorization, all providers' information
supplied to the Department of Medical Assistance Services (DMAS), service
authorization contractor, or the behavioral health service authorization
contractor or its contractor shall be fully substantiated throughout
individuals' medical records.
2. Providers shall be required to maintain documentation
detailing all relevant information about the Medicaid individuals who are in providers'
the provider's care. Such documentation shall fully disclose the extent
of services provided in order to support providers' the provider's
claims for reimbursement for services rendered. This documentation shall be
written, signed, and dated at the time the services are rendered unless
specified otherwise.
C. DMAS, or its designee contractor, shall
perform reviews of the utilization of all Medicaid covered services pursuant to
42 CFR 440.260 and 42 CFR Part 456.
D. DMAS shall recover expenditures made for covered services
when providers' documentation does not comport with standards specified in all
applicable regulations.
E. Providers who are determined not to be in compliance with
DMAS requirements shall be subject to 12VAC30-80-130 for the repayment of those
overpayments to DMAS.
F. Utilization review requirements specific to community
mental health services and residential treatment services, including
therapeutic group homes and psychiatric residential treatment facilities
(PRTFs), as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be as
follows:
1. To apply to be reimbursed as a Medicaid provider, the
required Department of Behavioral Health and Developmental Services (DBHDS)
license shall be either a full, annual, triennial, or conditional license.
Providers must be enrolled with DMAS or the BHSA its contractor
to be reimbursed. Once a health care entity has been enrolled as a provider, it
shall maintain, and update periodically as DMAS or its contractor
requires, a current Provider Enrollment Agreement for each Medicaid service
that the provider offers.
2. Health care entities with provisional licenses shall not be
reimbursed as Medicaid providers of community mental health services.
3. Payments shall not be permitted to health care entities
that either hold provisional licenses or fail to enter into a Medicaid
Provider Enrollment Agreement provider contract with DMAS or its
contractor for a service prior to rendering that service.
4. The behavioral health service authorization contractor
DMAS or its contractor shall apply a national standardized set of
medical necessity criteria in use in the industry, such as McKesson
InterQual Criteria, or an equivalent standard authorized in advance by
DMAS. Services that fail to meet medical necessity criteria shall be denied
service authorization.
5. For purposes of Medicaid reimbursement for services
provided by staff in residency, the following terms shall be used after their
signatures to indicate such status:
a. An LMHP-R shall use the term "Resident" after
his signature.
b. An LMHP-RP shall use the term "Resident in
Psychology" after his signature.
c. An LMHP-S shall use the term "Supervisee in Social
Work" after his signature.
12VAC30-60-50. Utilization control: Intermediate Care
Facilities care facilities for the Mentally Retarded (ICF/MR)
persons with intellectual and developmental disabilities and Institutions
institutions for Mental Disease (IMD) mental disease.
A. "Institution for mental disease" or
"IMD" means the same as that term is defined in § 1905(i) of the
Social Security Act.
B. With respect to each Medicaid-eligible resident in
an ICF/MR intermediate care facility for persons with intellectual
and developmental disabilities (ICF/ID) or an IMD in Virginia, a
written plan of care must be developed prior to admission to or authorization
of benefits in such facility, and a regular program of independent professional
review (including a medical evaluation) shall be completed periodically for
such services. The purpose of the review is to determine: the adequacy of the
services available to meet his the resident's current health
needs and promote his the resident's maximum physical well being;
the necessity and desirability of his the resident's continued
placement in the facility; and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Long-term care of residents in such facilities will
be provided in accordance with federal law that is based on the resident's
medical and social needs and requirements.
B. C. With respect to each ICF/MR ICF/ID
or IMD, periodic on-site onsite inspections of the care being
provided to each person receiving medical assistance, by one or more
independent professional review teams (composed of a physician or registered
nurse and other appropriate health and social service personnel), shall be
conducted. The review shall include, with respect to each recipient, a
determination of the adequacy of the services available to meet his the
resident's current health needs and promote his the resident's
maximum physical well-being, the necessity and desirability of continued
placement in the facility, and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Full reports shall be made to the state agency by
the review team of the findings of each inspection, together with any
recommendations.
C. D. In order for reimbursement to be made to
a facility for the mentally retarded persons with intellectual and
developmental disabilities, the resident must meet criteria for placement
in such facility as described in 12VAC30-60-360 and the facility must provide
active treatment for mental retardation intellectual or developmental
disabilities.
D. E. In each case for which payment for
nursing facility services for the mentally retarded persons with
intellectual or developmental disabilities or institution for mental
disease services is made under the State Plan:
1. A physician must certify for each applicant or recipient
that inpatient care is needed in a facility for the mentally retarded or an
institution for mental disease. A certificate of need shall be completed
by an independent certification team according to the requirements of
12VAC30-50-130 D 5. Recertification shall occur at least every 60 calendar days
by a physician, or by a physician assistant or nurse practitioner acting within
their scope of practice as defined by state law and under the supervision of a
physician. The certification must be made at the time of admission or, if an
individual applies for assistance while in the facility, before the Medicaid
agency authorizes payment; and
2. A physician, or physician assistant or nurse practitioner
acting within the scope of the practice as defined by state law and under the
supervision of a physician, must recertify for each applicant at least every 365
60 calendar days that services are needed in a facility for the
mentally retarded persons with intellectual and developmental
disabilities or an institution for mental disease.
E. F. When a resident no longer meets criteria
for facilities for the mentally retarded persons with intellectual
and developmental disabilities or for an institution for mental
disease, or no longer requires active treatment in a facility for the
mentally retarded persons with intellectual and developmental
disabilities then the resident must shall be discharged.
F. G. All services provided in an IMD and in
an ICF/MR ICF/ID shall be provided in accordance with guidelines
found in the Virginia Medicaid Nursing Home Manual.
H. All services provided in an IMD shall be provided with
the applicable provider agreement and all documents referenced therein.
I. Psychiatric services in IMDs shall only be covered for
eligible individuals younger than 21 years of age.
J. IMD services provided without service authorization
from DMAS or its contractor shall not be covered.
K. Absence of any of the required IMD documentation shall
result in denial or retraction of reimbursement.
L. In each case for which payment for IMD services is made
under the State Plan:
1. A physician shall certify at the time of admission, or
at the time the IMD is notified of an individual's retroactive eligibility status,
that the individual requires or required inpatient services in an IMD
consistent with 42 CFR 456.160.
2. The physician, or physician assistant or nurse
practitioner acting within the scope of practice as defined by state law and
under the supervision of a physician, shall recertify at least every 60
calendar days that the individual continues to require inpatient services in an
IMD.
3. Before admission to an IMD or before authorization
for payment, the attending physician or staff physician shall perform a medical
evaluation of the individual, and appropriate personnel shall complete a
psychiatric and social evaluation as described in 42 CFR 456.170.
4. Before admission to an IMD or before authorization for
payment, the attending physician or staff physician shall establish a written
plan of care for each individual as described in 42 CFR 441.155 and 42 CFR
456.180.
M. It shall be documented that the individual requiring
admission to an IMD who is younger than 21 years of age, that treatment is medically
necessary, and that the necessity was identified as a result of an independent
certification of need team review. Required documentation shall include the
following:
1. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition 2013, American Psychiatric
Association, and based on an evaluation by a psychiatrist completed within 30
calendar days of admission or if the diagnosis is confirmed, in writing, by a
previous evaluation completed within one year within admission.
2. A certification of the need for services as defined in
42 CFR 441.152 by an interdisciplinary team meeting the requirements of 42
CFR 441.153 or 42 CFR 441.156 and the Psychiatric Treatment of Minors Act (§
16.1-335 et seq. of the Code of Virginia).
N. The use of seclusion and restraint in an IMD shall be
in accordance with 42 CFR 483.350 through 42 CFR 483.376. Each use of a
seclusion or restraint, as defined in 42 CFR 483.350 through 42 CFR
483.376, shall be reported by the service provider to DMAS or its contractor
within one calendar day of the incident.
12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health and
behavioral therapy services for children.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:
"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian parent or
guardian is unable to manage the individual's mental, behavioral, or
emotional problems in the home and is actively, within the past two to four
weeks, seeking an out-of-home placement; (iii) a representative of either a
juvenile justice agency, a department of social services (either the state
agency or local agency), a community services board/behavioral health
authority, the Department of Education, or an LMHP, as defined in
12VAC35-105-20, and who is neither an employee of nor consultant to the
intensive in-home (IIH) services or therapeutic day treatment (TDT) provider,
has recommended an out-of-home placement absent an immediate change of
behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 calendar days; or
(v) the treatment team or family assessment planning team (FAPT) recommends IIH
services or TDT for an individual currently who is either: (a) transitioning
out of psychiatric residential treatment facility Level C (PRTF)
services, (b) transitioning out of a therapeutic group home Level A
or B services, (c) transitioning out of acute psychiatric hospitalization,
or (d) transitioning between foster homes, mental health case management,
crisis intervention, crisis stabilization, outpatient psychotherapy, or
outpatient substance abuse services.
"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the services did not treat or resolve the individual's mental
health or behavioral issues.
"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or and adolescents ages 12
through 20 years.
"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.
"Licensed behavior analyst" means a person who has
met the licensing requirements of 18VAC85-150 and holds a valid license issued
by the Department of Health Professions.
"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.
"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B therapeutic
group home; (ii) regular foster home if the individual is currently residing
with his the individual's biological family and, due to his
behavior problems, is at risk of being placed in the custody of the local
department of social services; (iii) treatment foster care if the individual is
currently residing with his the individual's biological family or
a regular foster care family and, due to the individual's behavioral problems,
is at risk of removal to a higher level of care; (iv) Level C psychiatric
residential treatment facility; (v) emergency shelter for the individual
only due either to his mental health or behavior or both; (vi) psychiatric
hospitalization; or (vii) juvenile justice system or incarceration.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized progress notes are part of the minimum documentation
requirements and shall convey the individual's status, staff interventions,
and, as appropriate, the individual's progress or lack of progress toward goals
and objectives in the plan of care. The progress notes shall also include, at a
minimum, the name of the service rendered, the date of the service rendered,
the signature and credentials of the person who rendered the service, the
setting in which the service was rendered, and the amount of time or units
required to deliver the service. The content of each progress note shall
corroborate the time or units billed. Progress notes shall be documented for
each service that is billed.
"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.
B. Utilization review requirements for all services in this
section.
1. The services described in this section shall be rendered
consistent with the definitions, service limits, and requirements described in
this section and in 12VAC30-50-130.
2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.
3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.
C. Utilization review of intensive in-home (IIH) services for
children and adolescents.
1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.
2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness that results in significant functional impairments in major life
activities. Individuals must meet at least two of the following criteria on a
continuing or intermittent basis to be authorized for these services:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.
4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian parent
or guardian within 30 calendar days of initiation of services. The
ISP shall meet all of the requirements as defined in 12VAC30-50-226.
5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.
6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered
in the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the
implementation of the ISP. For services provided outside of the home, there
shall be documentation reflecting therapeutic treatment as set forth in the ISP
provided for that date of service in the appropriately signed and dated
progress notes.
7. These services shall be provided when the clinical needs of
the individual put him the individual at risk for out-of-home
placement, as these terms are defined in this section:
a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,;
or
b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.
The service-specific provider intake shall describe how the
individual meets either subdivision 7 a or 7 b of this subdivision
7 subsection.
8. Services shall not be provided if the individual is no
longer a resident of the home.
9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual and
responsible parent/guardian parent or guardian shall be available
and in agreement to participate in the transition.
10. At least one parent/legal parent or legal
guardian or responsible adult with whom the individual is living must be
willing to participate in the intensive in-home services with the goal of
keeping the individual with the family. In the instance of this service, a
responsible adult shall be an adult who lives in the same household with the
child and is responsible for engaging in therapy and service-related activities
to benefit the individual.
11. The enrolled provider shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) as a provider of
intensive in-home services. The provider shall also have a provider enrollment
agreement with DMAS or its contractor in effect prior to the delivery of this
service that indicates that the provider will offer intensive in-home services.
12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.
13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family individual
or family per week in the initial phase of treatment. It is expected that
the pattern of service provision may show more intensive services and more
frequent contact with the individual and family initially with a lessening or
tapering off of intensity toward the latter weeks of service. Service plans
shall incorporate an individualized discharge plan that describes transition
from intensive in-home to less intensive or nonhome based services.
14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal members or legal
guardian or the individual with the provider, the provider shall discharge the
individual. If the individual continues to need services, then a new intake/admission
intake or admission shall be documented and a new service authorization
shall be required.
15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.
16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430,
the provider shall contact the case manager and provide notification of
the provision of services. In addition, the provider shall send monthly updates
to the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.
17. Emergency assistance shall be available 24 hours per day,
seven days a week.
18. Providers shall comply with DMAS marketing requirements at
12VAC30-130-2000. Providers that DMAS determines violate these marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him the primary care provider of the individual's receipt
of IIH services. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
D. Utilization review of therapeutic day treatment for
children and adolescents.
1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.
2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following criteria:
a. Children and adolescents who require year-round treatment
in order to sustain behavior or emotional gains.
b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:
(1) This programming during the school day; or
(2) This programming to supplement the school day or school
year.
c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.
d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; or (iv) are extremely depressed or marginally
connected with reality.
e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral emotional or
behavioral problems are so severe that they the children
cannot function in these programs without additional services.
3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.
4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.
5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian parent or guardian within 30 calendar
days of initiation of services and shall meet all requirements of an ISP as
defined in 12VAC30-50-226. Individual progress notes shall be required for each
contact with the individual and shall meet all of the requirements as defined
in 12VAC30-50-130 this section.
6. Such services shall not duplicate those services provided
by the school.
7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Individuals shall meet at least two of
the following criteria on a continuing or intermittent basis:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate social
behavior.
8. The enrolled provider of therapeutic day treatment for
child and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.
9. Services shall be provided by an LMHP, LMHP-supervisee,
LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E.
10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.
11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.
12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.
13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.
14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
the individual's parent or legal guardian, shall inform the primary care
provider of the child's the individual's receipt of community
mental health rehabilitative services. The documentation shall include who was
contacted, when the contact occurred, and what information was transmitted. The
parent/legal parent or legal guardian shall be required to give
written consent that this provider has permission to inform the primary care
provider of the child's or adolescent's receipt of community mental health
rehabilitative services.
16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission intake
or admission documentation shall be prepared and a new service
authorization shall be required.
E. Utilization review of community-based services for
children and adolescents younger than 21 years of age (Level A).
1. The staff ratio must be at least one to six during the
day and at least one to 10 between 11 p.m. and 7 a.m. The program
director supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E
(as defined in 12VAC35-105-20). The program director must be employed full
time.
2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.
3. Authorization is required for Medicaid reimbursement.
All community-based services for children and adolescents younger than 21
(Level A) require authorization prior to reimbursement for these services.
Reimbursement shall not be made for this service when other less intensive
services may achieve stabilization.
4. Services must be provided in accordance with an
individual service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.
5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.
6. Such service-specific provider intakes shall be
performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
7. If an individual receiving community-based services for
children and adolescents younger than 21 years of age (Level A) is also
receiving case management services, the provider shall collaborate with the
case manager by notifying the case manager of the provision of Level A services
and shall send monthly updates on the individual's progress. When the
individual is discharged from Level A services, a discharge summary shall be
sent to the case manager within 30 days of the service discontinuation
date. Providers and case managers who are using the same electronic health
record for the individual shall meet requirements for the delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
F. E. Utilization review of therapeutic behavioral
services group home for children and adolescents younger than 21
years of age (Level B).
1. The staff ratio must be at least one to four during the
day and at least one to eight between 11 p.m. and 7 a.m. approved
by the Office of Licensure at the Department of Behavioral Health and
Developmental Services. The clinical director must shall be a
licensed mental health professional. The caseload of the clinical director must
not exceed 16 individuals including all sites for which the same clinical
director is responsible.
2. The program director must shall be full time
and be a QMHP-C or QMHP-E with a bachelor's degree and at least one year's
clinical experience meet the requirements for a program director as
defined in 12VAC35-46-350.
3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the therapeutic group home shall
meet DBHDS paraprofessional staff qualified paraprofessional in
mental health (QPPMH) criteria, as defined in 12VAC35-105-20. The program/group
therapeutic group home must shall coordinate services with
other providers.
4. All therapeutic behavioral group home
services (Level B) shall be authorized prior to reimbursement for these
services. Services rendered without such prior authorization shall not be
covered.
5. Services must be provided in accordance with an ISP a
comprehensive individual plan of care as defined in 12VAC30-50-130, which
shall be fully completed within 30 calendar days of authorization for
Medicaid reimbursement.
6. Prior to admission, a service-specific provider intake
an assessment shall be performed using all elements specified by DMAS in
12VAC30-50-130.
7. Such service-specific provider intakes assessments
shall be performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
8. If an individual receiving therapeutic behavioral group
home services for children and adolescents younger than 21 years of age (Level
B) is also receiving case management services, the therapeutic behavioral
group home services provider must collaborate with the care
coordinator/case manager by notifying him of the provision of Level B therapeutic
group home services and the Level B therapeutic group home
services provider shall send monthly updates on the individual's treatment
status. When the individual is discharged from Level B services, a discharge
summary shall be sent to the care coordinator/case manager within 30 days of
the discontinuation date.
9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian parent or legally authorized representative, shall inform
the primary care provider of the individual's receipt of these Level B therapeutic
group home services. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted. If these
individuals are children or adolescents, then the parent/legal guardian parent
or legally authorized representative shall be required to give written
consent that this provider has permission to inform the primary care provider
of the individual's receipt of community mental health rehabilitative services.
G. Utilization review. Utilization reviews for
community-based services for children and adolescents younger than 21 years of
age (Level A) and therapeutic behavioral services for children and adolescents
younger than 21 years of age (Level B) shall include determinations whether
providers meet all DMAS requirements, including compliance with DMAS marketing
requirements. Providers that DMAS determines have violated the DMAS marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
H. F. Utilization review of behavioral therapy
services for children individuals younger than 21 years of age.
1. In order for Medicaid to cover behavioral therapy services,
the provider shall be enrolled with DMAS or its contractor as a Medicaid
provider. The provider enrollment agreement shall be in effect prior to the
delivery of services for Medicaid reimbursement.
2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.
3. Behavioral therapy services require service authorization.
Services shall be authorized only when eligibility and medical necessity
criteria are met.
4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), LMHP,
LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
behaviors targeted for treatment with their frequency, duration, and intensity)
and describing how service needs can best be met through behavioral therapy.
The service-specific provider intake shall be conducted face-to-face in the
individual's residence with the individual and parent or guardian.
5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP as defined in
12VAC30-50-130 shall be fully completed, signed, and dated by an LBA, LABA,
LMHP, LMHP-R, LMHP-RP, or LMHP-S. Every three months, the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall review the ISP, modify the ISP as appropriate,
and update the ISP, and all of these activities shall occur with the individual
in a manner in which the individual may participate in the process. The ISP
shall be rewritten at least annually.
6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.
7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision of unlicensed staff shall
occur at least weekly. As documented in the individual's medical record,
clinical supervision shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. Clinical supervision shall be documented by, at a
minimum, the contemporaneously dated signature of the clinical supervisor.
8. Family training involving the individual's family and
significant others to advance the treatment goals of the individual shall be
provided when (i) the training with the family member or significant other is
for the direct benefit of the individual, (ii) the training is not aimed at
addressing the treatment needs of the individual's family or significant
others, (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.
9. The following shall not be covered under this service:
a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.
b. Services other than the initial service-specific provider intake
that are provided but are not based upon the individual's ISP or linked to a
service in the ISP. Time not actively involved in providing services directed
by the ISP shall not be reimbursed.
c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.
d. Sessions that are conducted for family support, education,
recreational, or custodial purposes, including respite or child care.
e. Services that are provided by a provider but are rendered
primarily by a relative or guardian who is legally responsible for the
individual's care.
f. Services that are provided in a clinic or provider's office
without documented justification for the location in the ISP.
g. Services that are provided in the absence of the individual
or a parent or other authorized caregiver identified in the ISP with the
exception of treatment review processes described in subdivision 12 e of this
subsection, care coordination, and clinical supervision.
h. Services provided by a local education agency.
i. Provider travel time.
10. Behavioral therapy services shall not be reimbursed
concurrently with community mental health services described in 12VAC30-50-130 B
5 C or 12VAC30-50-226, or behavioral, psychological, or psychiatric
therapeutic consultation described in 12VAC30-120-756, 12VAC30-120-1000,
or 12VAC30-135-320.
11. If the individual is receiving targeted case management
services under the Medicaid state plan State Plan (defined in
12VAC30-50-410 through 12VAC30-50-491 12VAC30-50-491), the
provider shall notify the case manager of the provision of behavioral therapy
services unless the parent or guardian requests that the information not be
released. In addition, the provider shall send monthly updates to the case
manager on the individual's status pursuant to a valid release of information.
A discharge summary shall be sent to the case manager within 30 days of the
service discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.
12. Other standards to ensure quality of services:
a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.
b. Individual-specific services shall be directed toward the
treatment of the eligible individual and delivered in the family's residence
unless an alternative location is justified and documented in the ISP.
c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.
d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.
e. Billable time is permitted for the LBA, LABA, LMHP, LMHP-R,
LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision 12 c of this subsection.
13. Failure to comply with any of the requirements in
12VAC30-50-130 or in this section shall result in retraction.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)
Department of Medical Assistance Services Provider Manuals (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManuals):
Virginia Medicaid Nursing Home Manual
Virginia Medicaid Rehabilitation Manual
Virginia Medicaid Hospice Manual
Virginia Medicaid School Division Manual
Development of Special Criteria for the Purposes
of Pre-Admission Screening, Medicaid Memo, October 3, 2012, Department of
Medical Assistance Services
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association
Patient Placement Criteria for the Treatment of
Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001,
American Society on Addiction Medicine, Inc.
Medicaid Special Memo, Subject: New Service
Authorization Requirement for an Independent Clinical Assessment for Medicaid
and FAMIS Children's Community Mental Health Rehabilitative Services, dated
June 16, 2011, Department of Medical Assistance Services
Medicaid Special Memo, Subject: Changes to Children
Community Mental Health Rehabilitative Services - Children's Services, July 1,
2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Medicaid Special Memo, Subject: Changes to
Community Mental Health Rehabilitative Services - Adult-Oriented Services, July
1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018
Part XIV
Residential Psychiatric Treatment for Children and Adolescents (Repealed)
12VAC30-130-850. Definitions. (Repealed.)
The following words and terms when used in this part shall
have the following meanings, unless the context clearly indicates otherwise:
"Active treatment" means implementation of a
professionally developed and supervised individual plan of care that must be
designed to achieve the recipient's discharge from inpatient status at the
earliest possible time.
"Certification" means a statement signed by a
physician that inpatient services in a residential treatment facility are or
were needed. The certification must be made at the time of admission, or, if an
individual applies for assistance while in a mental hospital or residential
treatment facility, before the Medicaid agency authorizes payment.
"Comprehensive individual plan of care" or
"CIPOC" means a written plan developed for each recipient in
accordance with 12VAC30-130-890 to improve his condition to the extent that
inpatient care is no longer necessary.
"Emergency services" means a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.
"Individual" or "individuals" means a
child or adolescent younger than 21 years of age who is receiving a service
covered under this part of this chapter.
"Initial plan of care" means a plan of care established
at admission, signed by the attending physician or staff physician, that meets
the requirements in 12VAC30-130-890.
"Inpatient psychiatric facility" or
"IPF" means a private or state-run freestanding psychiatric hospital
or psychiatric residential treatment center.
"Recertification" means a certification for each
applicant or recipient that inpatient services in a residential treatment
facility are needed. Recertification must be made at least every 60 days by a
physician, or physician assistant or nurse practitioner acting within the scope
of practice as defined by state law and under the supervision of a physician.
"Recipient" or "recipients" means the
child or adolescent younger than 21 years of age receiving this covered
service.
"RTC-Level C" means a psychiatric residential
treatment facility (Level C).
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in an IPF that are billed by the arranged
practitioners separately from the IPF per diem.
12VAC30-130-860. Service coverage; eligible individuals;
service certification. (Repealed.)
A. Residential treatment programs (Level C) shall be
24-hour, supervised, medically necessary, out-of-home programs designed to
provide necessary support and address the special mental health and behavioral
needs of a child or adolescent in order to prevent or minimize the need for
more intensive inpatient treatment. Services must include, but shall not be
limited to, assessment and evaluation, medical treatment (including drugs),
individual and group counseling, and family therapy necessary to treat the child.
B. Residential treatment programs (Level C) shall provide
a total, 24 hours per day, specialized form of highly organized, intensive and
planned therapeutic interventions that shall be utilized to treat some of the
most severe mental, emotional, and behavioral disorders. Residential treatment
is a definitive therapeutic modality designed to deliver specified results for
a defined group of problems for children or adolescents for whom outpatient day
treatment or other less intrusive levels of care are not appropriate, and for
whom a protected, structured milieu is medically necessary for an extended
period of time.
C. Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B) and Community-Based Services for Children and
Adolescents under 21 (Level A) must be therapeutic services rendered in a
residential type setting such as a group home or program that provides
structure for daily activities, psychoeducation, therapeutic supervision and
mental health care to ensure the attainment of therapeutic mental health goals
as identified in the individual service plan (plan of care). The child or
adolescent must have a medical need for the service arising from a condition
due to mental, behavioral or emotional illness that results in significant functional
impairments in major life activities.
D. Active treatment shall be required. Residential
Treatment, Therapeutic Behavioral and Community-Based Services for Children and
Adolescents under age 21 shall be designed to serve the mental health needs of
children. In order to be reimbursed for Residential Treatment (Level C),
Therapeutic Behavioral Services for Children and Adolescents under 21 (Level
B), and Community-Based Services for Children and Adolescents under 21 (Level
A), the facility must provide active mental health treatment beginning at
admission and it must be related to the recipient's principle diagnosis and
admitting symptoms. To the extent that any recipient needs mental health
treatment and his needs meet the medical necessity criteria for the service, he
will be approved for these services. These services do not include
interventions and activities designed only to meet the supportive nonmental
health special needs, including but not limited to personal care, habilitation
or academic educational needs of the recipients.
E. An individual eligible for Residential Treatment
Services (Level C) is a recipient under the age of 21 years whose treatment
needs cannot be met by ambulatory care resources available in the community,
for whom proper treatment of his psychiatric condition requires services on an
inpatient basis under the direction of a physician.
An individual eligible for Therapeutic Behavioral Services
for Children and Adolescents under 21 (Level B) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a Licensed Mental Health Professional.
An individual eligible for Community-Based Services for
Children and Adolescents under 21 (Level A) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a qualified mental health professional. The services for all three
levels can reasonably be expected to improve the child's or adolescent's
condition or prevent regression so that the services will no longer be needed.
F. In order for Medicaid to reimburse for Residential
Treatment (Level C), Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B), and Community-Based Services for Children and
Adolescents under 21 (Level A), the need for the service must be certified
according to the standards and requirements set forth in subdivisions 1 and 2
of this subsection. At least one member of the independent certifying team must
have pediatric mental health expertise.
1. For an individual who is already a Medicaid recipient
when he is admitted to a facility or program, certification must:
a. Be made by an independent certifying team that includes
a licensed physician who:
(1) Has competence in diagnosis and treatment of pediatric
mental illness; and
(2) Has knowledge of the recipient's mental health history
and current situation.
b. Be signed and dated by a physician and the team.
2. For a recipient who applies for Medicaid while an
inpatient in the facility or program, the certification must:
a. Be made by the team responsible for the plan of care;
b. Cover any period of time before the application for
Medicaid eligibility for which claims for reimbursement by Medicaid are made;
and
c. Be signed and dated by a physician and the team.
12VAC30-130-870. Preauthorization. (Repealed.)
A. Authorization for Residential Treatment (Level C) shall
be required within 24 hours of admission and shall be conducted by DMAS or its
utilization management contractor using medical necessity criteria specified by
DMAS. At preauthorization, an initial length of stay shall be assigned and the
residential treatment provider shall be responsible for obtaining authorization
for continued stay.
B. DMAS will not pay for admission to or continued stay in
residential facilities (Level C) that were not authorized by DMAS.
C. Information that is required in order to obtain
admission preauthorization for Medicaid payment shall include:
1. A completed state-designated uniform assessment
instrument approved by the department.
2. A certification of the need for this service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the recipient;
b. Proper treatment of the recipient's psychiatric
condition requires services on an inpatient basis under the direction of a
physician; and
c. The services can reasonably be expected to improve the
recipient's condition or prevent further regression so that the services will
not be needed.
3. Additional required written documentation shall include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental Retardation,
Axis III (General Medical Conditions), Axis IV (Psychosocial and Environmental
Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the seven
days immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
D. Continued stay criteria for Residential Treatment
(Level C): information for continued stay authorization (Level C) for Medicaid
payment must include:
1. A state uniform assessment instrument, completed no more
than 90 days prior to the date of submission;
2. Documentation that the required services are provided as
indicated;
3. Current (within the last 30 days) information on
progress related to the achievement of treatment goals. The treatment goals
must address the reasons for admission, including a description of any new
symptoms amenable to treatment;
4. Description of continued impairment, problem behaviors,
and need for Residential Treatment level of care.
E. Denial of service may be appealed by the recipient
consistent with 12VAC30-110-10 et seq.; denial of reimbursement may be appealed
by the provider consistent with the Administrative Process Act (§ 2.2-4000 et
seq. of the Code of Virginia).
F. DMAS will not pay for services for Therapeutic
Behavioral Services for Children and Adolescents under 21 (Level B), and
Community-Based Services for Children and Adolescents under 21 (Level A) that
are not prior authorized by DMAS.
G. Authorization for Level A and Level B residential
treatment shall be required within three business days of admission.
Authorization for services shall be based upon the medical necessity criteria
described in 12VAC30-50-130. The authorized length of stay must not exceed six
months and may be reauthorized. The provider shall be responsible for documenting
the need for a continued stay and providing supporting documentation.
H. Information that is required in order to obtain
admission authorization for Medicaid payment must include:
1. A current completed state-designated uniform assessment
instrument approved by the department. The state designated uniform assessment
instrument must indicate at least two areas of moderate impairment for Level B
and two areas of moderate impairment for Level A. A moderate impairment is
evidenced by, but not limited to:
a. Frequent conflict in the family setting, for example,
credible threats of physical harm.
b. Frequent inability to accept age appropriate direction
and supervision from caretakers, family members, at school, or in the home or
community.
c. Severely limited involvement in social support; which
means significant avoidance of appropriate social interaction, deterioration of
existing relationships, or refusal to participate in therapeutic interventions.
d. Impaired ability to form a trusting relationship with at
least one caretaker in the home, school or community.
e. Limited ability to consider the effect of one's
inappropriate conduct on others, interactions consistently involving conflict,
which may include impulsive or abusive behaviors.
2. A certification of the need for the service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the child;
b. Proper treatment of the child's psychiatric condition
requires services in a community-based residential program; and
c. The services can reasonably be expected to improve the
child's condition or prevent regression so that the services will not be
needed.
3. Additional required written documentation must include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental
Retardation), Axis III (General Medical Conditions), Axis IV (Psychosocial and
Environmental Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the 30 days
immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
I. Denial of service may be appealed by the child
consistent with 12VAC30-110; denial of reimbursement may be appealed by the
provider consistent with the Administrative Process Act (§ 2.2-4000 et seq. of
the Code of Virginia).
J. Continued stay criteria for Levels A and B:
1. The length of the authorized stay shall be determined by
DMAS or its contractor.
2. A current Individual Service Plan (ISP) (plan of care)
and a current (within 30 days) summary of progress related to the goals and
objectives on the ISP (plan of care) must be submitted for continuation of the
service.
3. For reauthorization to occur, the desired outcome or
level of functioning has not been restored or improved, over the time frame
outlined in the child's ISP (plan of care) or the child continues to be at risk
for relapse based on history or the tenuous nature of the functional gains and
use of less intensive services will not achieve stabilization. Any one of the
following must apply:
a. The child has achieved initial service plan (plan of
care) goals but additional goals are indicated that cannot be met at a lower
level of care.
b. The child is making satisfactory progress toward meeting
goals but has not attained ISP goals, and the goals cannot be addressed at a
lower level of care.
c. The child is not making progress, and the service plan
(plan of care) has been modified to identify more effective interventions.
d. There are current indications that the child requires
this level of treatment to maintain level of functioning as evidenced by
failure to achieve goals identified for therapeutic visits or stays in a
nontreatment residential setting or in a lower level of residential treatment.
K. Discharge criteria for Levels A and B.
1. Reimbursement shall not be made for this level of care
if either of the following applies:
a. The level of functioning has improved with respect to
the goals outlined in the service plan (plan of care) and the child can reasonably
be expected to maintain these gains at a lower level of treatment; or
b. The child no longer benefits from service as evidenced
by absence of progress toward service plan goals for a period of 60 days.
12VAC30-130-880. Provider qualifications. (Repealed.)
A. Providers must provide all Residential Treatment
Services (Level C) as defined within this part and set forth in 42 CFR Part 441
Subpart D.
B. Providers of Residential Treatment Services (Level C)
must be:
1. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric hospital
accredited by the Joint Commission on Accreditation of Healthcare
Organizations;
2. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric unit of an
acute general hospital accredited by the Joint Commission on Accreditation of
Healthcare Organizations; or
3. A psychiatric facility that is (i) accredited by the
Joint Commission on Accreditation of Healthcare Organizations, the Commission
on Accreditation of Rehabilitation Facilities, the Council on Quality and
Leadership in Supports for People with Disabilities, or the Council on
Accreditation of Services for Families and Children and (ii) licensed by DMHMRSAS
as a residential treatment program for children and adolescents.
C. Providers of Community-Based Services for Children and
Adolescents under 21 (Level A) must be licensed by the Department of Social
Services, Department of Juvenile Justice, or Department of Education under the
Standards for Interdepartmental Regulation of Children's Residential Facilities
(22VAC42-10).
D. Providers of Therapeutic Behavioral Services (Level B)
must be licensed by the Department of Mental Health, Mental Retardation, and Substance
Abuse Services (DMHMRSAS) under the Standards for Interdepartmental Regulation
of Children's Residential Facilities (22VAC42-10).
12VAC30-130-890. Plans of care; review of plans of care.
(Repealed.)
A. All Medicaid services are subject to utilization review
and audit. The absence of any required documentation may result in denial or
retraction of any reimbursement.
B. For Residential Treatment Services (Level C) (RTS-Level
C), an initial plan of care must be completed at admission and a Comprehensive
Individual Plan of Care (CIPOC) must be completed no later than 14 days after
admission.
C. Initial plan of care (Level C) must include:
1. Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
2. A description of the functional level of the individual;
3. Treatment objectives with short-term and long-term
goals;
4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and
special procedures recommended for the health and safety of the individual and
a list of services provided under arrangement (see 12VAC30-50-130 for eligible
services provided under arrangement) that will be furnished to the individual
through the RTC-Level C's referral to an employed or a contracted provider of
services under arrangement, including the prescribed frequency of treatment and
the circumstances under which such treatment shall be sought;
5. Plans for continuing care, including review and modification
to the plan of care;
6. Plans for discharge; and
7. Signature and date by the physician.
D. The CIPOC for Level C must meet all of the following
criteria:
1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for inpatient psychiatric care;
2. Be developed by an interdisciplinary team of physicians
and other personnel specified under subsection G of this section, who are
employed by, or provide services to, patients in the facility in consultation
with the individual and his parents, legal guardians, or appropriate others in
whose care he will be released after discharge;
3. State treatment objectives that must include measurable
short-term and long-term goals and objectives, with target dates for
achievement;
4. Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis;
5. Include a list of services provided under arrangement
(described in 12VAC30-50-130) that will be furnished to the individual through
referral to an employee or a contracted provider of services under arrangement,
including the prescribed frequency of treatment and the circumstances under
which such treatment shall be sought; and
6. Describe comprehensive discharge plans and coordination
of inpatient services and post-discharge plans with related community services
to ensure continuity of care upon discharge with the individual's family,
school, and community.
E. Review of the CIPOC for Level C. The CIPOC must be
reviewed every 30 days by the team specified in subsection G of this section
to:
1. Determine that services being provided are or were
required on an inpatient basis; and
2. Recommend changes in the plan as indicated by the
individual's overall adjustment as an inpatient.
F. The development and review of the plan of care for
Level C as specified in this section satisfies the facility's utilization
control requirements for recertification and establishment and periodic review
of the plan of care, as required in 42 CFR 456.160 and 456.180.
G. Team developing the CIPOC for Level C. The following
requirements must be met:
1. At least one member of the team must have expertise in
pediatric mental health. Based on education and experience, preferably
including competence in child psychiatry, the team must be capable of all of
the following:
a. Assessing the individual's immediate and long-range therapeutic
needs, developmental priorities, and personal strengths and liabilities;
b. Assessing the potential resources of the individual's
family;
c. Setting treatment objectives; and
d. Prescribing therapeutic modalities to achieve the plan's
objectives.
2. The team must include, at a minimum, either:
a. A board-eligible or board-certified psychiatrist;
b. A clinical psychologist who has a doctoral degree and a
physician licensed to practice medicine or osteopathy; or
c. A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases, and a psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.
3. The team must also include one of the following:
a. A psychiatric social worker;
b. A registered nurse with specialized training or one
year's experience in treating mentally ill individuals;
c. An occupational therapist who is licensed, if required
by the state, and who has specialized training or one year of experience in
treating mentally ill individuals; or
d. A psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.
H. The RTC-Level C shall not receive a per diem
reimbursement for any day that:
1. The initial or comprehensive written plan of care fails
to include within three business days of the initiation of the service provided
under arrangement:
a. The prescribed frequency of treatment of such service,
or includes a frequency that was exceeded; or
b. All services that the individual needs while residing at
the RTC-Level C and that will be furnished to the individual through the
RTC-Level C referral to an employed or contracted provider of services under
arrangement;
2. The initial or comprehensive written plan of care fails
to list the circumstances under which the service provided under arrangement
shall be sought;
3. The referral to the service provided under arrangement
was not present in the individual's RTC-Level C record;
4. The service provided under arrangement was not supported
in that provider's records by a documented referral from the RTC-Level C;
5. The medical records from the provider of services under
arrangement (i.e., admission and discharge documents, treatment plans, progress
notes, treatment summaries, and documentation of medical results and findings)
(i) were not present in the individual's RTC-Level C record or had not been
requested in writing by the RTC-Level C within seven days of discharge from or
completion of the service or services provided under arrangement or (ii) had
been requested in writing within seven days of discharge from or completion of
the service or services provided under arrangement, but not received within 30
days of the request, and not re-requested;
6. The RTC-Level C did not have a fully executed contract
or employee relationship with an independent provider of services under
arrangement in advance of the provision of such services. For emergency
services, the RTC-Level C shall have a fully executed contract with the
emergency services provider prior to submission of the emergency service
provider's claim for payment;
7. A physician's order for the service under arrangement is
not present in the record; or
8. The service under arrangement is not included in the
individual's CIPOC within 30 calendar days of the physician's order.
I. The provider of services under arrangement shall be
required to reimburse DMAS for the cost of any such service provided under
arrangement that was (i) furnished prior to receiving a referral or (ii) in
excess of the amounts in the referral. Providers of services under arrangement
shall be required to reimburse DMAS for the cost of any such services provided
under arrangement that were rendered in the absence of an employment or
contractual relationship.
J. For therapeutic behavioral services for children and
adolescents under 21 (Level B), the initial plan of care must be completed at
admission by the licensed mental health professional (LMHP) and a CIPOC must be
completed by the LMHP no later than 30 days after admission. The assessment
must be signed and dated by the LMHP.
K. For community-based services for children and
adolescents under 21 (Level A), the initial plan of care must be completed at
admission by the QMHP and a CIPOC must be completed by the QMHP no later than
30 days after admission. The individualized plan of care must be signed and
dated by the program director.
L. Initial plan of care for Levels A and B must include:
1. Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
2. A description of the functional level of the individual;
3. Treatment objectives with short-term and long-term
goals;
4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and
special procedures recommended for the health and safety of the patient;
5. Plans for continuing care, including review and
modification to the plan of care; and
6. Plans for discharge.
M. The CIPOC for Levels A and B must meet all of the
following criteria:
1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for residential psychiatric care;
2. The CIPOC for both levels must be based on input from
school, home, other health care providers, the individual and family (or legal
guardian);
3. State treatment objectives that include measurable
short-term and long-term goals and objectives, with target dates for achievement;
4. Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis; and
5. Describe comprehensive discharge plans with related
community services to ensure continuity of care upon discharge with the
individual's family, school, and community.
N. Review of the CIPOC for Levels A and B. The CIPOC must
be reviewed, signed, and dated every 30 days by the QMHP for Level A and by the
LMHP for Level B. The review must include:
1. The response to services provided;
2. Recommended changes in the plan as indicated by the
individual's overall response to the plan of care interventions; and
3. Determinations regarding whether the services being
provided continue to be required.
Updates must be signed and dated by the service provider.
VA.R. Doc. No. R17-4495; Filed February 6, 2019, 2:45 p.m.
TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Proposed Regulation
Title of Regulation:
12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-165).
Statutory Authority: § 32.1-325 of the Code of
Virginia; 42 USC § 1396 et seq.
Public Hearing Information: No public hearings are
scheduled.
Public Comment Deadline: May 3, 2019.
Agency Contact: Emily McClellan, Regulatory Supervisor,
Policy Division, Department of Medical Assistance Services, 600 East Broad
Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)
786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants
the Board of Medical Assistance Services the authority to administer and amend
the State Plan for Medical Assistance and promulgate regulations. Section 32.1-324
authorizes the Director of the Department of Medical Assistance Services to
administer and amend the State Plan for Medical Assistance according to the
board's requirements and promulgate regulations. The Medicaid authority as
established by § 1902(a) of the Social Security Act
(42 USC § 1396a) provides governing authority for payments for
services.
Purpose: As practices evolve and coverage is provided
under the State Plan, there are times when it becomes necessary to amend
regulations to conform them to best practices and new guidance from the Centers
for Medicare and Medicaid Services (CMS) to eliminate areas of confusion. It is
expected that these changes will clarify coverage of durable medical equipment
(DME) for DME providers and Medicaid beneficiaries, and reduce unnecessary
documentation elements for DME providers. Further, the changes will improve
coverage by permitting newer and better forms of service delivery that have
evolved in recent years and will align Virginia's coverage with recent guidance
from CMS for enteral nutrition.
These regulatory changes will improve the health, safety, and
welfare of the affected Medicaid individuals by providing care coordination and
well-person preventive services.
Substance:
1. Enteral nutrition. Current coverage requires that enteral
nutrition be the primary or sole source of nutrition (defined) in order to
qualify for coverage. In addition, DME providers must indicate on the
certificate of medical necessity (CMN) if the enteral nutrition is covered
through Women, Infants, and Children (WIC), a program of the U.S. Department of
Agriculture. CMS has provided new, written guidance to Virginia on coverage for
enteral nutrition. The guidance includes the elimination of the requirement
that such enteral nutrition be the Medicaid beneficiary's primary or sole
source of nutrition. The guidance further spells out coverage requirements
related to medical foods, over-the-counter products, and dietary restrictions.
Lastly, the subsection on enteral nutrition has documentation requirements that
are redundant and required of all providers as stated in an earlier subsection.
The proposed changes amend the section to update and conform Medicaid coverage
of enteral nutrition to guidance from CMS and to reduce redundant language and
requirements.
2. Infusion therapy. Current coverage in Virginia defines home
infusion therapy as the administration of intravenous fluids, drugs, chemical
agents, or nutritional supplements. Best practices for delivering home infusion
therapy now include the option for providing such services intravenously (I.V.)
or through an implantable pump. The proposed changes amend the section to
permit the use of implantable pumps for delivering home infusion therapy.
3. Delivery ticket components. Current coverage requires DME
providers to include the Medicaid beneficiary's name and Medicaid number or
date of birth on the delivery ticket. Further, DME providers must include the
serial numbers or the product numbers of the DME or supplies. The delivery ticket
requirements are unnecessary and burdensome to DME providers. The proposed
changes amend the delivery ticket requirements to streamline and enhance
flexibility and provide an alternative option of using an individual's medical
record number.
4. Replacement DME. Currently, the regulation does not identify
a process for providing replacement DME to Medicaid beneficiaries who have lost
DME or had DME destroyed as a result of a disaster. It has become evident to
DMAS that a process should be developed and implemented to ensure quality care
and protect the health and safety of Medicaid beneficiaries. The proposed
changes amend the section to identify the process and requirements for
providing replacement DME to Medicaid beneficiaries who have lost DME or had DME
destroyed as a result of a disaster.
Issues: The current coverages do not conform to best
practices and processes as required by CMS to ensure quality care and protect
the health and safety of Medicaid individuals. The primary advantages to the
public, the agency, and the Commonwealth from the proposed amendments include
enhanced service delivery to DME beneficiaries and greater consistency between
Virginia regulations and current CMS practice. There are no disadvantages to
the public or the Commonwealth as a result of these regulatory changes.
Department of Planning and Budget's Economic Impact
Analysis:
Summary of the Proposed Amendments to Regulation. On behalf of
the Board of Medical Assistance Services, the Director of the Department of
Medical Assistance Services (DMAS) proposes to: 1) eliminate the requirement
that enteral nutrition (EN) be the Medicaid beneficiary's primary or sole
source of nutrition in order to cover EN, 2) amend text to clarify that the use
of implantable pumps for delivering home infusion therapy is permitted and
covered, 3) reduce requirements concerning the delivery ticket, and 4) clarify
the process for providing replacement durable medical equipment and supplies
(DME) to Medicaid beneficiaries who have lost DME or had DME destroyed as a
result of a natural disaster.
Result of Analysis. The benefits likely exceed the costs for
all proposed changes.
Estimated Economic Impact.
Enteral Nutrition: EN is defined as "any method of feeding
that uses the gastrointestinal tract to deliver part or all of an individual's
caloric requirements. Enteral nutrition may include a routine oral diet, the
use of liquid supplements, or delivery of part or all of the daily requirements
by use of a tube (tube feeding)." EN can be effective in helping prevent
malnutrition for patients with a variety of conditions.1 It has been
found to reduce hospital complications, duration of stay, and mortality.2
The current regulation requires that EN be the primary or sole
source of nutrition in order to qualify for coverage. Pursuant to guidance from
the federal Centers for Medicare and Medicaid Services (CMS), the Director
proposes to eliminate the requirement that enteral nutrition EN be the Medicaid
beneficiary's primary or sole source of nutrition in order to qualify for
coverage. DMAS estimates the annual cost of this proposed change to be
$2,308,065, half to be paid with state funds and half to be paid with federal
funds. As described above, expanding the use of EN can have significant health
benefits.
Home Infusion Therapy: The current regulation defines home
infusion therapy as the administration of intravenous fluids, drugs, chemical
agents, or nutritional supplements. The Director proposes to amend the
definition of home infusion therapy to indicate that it can be administered
either intravenously or through the use of an implantable pump. In practice,
the use of an implantable pump has been covered.3 Thus, this
proposed amendment would effectively just be a clarification for readers of the
regulation. Nevertheless, it would be beneficial in that it would reduce the
likelihood of confusion over whether implantable pumps are covered.
Delivery Ticket Components: Under the current regulation, DME
providers must include the Medicaid beneficiary's name and Medicaid number or
date of birth on the delivery ticket. Further, DME providers must include the
serial number(s) or the product numbers of the DME or supplies. The Director
proposes to: 1) allow DME providers the option of having a unique identifier
(e.g., an individual's medical record number) instead of the Medicaid number or
date of birth on the ticket, and 2) no longer require serial number(s) or the
product numbers on the ticket. This proposal reduces the burden on DME
providers.
Replacement DME: The current regulation does not address the
process for providing replacement DME to Medicaid beneficiaries who have lost
DME or had DME destroyed due to a natural disaster. The Director proposes to
add a section to the regulation to identify the process and requirements for
providing replacement DME to Medicaid beneficiaries who have lost DME or had
DME destroyed due to a natural disaster. According to DMAS, the proposed
language matches how this is currently done in practice. However, adding the
section would likely be beneficial in that it helps inform Medicaid recipients,
Medicaid enrolled providers, and other interested parties who may not be
specifically aware of the process and requirements.
Businesses and Entities Affected. The proposed amendments
affect the approximate 1,400 Medicaid-enrolled DME providers,4 and
Medicaid recipients. Most providers would qualify as small businesses.
Localities Particularly Affected. The proposed amendments do
not disproportionately affect particular localities.
Projected Impact on Employment. The proposal to cover EN even
when it is not the sole or primary source of nutrition would increase demand
for tubing and other supplies associated with EN. There may consequently be a
moderate increase in employment at firms that provide these supplies.
Effects on the Use and Value of Private Property. The proposal
to cover EN even when it is not the sole or primary source of nutrition would
increase demand for tubing and other supplies associated with EN. There may
consequently be a moderate increase in the value of firms that provide these
supplies.
Real Estate Development Costs. The proposed amendments do 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 proposals to allow DME providers
the option of having a unique identifier instead of the Medicaid number or date
of birth on the delivery ticket, and to no longer require serial number(s) or
the product numbers, would moderately reduce costs for small DME providers.
Alternative Method that Minimizes Adverse Impact. The proposed
amendments do not adversely affect small businesses.
Adverse Impacts:
Businesses. The proposed amendments do not adversely affect
businesses.
Localities. The proposed amendments do not adversely affect
localities.
Other Entities. The proposed amendments do not adversely affect
other entities.
________________________
1See Thomas D "Enteral Tube Nutrition" Merck
Manual February 2017.
2See Stroud M, Duncan H, Nightingale J "Guidelines
for enteral feeding in adult hospital patients" Gut 2003;52: vii1-vii12.
3Source: Department of Medical Assistance Services
4Data source: Department of Medical Assistance Services
Agency's Response to Economic Impact Analysis: The
agency has reviewed the economic impact analysis prepared by the Department of
Planning and Budget and concurs with this analysis.
Summary:
The proposed amendments update coverage and documentation
requirements for durable medical equipment (DME) by (i) eliminating the
requirement that enteral nutrition be the Medicaid beneficiary's primary or
sole source of nutrition and redundant language and requirements regarding
enteral nutrition, (ii) permitting the use of implantable pumps for delivering
home infusion therapy, (iii) streamlining the delivery ticket requirements to
enhance flexibility and provide an alternative option of using an individual's
medical record number on the ticket, and (iv) identifying the process and
requirements for providing replacement DME to Medicaid beneficiaries who have
lost DME or had DME destroyed as a result of a disaster.
12VAC30-50-165. Durable medical equipment (DME) and supplies
suitable for use in the home.
A. Definitions. The following words and terms when used in these
regulations this section shall have the following meanings unless
the context clearly indicates otherwise:
"Affirmative contact" means speaking, either
face-to-face or by phone, with either the individual or caregiver in order to
ascertain that the DME and supplies are is still needed and
appropriate. Such contacts shall be documented in the individual's medical
record.
"Certificate of Medical Necessity" or
"CMN" means the DMAS-352 form required to be completed and submitted
in order for DMAS to provide reimbursement.
"Designated agent" means an entity with whom DMAS
has contracted to perform contracted functions such as provider audits
and prior authorizations of services.
"DMAS" means the Department of Medical
Assistance Services.
"DME provider" means those entities enrolled with
DMAS to render DME services.
"Durable medical equipment" or "DME"
means medical equipment, supplies, and appliances suitable for use in the home
consistent with 42 CFR 440.70(b)(3) that treat a diagnosed condition or
assist the individual with functional limitations.
"Enteral nutrition" refers to any method of
feeding that uses the gastrointestinal tract to deliver part or all of an
individual's caloric requirements. "Enteral nutrition" may include a
routine oral diet, the use of liquid supplements, or delivery of part or all of
the daily requirements by use of a tube, which is called tube feeding.
"Expendable supply" means an item that is used and
then disposed of.
"Frequency of use" means the rate of use by the
individual as documented by the number of times per day/week/month day,
week, or month, as appropriate, a supply is used by the individual.
Frequency of use must be recorded on the face of the CMN in such a way that
reflects whether a supply is used by the individual on a daily, weekly, or
monthly basis. Frequency of use may be documented on the CMN as a range of the
rate of use. By way of example and not limitation, the frequency of use of a
supply may be expressed as a range, such as four to six adult diapers per day.
However, large ranges shall not be acceptable documentation of frequency of use
(for, for example, the range of one to six adult diapers per day
shall not be acceptable.) The frequency of use provides the
justification for the total quantity of supplies ordered on the CMN.
"Functional limitation" means the inability to
perform a normal activity.
"Practitioner" means a licensed provider of
physician services as defined in 42 CFR 440.50.
"Prior authorization" or "PA" (also
"service authorization") means the process of approving either by
DMAS or its prior authorization (or service authorization) contractor
for the purposes of DMAS reimbursement for the service for the individual
before it is rendered or reimbursed.
"Quantity" means the total number of supplies ordered
on a monthly basis as reflected on the CMN. The monthly quantity of supplies
ordered for the individual shall be dependent upon the individual's frequency
of use.
"Sole source of nutrition" means that the
individual is unable to tolerate (swallow or absorb) any other form of oral
nutrition in instances when more than 75% of the individual's daily caloric
intake is received from nutritional supplements.
B. General requirements and
conditions.
1. a. All medically necessary supplies and equipment shall be
covered. Unusual amounts, types, and duration of usage must be authorized by
DMAS in accordance with published policies and procedures. When determined to
be cost effective by DMAS, payment may be made for rental of the equipment in
lieu of purchase.
b. No provider shall have a claim of ownership on DME
reimbursed by Virginia Medicaid once it has been delivered to the Medicaid
individual. Providers shall only be permitted to recover DME, for
example, when DMAS determines that it does not fulfill the required medically
necessary purpose as set out in the Certificate of Medical Necessity, when
there is an error in the ordering practitioner's CMN, or when the equipment was
rented.
2. DME providers shall adhere to all applicable federal and
state laws and regulations and DMAS policies for DME and supplies. DME
providers shall comply with all other applicable Virginia laws and regulations
requiring licensing, registration, or permitting. Failure to comply with such
laws and regulations that are required by such a licensing agency
or agencies shall result in denial of coverage for DME or supplies.
3. DME products or supplies must be furnished pursuant
to a properly completed Certificate of Medical Necessity (CMN) (DMAS-352). In
order to obtain Medicaid reimbursement, specific fields of the DMAS-352 form
shall be completed as specified in 12VAC30-60-75.
4. DME and supplies shall be ordered by the licensed
practitioner and shall be related to medical treatment of the Medicaid
individual. The complete DME order shall be recorded on the CMN for Medicaid
individuals to receive such services. In the absence of a different effective
period determined by DMAS or its designated agent, the CMN shall be valid for a
maximum period of six months for Medicaid individuals younger than 21 years of
age. In the absence of a different effective period determined by DMAS or its
designated agent, the maximum valid time period for CMNs for Medicaid
individuals 21 years of age and older shall be 12 months. The validity of the
CMN shall terminate when the individual's medical need for the prescribed DME or
supplies no longer exists as determined by the licensed practitioner.
5. DME shall be furnished exactly as ordered by the licensed
practitioner who signed the CMN. The CMN and any supporting verifiable
documentation shall be fully completed, signed, and dated by the licensed
practitioner, and in the DME provider's possession within 60 days from the time
the ordered DME and supplies are is initially furnished by the
DME provider. Each component of the DME items shall be specifically
ordered on the CMN by the licensed practitioner.
6. The CMN shall not be changed, altered, or amended after the
licensed practitioner has signed it. If the individual's condition indicates
that changes in the ordered DME or supplies are is necessary, the
DME provider shall obtain a new CMN. All new CMNs shall be signed and dated by
the licensed practitioner within 60 days from the time the ordered supplies are
furnished by the DME provider.
7. DMAS or its designated agent shall have the authority to
determine a different (from those specified above) length of time from
those specified in subdivisions 4, 5, and 6 of this subsection that a CMN
may be valid based on medical documentation submitted on the CMN. The CMN may
be completed by the DME provider or other appropriate health care
professionals, but it shall be signed and dated by the licensed practitioner,
as specified in subdivision 5 of this subsection. Supporting documentation may
be attached to the CMN but the licensed practitioner's entire order for DME and
supplies shall be on the CMN.
8. The DME provider shall retain a copy of the CMN and all
supporting verifiable documentation on file for DMAS' purposes of the
DMAS post payment audit review purposes. DME providers shall not
create or revise CMNs or supporting documentation for this service after the
initiation of the post payment review audit process. Licensed practitioners
shall not complete, sign, or date CMNs once the post payment audit review has
begun.
9. The DME provider shall be responsible for knowledge of
items requiring prior authorization and the limitation on the provision of
certain items as described in the Virginia Medicaid Durable Medical Equipment
and Supplies Manual, Appendix B. The Appendix B shall be the official
listing of all items covered through the Virginia Medicaid DME program and lists
list the service limits, items that require prior authorization, billing
units, and reimbursement rates.
10. The DME provider shall be required to make affirmative
contact with the individual or his caregiver and document the
interaction prior to the next month's delivery and prior to the recertification
CMN to assure that the appropriate quantity, frequency, and product are
provided to the individual.
11. Supporting documentation, added to a completed CMN, shall
be allowed to further justify the medical need for DME. Supporting
documentation shall not replace the requirement for a properly completed CMN.
The dates of the supporting documentation shall coincide with the dates of
service on the CMN, and the supporting documentation shall be fully
signed and dated by the licensed practitioner.
C. Effective July 1, 2010, the The billing unit
for incontinence supplies (such as diapers, pull-ups, and panty liners) shall
be by each product. For example, if the incontinence supply being provided is
diapers, the billing unit would be by individual diaper, rather than a case of
diapers. Prior authorization shall be required for incontinence supplies
provided in quantities greater than the allowable service limit per month.
D. Supplies, equipment, or appliances that are not covered
include, but shall not be limited to, the following:
1. Space conditioning equipment, such as room humidifiers, air
cleaners, and air conditioners;
2. DME and supplies for any hospital or nursing
facility resident, except ventilators and associated supplies or specialty beds
for the treatment of wounds consistent with DME criteria for nursing facility
residents that have been prior approved by the DMAS central office
or designated agent;
3. Furniture or appliances not defined as medical equipment
(such as blenders, bedside tables, mattresses other than for a hospital bed,
pillows, blankets or other bedding, special reading lamps, chairs with special
lift seats, hand-held shower devices, exercise bicycles, and bathroom scales);
4. Items that are only for the individual's comfort and
convenience or for the convenience of those caring for the individual (e.g., a
hospital bed or mattress because the individual does not have a bed; wheelchair
trays used as a desk surface); mobility items used in addition to primary
assistive mobility aide for caregiver's or individual's the
convenience of the individual or his caregiver (e.g., an electric
wheelchair plus a manual chair); and cleansing wipes;
5. Prosthesis, except for artificial arms, legs, and their
supportive devices, which shall be prior authorized by the DMAS central
office or designated agent;
6. Items and services that are not reasonable and necessary
for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member (e.g., dentifrices; toilet articles;
shampoos that do not require a licensed practitioner's prescription; dental
adhesives; electric toothbrushes; cosmetic items, soaps, and lotions that do
not require a licensed practitioner's prescription; sugar and salt substitutes;
and support stockings);
7. Orthotics, including braces, diabetic shoe inserts,
splints, and supports;
8. Home or vehicle modifications;
9. Items not suitable for or not used primarily in the home
setting (e.g., car seats, equipment to be used while at school, etc.);
10. Equipment for which the primary function is vocationally
or educationally related (e.g., computers, environmental control devices,
speech devices, etc.);
11. Diapers for routine use by children younger than three
years of age who have not yet been toilet trained;
12. Equipment or items that are not suitable for use in the
home; and
13. Equipment or items that the Medicaid individual or his
caregiver is unwilling or unable to use in the home.
E. For coverage of blood glucose meters for pregnant women,
refer to 12VAC30-50-510.
F. Coverage of home infusion therapy.
1. Home infusion therapy shall be defined as the intravenous
(I.V.) administration of fluids, drugs, chemical agents, or nutritional
substances to recipients individuals through intravenous (I.V.)
therapy or an implantable pump in the home setting. DMAS shall reimburse
for these services, supplies, and drugs on a service day rate methodology
established in 12VAC30-80-30. The therapies to be covered under this policy
shall be: hydration therapy, chemotherapy, pain management therapy, drug
therapy, and total parenteral nutrition (TPN). All the therapies that meet
criteria shall be covered and do not require prior authorization. The
established service day rate shall reimburse for all services delivered in a
single day. There shall be no additional reimbursement for special or
extraordinary services. In the event of incompatible drug administration, a
separate HCPCS code shall be used to allow for rental of a second infusion pump
and purchase of an extra administration tubing. When applicable, this code may
be billed in addition to the other service day rate codes. There shall be
documentation to support the use of this code on the I.V. Implementation Form.
Proper documentation shall include the need for pump administration of the
medications ordered, frequency of administration to support that they are
ordered simultaneously, and indication of incompatibility.
2. The service day rate payment methodology shall be mandatory
for reimbursement of all I.V. therapy services except for the individual who is
enrolled in the Technology Assisted Waiver.
3. The following limitations shall apply to this service:
a. This service must be medically necessary to treat an
individual's medical condition. The service must be ordered and provided in
accordance with accepted medical practice. The service must not be desired
solely for the convenience of the individual or the individual's caregiver.
b. In order for Medicaid to reimburse for this service, the
individual shall:
(1) Reside in either a private home or a domiciliary care
facility, such as an assisted living facility. Because the reimbursement for
DME is already provided under institutional reimbursement, individuals in
hospitals, nursing facilities, rehabilitation centers, and other institutional
settings shall not be covered for this service;
(2) Be under the care of a licensed practitioner who
prescribes the home infusion therapy and monitors the progress of the therapy;
(3) Have body sites available for peripheral intravenous
catheter or needle placement or have a central venous access; and
(4) Be capable of either self-administering such therapy or
have a caregiver who can be adequately trained, is capable of administering the
therapy, and is willing to safely and efficiently administer and monitor the
home infusion therapy. The caregiver must be willing to and be capable of
following appropriate teaching and adequate monitoring. In cases where the
individual is incapable of administering or monitoring the prescribed therapy
and there is no adequate or trained caregiver, it may be appropriate for a home
health agency to administer the therapy.
G. The DME and supply vendor shall provide the
equipment and supplies as prescribed by the licensed practitioner on the CMN.
Orders shall not be changed unless the vendor obtains a new CMN, which includes
the licensed practitioner's signature, prior to ordering the equipment or
supplies or providing the equipment or supplies to the individual.
H. Medicaid shall not provide reimbursement to the DME and
supply vendor for services that are provided either: (i) prior to
the date prescribed by the licensed practitioner; (ii) prior to the date of the
delivery; or (iii) when services are not provided in accordance with DMAS'
DMAS published regulations and guidance documents. If reimbursement is
denied for one or all of these reasons, the DME and supply vendor shall
not bill the Medicaid individual for the service that was provided.
I. The following criteria shall be satisfied through the
submission of adequate and verifiable documentation on the CMN satisfactory to
DMAS. Medically necessary DME and supplies shall be:
1. Ordered by the licensed practitioner on the CMN;
2. A reasonable and necessary part of the individual's
treatment plan;
3. Consistent with the individual's diagnosis and medical
condition, particularly the functional limitations and symptoms exhibited by
the individual;
4. Not furnished solely for the convenience, safety, or
restraint of the individual, the family or caregiver, the licensed
practitioner, or other licensed practitioner or supplier;
5. Consistent with generally accepted professional medical
standards (i.e., not experimental or investigational); and
6. Furnished at a safe, effective, and cost-effective level
suitable for use in the individual's home environment.
J. Medical documentation shall provide DMAS or the designated
agent with evidence of the individual's DME needs. Medical documentation may be
recorded on the CMN or evidenced in the supporting documentation attached to
the CMN. The following applies to the medical justification necessary for all
DME services regardless of whether prior authorization is required. The
documentation is necessary to identify:
1. The medical need for the requested DME;
2. The diagnosis related to the reason for the DME request;
3. The individual's functional limitation and its relationship
to the requested DME;
4. How the DME service will treat the individual's medical condition;
5. For expendable supplies, the quantity needed and the
medical reason the requested amount is needed;
6. The frequency of use to describe how often the DME is used
by the individual;
7. The estimated duration of use of the equipment (rental and
purchased);
8. Any other treatment being rendered to the individual
relative to the use of DME or supplies;
9. How the needs were previously met, identifying
changes that have occurred that necessitate the DME;
10. Other alternatives tried or explored and a description of
the success or failure of these alternatives;
11. How the DME service is required in the individual's home
environment; and
12. The individual's or his caregiver's ability,
willingness, and motivation to use the DME.
K. DME provider responsibilities. To receive reimbursement,
the DME provider shall, at a minimum, perform the following:
1. Verify the individual's current Medicaid eligibility;
2. Determine whether the ordered item or items are a
covered service and require prior authorization;
3. Deliver all of the item or items ordered by the
licensed practitioner;
4. Deliver only the quantities ordered by the licensed
practitioner on the CMN and prior authorized by DMAS if required;
5. Deliver only the item or items for the periods of
service covered by the licensed practitioner's order and prior authorized, if
required, by DMAS;
6. Maintain a copy of the licensed practitioner's signed CMN
and all verifiable supporting documentation for all DME and supplies
ordered;
7. Document and justify the description of services (i.e.,
labor, repairs, maintenance of equipment);
8. Document and justify the medical necessity, frequency,
and duration for all items and supplies as set out in the Medicaid DME guidance
documents;
9. Document all DME and supplies provided to an
individual in accordance with the licensed practitioner's orders. The delivery ticket/proof
ticket or proof of delivery shall document the requirements as stated in
subsection L of this section.; and
10. Documentation Meet documentation requirements
for the use of DME billing codes that have Individual Consideration (IC)
indicated as the reimbursement fee shall to include a complete
description of the item or items, a copy of the supply invoice or
supplies invoices or the manufacturer's cost information, and all discounts
that were received by the DME provider. Additional information regarding
requirements for the IC reimbursement process can be found in the relevant
agency guidance document.
L. Proof of delivery.
1. The delivery ticket shall contain the following
information:
a. The Medicaid individual's name and Medicaid number or date
of birth or a unique identifier (e.g., an individual's medical record
number);
b. A detailed description of the item or items being
delivered, including the product name or names and brand or
brands;
c. The serial number or numbers or the product numbers
of the DME or supplies, if available;
d. The quantity delivered; and
e. The dated signature of either the individual or his
caregiver.
2. If a commercial shipping service is used, the DME
provider's records shall reference, in addition to the information required in
subdivision 1 of this subsection, the delivery service's package identification
number or numbers with a copy of the delivery service's delivery ticket,
which may be printed from the online record on the delivery service's website.
a. The delivery service's ticket identification number or
numbers shall be recorded on the DME provider's delivery documentation.
b. The service delivery documentation may be substituted for
the individual's signature as proof of delivery.
c. In the absence of a delivery service's ticket, the DME
provider shall obtain the individual's or his caregiver's dated
signature on the DME provider's delivery ticket as proof of delivery.
3. Providers may use a postage-paid delivery invoice from the
individual or his caregiver as a form of proof of delivery. The
descriptive information concerning the item or items delivered, as
described in subdivisions 1 and 2 of this subsection, as well as the required
signature and date from either the individual or his caregiver,
shall be included on this invoice.
4. DME providers shall make affirmative contact with the
individual or his caregiver and document the interaction prior to
dispensing repeat orders or refills to ensure that:
a. The item is still needed;
b. The quantity, frequency, and product are still
appropriate; and
c. The individual still resides at the address in the
provider's records.
5. The DME provider shall contact the individual prior to each
delivery. This contact shall not occur any sooner than seven days prior to the
delivery or shipping date and shall be documented in the individual's record.
6. DME providers shall not deliver refill orders sooner than
five days prior to the end of the usage period.
7. Providers shall not bill for dates of service prior to
delivery. The provider shall confirm receipt of the DME or supplies via
the shipping service record showing the item was delivered prior to billing.
Claims for refill orders shall be the start of the new usage period and shall
not overlap with the previous usage period.
8. The purchase prices listed in the Virginia Medicaid Durable
Medical Equipment and Supplies Manual, Appendix B, represent the amount DMAS
shall pay for newly purchased equipment. Unless otherwise approved by DMAS or
its designated agent, documentation on the delivery ticket shall reflect that
the purchased equipment is new upon the date of the service billed. Any warranties
associated with new equipment shall be effective from the date of the service
billed. Since Medicaid is the payer of last resort, the DME provider shall
explore coverage available under the warranty prior to requesting coverage of
repairs from DMAS.
9. DME and supplies for home use for an individual
being discharged from a hospital or nursing facility may be delivered to the
hospital or nursing facility one day prior to the discharge. However, the DME
provider's claim date of service shall not begin prior to the date of the
individual's discharge from the hospital or nursing facility.
M. Enteral nutrition products. Coverage of enteral nutrition
(EN) that does not include a legend drug shall be limited to when the
nutritional supplement is the sole source form of nutrition, is
administered orally or through a nasogastric or gastrostomy tube, and is
necessary to treat a medical condition. DMAS shall provide coverage for
nutritional supplements for enteral feeding only if the nutritional supplements
are not available over the counter. Additionally, DMAS shall cover medical
foods that are (i) specific to inherited diseases, metabolic disorders, PKU,
etc.; (ii) not generally available in grocery stores, health food stores, or
the retail section of a pharmacy; and (iii) not used as food by the general
population. Coverage of EN shall not include the provision of routine
infant formula or feedings as meal replacement only. Coverage of medical
foods shall not extend to regular foods prepared to meet particular dietary
restrictions, limitations, or needs, such as meals designed to address the
situation of individuals with diabetes or heart disease. A nutritional
assessment shall be required for all recipients individuals for
whom nutritional supplements are ordered.
1. General requirements and conditions.
a. Enteral nutrition products shall only be provided by
enrolled DME providers.
b. DME providers shall adhere to all applicable DMAS policies,
laws, and regulations. DME providers shall also comply with all other
applicable Virginia laws and regulations requiring licensing, registration, or
permitting. Failure to comply with such laws and regulations shall result in
denial of coverage for enteral nutrition that is regulated by such licensing
agency or agencies.
2. Service units and service limitations.
a. DME and supplies shall be furnished pursuant to the
Certificate of Medical Necessity (CMN) (DMAS-352).
b. The DME provider shall include documentation related to the
nutritional evaluation findings on the CMN and may include supplemental
information on any supportive documentation submitted with the CMN.
c. DMAS shall reimburse for medically necessary formulae and
medical foods when used under a licensed practitioner's direction to augment
dietary limitations or provide primary nutrition to individuals via enteral or
oral feeding methods.
d. The CMN shall contain a licensed practitioner's order for
the enteral nutrition products that are medically necessary to treat the
diagnosed condition and the individual's functional limitation. The
justification for enteral nutrition products shall be demonstrated in the
written documentation either on the CMN or on the attached supporting
documentation. The CMN shall be valid for a maximum period of six months.
e. Regardless of the amount of time that may be left on a
six-month approval period, the validity of the CMN shall terminate when the
individual's medical need for the prescribed enteral nutrition products either
ends, as determined by the licensed practitioner, or when the enteral
nutrition products are no longer the primary source of nutrition.
f. A face-to-face nutritional assessment completed by trained
clinicians (e.g., physician, physician assistant, nurse practitioner,
registered nurse, or a registered dietitian) shall be completed as required
documentation of the need for enteral nutrition products.
g. The CMN shall not be changed, altered, or amended after
the licensed practitioner has signed it. As indicated by the individual's
condition, if changes are necessary in the ordered enteral nutrition products,
the DME provider shall obtain a new CMN.
(1) New CMNs shall be signed and dated by the licensed
practitioner within 60 days from the time the ordered enteral nutrition
products are furnished by the DME provider.
(2) The order shall not be backdated to cover prior
dispensing of enteral nutrition products. If the order is not signed within 60
days of the service initiation, then the date the order is signed becomes the
effective date.
h. g. Prior authorization of enteral nutrition
products shall not be required. The DME provider shall assure that there is a
valid CMN (i) completed every six months in accordance with subsection B of
this section and (ii) on file for all Medicaid individuals for whom enteral nutrition
products are provided.
(1) The DME provider is further responsible for assuring that
enteral nutrition products are provided in accordance with DMAS reimbursement
criteria in 12VAC30-80-30 A 6.
(2) Upon post payment review, DMAS or its designated contractor
may deny reimbursement for any enteral nutrition products that have not been
provided and billed in accordance with these regulations this section
and DMAS policies.
i. h. DMAS shall have the authority to determine
that the CMN is valid for less than six months based on medical documentation
submitted.
3. Provider responsibilities.
a. The DME provider shall provide the enteral nutrition
products as prescribed by the licensed practitioner on the CMN. Physician
orders shall not be changed unless the DME provider obtains a new CMN prior to
ordering or providing the enteral nutrition products to the individual.
b. The licensed practitioner's order (CMN) on the
CMN shall state that the enteral nutrition products are the sole source
of nutrition for the individual and specify either a brand name of the
enteral nutrition product being ordered or the category of enteral nutrition
products that must be provided. If a licensed practitioner orders a specific
brand of enteral nutrition product, the DME provider shall supply the brand
prescribed. The licensed practitioner order shall include the daily caloric
intake and the route of administration for the enteral nutrition product. Additional
supporting Supporting documentation may be attached to the CMN, but the
entire licensed practitioner's order shall be on the CMN.
c. The CMN shall be signed and dated by the licensed
practitioner within 60 days of the CMN begin service date. The order shall
not be backdated to cover prior dispensing of enteral nutrition products.
If the CMN is not signed and dated by the licensed practitioner within 60 days
of the CMN begin service date, the CMN shall not become valid until
the on the date of the licensed practitioner's signature.
d. The CMN shall include all of the following elements:
(1) Height of individual (or length for pediatric patients);
(2) Weight of individual. For initial assessments, indicate
the individual's weight loss over time;
(3) Tolerance of enteral nutrition product (e.g., is the
individual experiencing diarrhea, vomiting, constipation). This element is only
required if the individual is already receiving enteral nutrition products;
(4) Indication of whether or not the enteral nutrition
product is the primary or sole source of nutrition;
(5) (4) Route of administration; and
(6) (5) The daily caloric order and the number
of calories per package or can; and.
(7) Extent to which the quantity of the enteral nutrition
product is available through WIC, the Special Supplemental Nutrition Program
for Women, Infants and Children.
e. The DME provider shall retain a copy of the CMN and all
supporting verifiable documentation on file for DMAS' post payment review
purposes. DME providers shall not create or revise CMNs or supporting
documentation for this service after the initiation of the post payment review
process. Licensed practitioners shall not complete or sign and date CMNs once
the post payment review has begun.
f. e. Medicaid reimbursement shall be recovered
when the enteral nutrition products have not been ordered on the CMN.
Supporting documentation is allowed to justify the medical need for enteral
nutrition products. Supporting documentation shall not replace the requirement
for a properly completed CMN. The dates of the supporting documentation shall
coincide with the dates of service on the CMN, and the supporting documentation
shall be fully signed and dated by the licensed practitioner.
g. To receive reimbursement, the DME provider shall:
(1) Deliver only the item or items and quantity or
quantities ordered by the licensed practitioner and approved by DMAS or the
designated prior or service authorization contractor;
(2) Deliver only the item or items for the periods of
service covered by the licensed practitioner's order and approved by DMAS or
the designated prior or service authorization contractor;
(3) Maintain a copy of the licensed practitioner's order
and all verifiable supporting documentation for all DME ordered; and
(4) Document all supplies provided to an individual in
accordance with the licensed practitioner's orders. The delivery ticket must
document the individual's name and Medicaid number, the date of delivery, the
item or items that were delivered, and the quantity delivered.
h. N. Reimbursement denials.
1. DMAS shall deny payment to the DME provider if any
of the following occur:
(1) a. Absence of a current, fully completed CMN
appropriately signed and dated by the licensed practitioner;
(2) b. Documentation does not verify that the
item was provided to the individual;
(3) c. Lack of medical documentation, signed by
the licensed practitioner to justify the enteral nutrition products DME;
or
(4) d. Item is noncovered or does not meet DMAS
criteria for reimbursement.
i. 2. If reimbursement is denied by Medicaid,
the DME provider shall not bill the Medicaid individual for the service that
was provided.
O. Replacement DME following a natural disaster.
1. Medicaid individuals who (i) live in a disaster area,
(ii) can prove they were present in the disaster area when the disaster
occurred, or (iii) live in areas that have been declared by the Governor as a
disaster or emergency area in accordance with § 44-146.16 of the Code of
Virginia, and who need to replace DME previously approved by Medicaid that were
damaged as a result of the disaster or emergency, may contact a DME provider
(either enrolled in fee-for-service Medicaid or a Medicaid health plan) of
their choice to obtain a replacement.
a. If the individual's DME provider has gone out of
business or is unable to provide replacement DME, the individual may choose
another provider who is enrolled as a DME provider with Medicaid or the Medicaid
health plan. The original authorization will be canceled or amended and a new
authorization will be provided to the new DME provider.
b. The DME provider shall submit a signed statement from
the Medicaid individual requesting a change in DME provider in accordance with
the declaration by the Governor as a state of emergency due to a natural
disaster and giving the Medicaid individual's current place of residence.
c. The individual can contact the state Medicaid office or
the Medicaid health plan to get help finding a new DME provider.
2. For Medicaid enrolled providers, the provider shall make
a request to the service authorization contractor; however, a new CMN and
medical documentation is not required unless the DME is beyond the service
limit (e.g., the individual has a wheelchair that is older than five years).
The provider shall keep documentation in the individual's record that includes
the individual's current place of residence and states that the original DME
was lost due to the natural disaster.
VA.R. Doc. No. R17-5024; Filed February 6, 2019, 9:18 a.m.
TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Proposed Regulation
Titles of Regulations: 12VAC30-10. State Plan under
Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-540).
12VAC30-50. Amount, Duration, and Scope of Medical and
Remedial Care Services (amending 12VAC30-50-20, 12VAC30-50-30,
12VAC30-50-60, 12VAC30-50-70, 12VAC30-50-130, 12VAC30-50-226).
12VAC30-60. Standards Established and Methods Used to Assure
High Quality Care (amending 12VAC30-60-5, 12VAC30-60-50,
12VAC30-60-61).
12VAC30-130. Amount, Duration and Scope of Selected Services (repealing 12VAC30-130-850, 12VAC30-130-860,
12VAC30-130-870, 12VAC30-130-880, 12VAC30-130-890).
Statutory Authority: § 32.1-325 of the Code of Virginia;
42 USC § 1396 et seq.
Public Hearing Information: No public hearings are
scheduled.
Public Comment Deadline: May 3, 2019.
Agency Contact: Emily McClellan, Regulatory Supervisor,
Policy Division, Department of Medical Assistance Services, 600 East Broad
Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)
786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants
to the Board of Medical Assistance Services the authority to administer and
amend the State Plan for Medical Assistance and promulgate regulations. Section
32.1-324 of the Code of Virginia authorizes the Director of the Department of
Medical Assistance Services (DMAS) to administer and amend the State Plan for
Medical Assistance according to the board's requirements and promulgate
regulations. The Medicaid authority as established by § 1902(a) of the Social
Security Act (42 USC § 1396a) provides governing authority for payments
for services.
The agency is proposing this regulatory action to comply with
Item 301 OO and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly. Items
301 PP states: "The Department of Medical Assistance Services shall make
programmatic changes in the provision of Residential Treatment Facility (Level
C) and Levels A and B residential services (group homes) for children with
serious emotional disturbances in order to ensure appropriate utilization and
cost efficiency. The department shall consider all available options including,
but not limited to, prior authorization, utilization review and provider
qualifications. The department shall have authority to promulgate regulations
to implement these changes within 280 days or less from the enactment date of
this act."
Purpose: This regulatory action is essential to protect
the health, safety, or welfare of Medicaid-covered individuals who require
behavioral health services and their families to ensure that families are well
informed about their family member's behavioral health condition about service
options prior to receiving these services, that the services are medically
necessary, and that the services are rendered by providers who use
evidence-based treatment approaches.
When residential treatment services were initially implemented
by DMAS, individuals did not have access to standardized methods of effective
care coordination upon entry into residential treatment due to placement
processes at the time and DMAS reimbursement limitations. This resulted in a
fragmented coordination approach for these individuals who were at risk for
high levels of care and remained at risk of repeated placements at this level
of care. Also, at the time of the appropriations act mandate, the process in
place for Medicaid enrolled children placed in residential settings yielded an
average stay of 260 days and had high readmission rates.
While residential treatment is not a service that should be
approved with great frequency for a large number of individuals, it is a
service that should be accessible to the families and individuals who require
that level of care. The service model had significant operational layers to be
navigated to access residential services. The processes involved coordination
of care by local family access and planning teams (FAPTs) who have, over time,
demonstrated some influence on determining an individual's eligibility for FAPT
funded services. The local influence on the programs administration caused
limitations on individualized freedom of provider choice and inconsistent
authorization of funding for persons deemed to need psychiatric care out of the
home setting. This local administration of the primary referral source for
residential treatment was outside the purview of DMAS, and this situation
produced outcomes that are inadequate to meet Centers for Medicare and Medicaid
Services (CMS) requirements on ensuring the individual freedom of choice of
providers.
Also, the state rules on FAPT composition were not consistent
with the federal Medicaid requirement for certifying a child for
Medicaid-funded residential treatment placement. Changes to the program were
necessary to address concerns that arose from the reliance upon the FAPT to
fulfill the role as the federally mandated independent team to certify
residential treatment.
The residential treatment model requires an enhanced care
coordination model to support the individuals who receive this level of service
to ensure an effective return to the family or caregiver home environment with
follow up services to facilitate ongoing treatment progress in the least
restrictive environment. The added coordination is required to navigate a very
complex service environment for the individual as the individual returns to a
community setting to establish an effective aftercare environment that involves
service providers who may be contracted with a variety of entities such as DMAS
contracted managed care organizations (MCOs), enrolled providers, the local
FAPT team, local school divisions, and the local community services board
(CSB). The proposed amendments allow DMAS to implement a contracted care
coordination team to focus on attaining specific clinical outcomes for all residential
care episodes and to provide a single liaison who will ensure coordination of
care in a complex service environment for individuals upon discharge from
residential treatment and prior to the time when they will enroll in an MCO.
During this transition period, the individual is very vulnerable to repeated
admissions to residential or inpatient care and must be supported in the
fee-for-service (FFS) environment with resources from the local CSB and
enrolled service providers and requires ongoing support and coordination to
receive post-discharge follow up and transition services.
DMAS has the goal that individuals receive the correct level of
service at the correct time for the treatment (service) needs related to the
individual's medical or psychiatric condition. Residential treatment services
consist of behavioral health interventions and are intended to provide high
intensity clinical treatment that should be provided for a short duration.
Stakeholder feedback supported observations by DMAS of lengthy durations of
stay for many individuals. Residential treatment services will benefit from
clarification of the service definition and eligibility requirements to ensure
that residential treatment does not evolve into a long-term level of support
instead of the high intensity psychiatric treatment modality that defines this
level of care.
Substance: The sections of the State Plan for Medical
Assistance that are affected by this action are: Inspection of Care in
Intermediate Care Facilities (12VAC30-10-540), Mandatory Coverage:
Categorically Needy and other required special groups (12VAC30-30-10), the
Amount, Duration, and Scope of Medical and Remedial Services Provided to
Categorically/Medically Needy Individuals-EPSDT Services (12VAC30-50-130);
Applicability of utilization review requirements (12VAC30-60-5), Utilization
control: Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and
Institutions for Mental Disease (IMD) (12VAC30-60-50) and Services related to
the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT);
community mental health services for children (12VAC30-60-61). The state-only
regulations that are affected by this action are Residential Psychiatric
Treatment for Children and Adolescents (plans of care; review of plans of care
(12VAC30-130-850 through 130-890).
The proposed regulatory action will serve to better clarify
policy interpretations that revise program standards to allow for more evidence
based service delivery, allow DMAS to implement more effective utilization
management in collaboration with the BHSA, enhance individualized coordination
of care, implement standardized coordination of individualized aftercare
resources by ensuring access to medical and behavioral health service providers
in the individual's home community, and support DMAS audit practices. The
proposed regulatory changes move toward a service model that will reduce
lengths of stay and facilitate an evidence based treatment approach to better
support the individual's discharge into their home environment. These changes
also align DMAS in meeting the requirements set forth by the Centers for
Medicare and Medicaid Services (CMS) in 42 CFR 441 Subpart D and 42 CFR
441.453.
The proposed regulatory action incorporates changes made in the
emergency regulation, including changes to the following areas: (i) provider
qualifications including acceptable licensing standards; (ii) preadmission
assessment requirements, (iii) program requirements; (iv) new discharge
planning and care coordination requirements; and (iv) language enhancements for
utilization review requirements to clarify program requirements, to ensure
adequate documentation of service delivery, and to help providers avoid payment
retractions. These changes are part of a review of the services to ensure that
services are effectively delivered and utilized for individuals who meet the
medical necessity criteria. For each individual seeking residential treatment
treatment needs are assessed with enhanced requirements by the current independent
certification teams who coordinate clinical assessment information and assess
local resources for each individual requesting residential care to determine an
appropriate level of care. The certification teams are also better able to
coordinate referrals for care to determine, in accordance with DOJ
requirements, whether or not the individual seeking services can be safely
served using community based services in the least restrictive setting.
Independent team certifications are conducted prior to the onset of specified
services, as required by CMS guidelines, by the DMAS behavioral health services
administrator.
The proposed regulatory action includes changes to program
requirements that ensure that effective levels of care coordination and
discharge planning occurs for each individual during the individual's
residential stay by enhancing program rules and utilization management
principles that facilitate effective discharge planning, family engagement and
establish community-based services prior to the individual's discharge from
residential care. The proposed regulatory action requires enhanced care
coordination to provide the necessary objective evaluations of treatment
progress and to facilitate evidence based practices during the treatment to
reduce the length of stay by ensuring that medical necessity indicates the
correct level of care and that appropriate and effective care is delivered in a
person centered manner. The proposed regulatory action requires that service
providers and local systems use standardized preadmission and discharge
processes to ensure effective services are delivered.
Issues: The primary advantages of the proposed
regulatory action to the Commonwealth and to Medicaid members are that the
proposed amendments (i) better clarify policy interpretations that revise
program standards to allow for more evidence based service delivery, (ii) allow
DMAS to implement more effective utilization management in collaboration with
the behavioral health services administrator, (iii) enhance individualized
coordination of care and implement standardized coordination of individualized
aftercare resources by ensuring access to medical and behavioral health service
providers in the individual's home community, (iv) support DMAS audit
practices, and (v) move toward a service model that will reduce lengths of stay
and facilitate an evidence based treatment approach to better support the
individual's discharge into their home environment. There are no disadvantages
to the Commonwealth or the public as a result of the proposed regulatory
action.
Department of Planning and Budget's Economic Impact
Analysis:
Summary of the Proposed Amendments to Regulation. Pursuant to
legislative mandates, the Board of Medical Assistance Services (Board) proposes
numerous changes to the provision of psychiatric residential treatment
services. These changes were already implemented under an emergency regulation
on July 1, 2017.1 The proposed regulation is a permanent replacement
for the emergency regulation.
Result of Analysis. The benefits likely exceed the costs for
the proposed amendments.
Estimated Economic Impact. Pursuant to Item 301 OO paragraphs 7
through 18 and Item 301 PP of Chapter 665 of the 2015 Acts of Assembly, the
Board proposes to eliminate Level A group homes as they did not meet the
federal Centers for Medicare and Medicaid Services requirements and to change
the definition of "Level B" group homes to "Therapeutic Group
Homes." In response to the legislative mandates, the Board also proposes
changes to plan of care requirements, medical necessity requirements, discharge
planning, required clinical activities and documentation for Therapeutic Group
Homes (TGH); changes to Early and Periodic Screening, Diagnostic and Treatment
criteria, Independent Assessment, Certification and Coordination Team (IACCT)
provider requirements and required activities, admission practices, and plan of
care requirements for Psychiatric Residential Treatment Facilities (PRTF); and
changes to service authorization and continued stay requirements both for PRTF
and TGH.
According to DMAS, since 2001, when residential treatment
services were first implemented, individuals have not had access to
standardized methods of effective care coordination upon entry into residential
treatment due to locality influence and DMAS reimbursement limitations. This
has resulted in a fragmented coordination approach for these individuals who
are at risk for high level care and remain at risk of repeated placements at
this level of care. The residential treatment prior authorization and
utilization management structures require an enhanced care coordination model
to support the individuals who receive this level of service to ensure an
effective return to the family or caregiver home environment with follow up
services to facilitate ongoing treatment progress in the least restrictive
environment. The added coordination is required to navigate a very complex
service environment for the individual as they return to a community setting to
establish an effective aftercare environment that involves service providers
who may be contracted with a variety of entities such as managed care
organizations, enrolled providers, the local Family Assessment and Planning
Team (FAPT), local school divisions and the local Community Service Boards.
DMAS states that FAPT composition prior to the emergency
regulation was not consistent with the federal Medicaid requirement for
certifying a child for a Medicaid-funded residential treatment placement.
Changes to the program were necessary to address the concerns that arose from
the reliance upon the FAPT to fulfill the role as the federally mandated
independent team to certify residential treatment. The emergency regulation
implemented the IACCT approach to attain specific clinical outcomes for all
residential care episodes prior to managed care enrollment thorough discharge
from residential treatment. IACCT ensures meaningful communication across all
parts of the Children's Services Act providers, Department of Behavioral Health
and Developmental Services, Managed Care Organizations, and fee-for-servicer
systems to maximize efficiency of activities, eliminate duplicative and/or
conflicting efforts, and ensure established timelines are met. In addition, the
Virginia Independent Clinical Assessment Program (VICAP) process was originally
used to streamline high quality comprehensive assessments for services;
however, VICAP was sunset in order to use funds to pay for the IACCT.
These proposed changes are intended to ensure appropriate
utilization and cost efficiencies. Prior to the emergency regulation, the total
expenditures relating to the affected services were approximately $113 million.
In fiscal year 2018, the total expenditures decreased to $89.2 million. While
the precise total financial impact of these changes have not been quantified,
available data show that members utilizing PRTF have decreased from 1,104 in
the first quarter of 2016 to 887 in the third quarter of 2018 (a 20%
reduction); that members utilizing TGH have decreased from 349 in the first
quarter of 2016 to 311 in the third quarter of 2018 (an 11% reduction); that
members utilizing Level A group homes have decreased from 349 in the first
quarter of 2016 to 0 in the third quarter of 2018 (because it was completely
eliminated); that average length of stay in PRTF decreased from 215.2 days to
209 days (a 6.2-day reduction); and that average length of stay in TGH
decreased from 142.8 days to 120.9 days (a 21.9-day reduction).
Moreover, between September 2017 and August 2018, 3,231 IACCT
inquiries were received; 2,353 of these inquiries were referred for assessment.
Primary reasons for inquiries not leading to assessment included families not
returning calls, families deciding to continue with community services instead,
members being placed in juvenile detention, and families declining residential
services; 2,009 of the assessments recommended a residential placement (1,421
PRTF and 588 in a TGH). The remaining 344 individuals who received an
assessment but were not recommended for a residential placement, were
recommended for community services.
According to DMAS, the proposed changes are essential for
compliance with 42 CFR 441.153, which is prerequisite for federal match and for
members to receive services as appropriate.
Finally, this regulation has not been updated since 2001 when
psychiatric residential treatment services were first provided. Since then
major changes have occurred such as provision of behavioral health services
through Magellan, the Behavioral Health Service Administrator, implementation
of more evidence based service delivery systems, enhanced individualized
coordination of care, audit practices, etc. As a result, the proposed changes
also clarify provider qualifications including licensing standards; preadmission
assessment requirements, program requirements, discharge planning and care
coordination requirements in greater detail. Changes such as those are not
expected to create any significant economic impact upon promulgation of this
regulation. Added clarity of the regulatory requirements however would improve
compliance and produce a net benefit.
Businesses and Entities Affected. This regulation applies to 90
therapeutic group homes, 18 residential treatment facilities, 23 organizations
(including Community Service Boards, Comprehensive Services Act providers, and
private entities) providing Independent Assessment Certification and
Coordination services, and 128 Family Assessment and Planning Teams.
Localities Particularly Affected. No locality should be
affected any more than others.
Projected Impact on Employment. The proposed amendments were
implemented in July 2017. No impact on employment is expected upon promulgation
of the proposed amendments. However, the implementation of the emergency
regulations may have had a negative impact on group homes' and residential
treatment facilities' demand for labor to the extent it improved efficiencies
and eliminated duplicative and/or conflicting efforts. The establishment of the
IACCT approach should have added to demand for labor for them to perform their
functions.
Effects on the Use and Value of Private Property. No effects on
the use and value of private property is expected upon promulgation of the
proposed amendments.
Real Estate Development Costs. No impact on real estate
development costs is expected.
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 amendments do not impose
costs on small businesses; however, to the extent they improve efficiencies and
eliminate duplicative and/or conflicting efforts, they may reduce group homes
and residential treatment facility revenues.
Alternative Method that Minimizes Adverse Impact. There is no
known alternative method that would minimize the adverse impact while
accomplishing the same goals.
Adverse Impacts:
Businesses. The proposed amendments should not adversely affect
businesses upon promulgation.
Localities. The proposed amendments do not adversely affect
localities.
Other Entities. The proposed amendments do not adversely affect
other entities.
__________________________
1http://townhall.virginia.gov/L/viewstage.cfm?stageid=7424
Agency's Response to Economic Impact Analysis: The
agency has reviewed the economic impact analysis prepared by the Department of
Planning and Budget and raises no issues with this analysis.
Summary:
The proposed regulatory action implements Items 301 OO and
301 PP of Chapter 665 of the 2015 Acts of Assembly, which required the
department to develop and implement a care coordination model and make
programmatic changes in the provision of residential treatment for children.
The proposed action replaces emergency regulations published in 33:13 VA.R. 1436-1469 February 20, 2017,
and extended in 35:9 VA.R. 1130 December 24, 2018.
The proposed amendments clarify policy interpretations and
revise program standards to allow for more evidence-based service delivery,
allow the department to implement more effective utilization management in
collaboration with the behavioral health service administrator, enhance
individualized coordination of care, implement standardized coordination of
individualized aftercare resources by ensuring access to medical and behavioral
health service providers in the individual's home community, and support
department audit practices. The proposed action meets the requirements set
forth by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR
441 Subpart D and 42 CFR 441.453.
The proposed amendments include changes to the following
areas: (i) provider qualifications, including acceptable licensing standards;
(ii) preadmission assessment requirements; (iii) program requirements; (iv) new
discharge planning and care coordination requirements; and (v) language
enhancements for utilization review requirements to clarify program
requirements, ensure adequate documentation of service delivery, and help
providers avoid payment retractions.
The proposed action requires enhanced care coordination to
provide the necessary objective evaluations of treatment progress and to
facilitate evidence-based practices during the treatment to reduce the length
of stay by ensuring that medical necessity indicates the correct level of care,
that appropriate and effective care is delivered in a person centered manner,
and that service providers and local systems use standardized preadmission and
discharge processes to ensure effective services are delivered.
12VAC30-10-540. Inspection of care in intermediate care
facilities for the mentally retarded persons with intellectual and
developmental disabilities, facilities providing inpatient psychiatric
services for individuals under younger than 21 years of age,
and mental hospitals.
All applicable requirements of 42 CFR 456, Subpart I,
are met with respect to periodic inspections of care and services.*
Inpatient psychiatric services for individuals under age
21 are not provided under this plan.
*Inspection of Care (IOC) in Intermediate Care Facilities
for the Mentally Retarded and Institutions for Mental Diseases are Inspection
of care in intermediate care facilities for persons with intellectual and
developmental disabilities is completed through contractual arrangements
with the Virginia Department of Health.
12VAC30-50-20. Services provided to the categorically needy
without limitation.
The following services as described in Part III
(12VAC30-50-100 et seq.) of this chapter are provided to the categorically
needy without limitation:
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Services for individuals age 65 years of age
or over older in institutions for mental diseases: inpatient
hospital services; skilled nursing facility services; and services in an
intermediate care facility.
3. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined, in
accordance with § 1902(a)(31)(A) of the Social Security Act (the Act),
to be in need of such care, including such services in a public institution (or
distinct part thereof) for the mentally retarded or persons with intellectual
or developmental disability or related conditions.
4. Hospice care (in accordance with § 1905(o) of the Act).
5. Any other medical care and any type of remedial care recognized
under state law, specified by the U.S. Secretary of Health and Human
Services: care and services provided in religious nonmedical health care
institutions;, nursing facility services for patients under
younger than 21 years of age;, or emergency hospital
services.
6. Private health insurance premiums, coinsurance, and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
7. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for categorically needy individuals without limitation.
8. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21
years of age.
12VAC30-50-30. Services not provided to the categorically
needy.
The following services and devices are not provided to the
categorically needy:
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Other diagnostic and preventive services other than those
provided elsewhere in this plan: diagnostic services (see 12VAC30-50-95 et
seq.).
5. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
6. Special tuberculosis (TB) related services under § 1902(z)(2)(F)
of the Social Security Act (the Act).
7. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
8. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
9. Any other medical care and any type of remedial care
recognized under state law specified by the U.S. Secretary of Health
and Human Services: personal care services in recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12VAC30-50-60. Services provided to all medically needy groups
without limitations.
Services as described in Part III (12VAC30-50-100 et seq.) of
this chapter are provided to all medically needy groups without limitations.
1. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
2. Early and periodic screening and diagnosis of individuals under
younger than 21 years of age, and treatment of conditions found.
3. Pursuant to Pub. L. P.L. No. 111-148 § 4107,
counseling and pharmacotherapy for cessation of tobacco use by pregnant women
shall be covered.
a. Counseling and pharmacotherapy for cessation of tobacco use
by pregnant women means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and nonprescription
tobacco cessation agents approved by the U.S. Food and Drug
Administration) for cessation of tobacco use by pregnant women who use tobacco
products or who are being treated for tobacco use that is furnished (i) by or
under the supervision of a physician, (ii) by any other health care
professional who is legally authorized to provide tobacco cessation services
under state law and is authorized to provide Medicaid coverable services other
than tobacco cessation services, or (iii) by any other health care professional
who is legally authorized to provide tobacco cessation services under state law
and who is specifically designated by the U.S. Secretary of Health and Human
Services in federal regulations for this purpose.
b. No cost sharing shall be applied to these services. In
addition to other services that are covered for pregnant women, 12VAC30-50-510
also provides for other smoking cessation services that are covered for
pregnant women.
4. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the
Act) to be in need of such care.
5. Hospice care (in accordance with § 1905(o) of the Act).
6. Any other medical care or any other type of remedial care
recognized under state law, specified by the secretary U.S. Secretary
of Health and Human Services, including: care and services provided in
religious nonmedical health care institutions;, skilled nursing
facility services for patients under younger than 21 years of age;,
and emergency hospital services.
7. Private health insurance premiums, coinsurance and
deductibles when cost effective (pursuant to Pub. L. P.L. No.
101-508 § 4402).
8. Program of All-Inclusive Care for the Elderly (PACE)
services are provided for eligible individuals as an optional State Plan
service for medically needy individuals without limitation.
9. Inpatient psychiatric facility services and residential
psychiatric treatment services (including therapeutic group homes and
psychiatric residential treatment facilities) for individuals younger than 21 years
of age.
12VAC30-50-70. Services or devices not provided to the
medically needy.
1. Chiropractors' Chiropractor services.
2. Private duty nursing services.
3. Dentures.
4. Diagnostic or preventive services other than those provided
elsewhere in the State Plan.
5. Inpatient hospital services, skilled nursing facility
services, and intermediate care facility services for individuals age 65
years of age or older in institutions for mental disease(s) diseases.
6. Intermediate care facility services (other than such
services in an institution for mental diseases) for persons determined in
accordance with § 1905(a)(4)(A) of the Social Security Act (the Act),
to be in need of such care in a public institution, or a distinct part thereof,
for the mentally retarded or persons with intellectual or
developmental disability or related conditions.
7. Inpatient psychiatric facility services for individuals
under 21 years of age, other than those covered under early and periodic
screening, diagnosis, and treatment (at 12VAC30-50-130). (Reserved.)
8. Special tuberculosis (TB) services under §
1902(z)(2)(F) of the Act.
9. Respiratory care services (in accordance with § 1920(e)(9)(A)
through (C) of the Act).
10. Ambulatory prenatal care for pregnant women furnished
during a presumptive eligibility period by a qualified provider (in accordance
with § 1920 of the Act).
11. Personal care services in a recipient's home, prescribed
in accordance with a plan of treatment and provided by a qualified person under
supervision of a registered nurse.
12. Home and community care for functionally disabled elderly
individuals, as defined, described and limited in 12VAC30-50-460 and
12VAC30-50-470.
13. Personal care services furnished to an individual who is
not an inpatient or resident of a hospital, nursing facility, intermediate care
facility for the mentally retarded intellectually or developmentally
disabled persons, or institution for mental disease that are (i) authorized
for the individual by a physician in accordance with a plan of treatment, (ii)
provided by an individual who is qualified to provide such services and who is
not a member of the individual's family, and (iii) furnished in a home.
12VAC30-50-130. Nursing facility services, EPSDT, including
school health services, and family planning.
A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or
performed within the scope of a license of the practitioner of the healing
arts.
B. Early General provisions for early and
periodic screening and, diagnosis, and treatment (EPSDT)
of individuals younger than 21 years of age, and treatment of conditions
found.
1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid
eligible, for medically necessary stays in acute care facilities,
and the accompanying attendant physician care, in excess of 21 days per
admission when such services are rendered for the purpose of diagnosis and
treatment of health conditions identified through a physical examination.
2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local departments
of social services departments on specific referral from those
departments.
3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department DMAS shall place appropriate
utilization controls upon this service.
4. Consistent with § 6403 of the Omnibus Budget
Reconciliation Act of 1989 § 6403, early and periodic screening,
diagnostic, and treatment services means the following services: screening
services, vision services, dental services, hearing services, and such other
necessary health care, diagnostic services, treatment, and other measures
described in Social Security Act § 1905(a) to correct or ameliorate defects and
physical and mental illnesses and conditions discovered by the screening
services and that are medically necessary, whether or not such services are
covered under the State Plan and notwithstanding the limitations, applicable to
recipients ages 21 years of age and older, provided for by §
1905(a) of the Social Security Act.
5. C. Community mental health services provided
through early and periodic screening diagnosis and treatment (EPSDT) for
individuals younger than 21 years of age. These services in order to be
covered (i) shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and (ii) are
shall be reflected in provider records and on providers' provider
claims for services by recognized diagnosis codes that support and are
consistent with the requested professional services.
a. 1. Definitions. The following words and terms
when used in this section shall have the following meanings unless the context
clearly indicates otherwise:
"Activities of daily living" means personal care
activities and includes bathing, dressing, transferring, toileting, feeding,
and eating.
"Adolescent or child" means the individual
receiving the services described in this section. For the purpose of the use of
these terms this term, adolescent means an individual 12 through
20 years of age; a child means an individual from birth up to 12 years of
age.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.
"Care coordination" means the collaboration
and sharing of information among health care providers, who are involved
with an individual's health care, to improve the care.
"Caregiver" means the same as defined
in 12VAC30-130-5160.
"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.
"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Child" means an individual ages birth through 11
years.
"DBHDS" means the Department of Behavioral Health
and Developmental Services.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined
in 12VAC35-105-20 with at least two consecutive years of documented
experience as a QMHP, and who has documented completion of the DBHDS PRS
supervisor training; or (iii) shall be an LMHP who has documented completion of
the DBHDS PRS supervisor training who is acting within his scope of practice
under state law. An LMHP providing services before April 1, 2018, shall have
until April 1, 2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractors.
"EPSDT" means early and periodic screening,
diagnosis, and treatment.
"Family support partners" means the same as defined
in 12VAC30-130-5170.
"Human services field" means the same as the term is
defined by DBHDS the Department of Health Professions in the
document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013 Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment practitioners.
An LMHP-resident shall be in continuous compliance with the regulatory
requirements of the applicable counseling profession for supervised practice
and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title "Resident"
in connection with the applicable profession after their signatures to indicate
such status.
"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the supervision
for specific clinical duties at a specific site has been preapproved in writing
by the Virginia Board of Psychology. For purposes of Medicaid reimbursement
by supervisors for services provided by such residents, they shall use the
title "Resident in Psychology" after their signatures to indicate
such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status,
staff interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.
"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.
"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.
"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590 including a
"QMHP-trainee" as defined by the Department of Health Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member as appropriate, about
the child's or adolescent's mental health status. It includes documented
history of the severity, intensity, and duration of mental health care problems
and issues and shall contain all of the following elements: (i) the presenting issue/reason
issue or reason for referral, (ii) mental health
history/hospitalizations, (iii) previous interventions by providers and
timeframes and response to treatment, (iv) medical profile, (v) developmental
history including history of abuse, if appropriate, (vi) educational/vocational
educational or vocational status, (vii) current living situation and
family history and relationships, (viii) legal status, (ix) drug and alcohol
profile, (x) resources and strengths, (xi) mental status exam and profile,
(xii) diagnosis, (xiii) professional summary and clinical formulation, (xiv)
recommended care and treatment goals, and (xv) the dated signature of the LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
"Services provided under arrangement" means the
same as defined in 12VAC30-130-850.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
b. 2. Intensive in-home services (IIH) to
children and adolescents younger than 21 years of age shall be time-limited
interventions provided in the individual's residence and when clinically
necessary in community settings. All interventions and the settings of the
intervention shall be defined in the Individual Service Plan. All IIH services
shall be designed to specifically improve family dynamics, and
provide modeling, and the clinically necessary interventions that
increase functional and therapeutic interpersonal relations between family
members in the home. IIH services are designed to promote psychoeducational
benefits of psychoeducation in the home setting of an individual who is
at risk of being moved into an out-of-home placement or who is being transitioned
to home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his the individual's parents or guardians, as appropriate, to
understand and practice appropriate problem solving, anger management, and
interpersonal interaction, etc.); care coordination with other required
services; and 24-hour emergency response.
(1) a. Service authorization shall be required
for Medicaid reimbursement prior to the onset of services. Services rendered
before the date of authorization shall not be reimbursed.
(2) b. Service-specific provider intakes shall
be required prior to the start of services at the onset of services and
ISPs shall be required during the entire duration of services. Services based
upon incomplete, missing, or outdated service-specific provider intakes or ISPs
shall be denied reimbursement. Requirements for service-specific provider
intakes and ISPs are set out in this section.
(3) c. These services may shall
only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C,
or a QMHP-E.
c. 3. Therapeutic day treatment (TDT) shall be
provided two or more hours per day in order to provide therapeutic
interventions (a unit is defined in 12VAC30-60-61 D 11). Day treatment
programs provide evaluation; medication education and management; opportunities
to learn and use daily living skills and to enhance social and interpersonal
skills (e.g., problem solving, anger management, community responsibility,
increased impulse control, and appropriate peer relations, etc.); and
individual, group, and family counseling.
(1) a. Service authorization shall be required
for Medicaid reimbursement.
(2) b. Service-specific provider intakes shall
be required at prior to the onset start of services,
and ISPs shall be required during the entire duration of services. Services
based upon incomplete, missing, or outdated service-specific provider intakes
or ISPs shall be denied reimbursement. Requirements for service-specific
provider intakes and ISPs are set out in this section.
(3) c. These services may shall be
rendered only by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or
a QMHP-E.
d. Community-based services for children and adolescents
younger than 21 years of age (Level A) pursuant to 42 CFR 440.031(d).
(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.
(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.
(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.
(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.
(5) Room and board costs shall not be reimbursed. DMAS
shall reimburse only for services provided in facilities or programs with no
more than 16 beds.
(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).
(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include development or maintenance of daily living skills, anger management,
social skills, family living skills, communication skills, stress management,
and any care coordination activities.
(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
(9) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.
(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.
D. Therapeutic group home services and psychiatric
residential treatment facility (PRTF) services for early and periodic screening
diagnosis and treatment (EPSDT) of individuals younger than 21 years of age.
1. Definitions. The following words and terms when used in
this subsection shall have the following meanings:
"Active treatment" means implementation of an
initial plan of care (IPOC) and comprehensive individual plan of care (CIPOC).
"Assessment" means the face-to-face interaction
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S to obtain information from the child or
adolescent and parent, guardian, or other family member, as appropriate,
utilizing a tool or series of tools to provide a comprehensive evaluation and review
of the child's or adolescent's mental health status. The assessment shall
include a documented history of the severity, intensity, and duration of mental
health problems and behavioral and emotional issues.
"Certificate of need" or "CON" means a
written statement by an independent certification team that services in a
therapeutic group home or PRTF are or were needed.
"Combined treatment services" means a structured,
therapeutic milieu and planned interventions that promote (i) the development
or restoration of adaptive functioning, self-care, and social skills; (ii)
community integrated activities and community living skills that each
individual requires to live in less restrictive environments; (iii) behavioral
consultation; (iv) individual and group therapy; (v) skills restoration, the
restoration of coping skills, family living and health awareness, interpersonal
skills, communication skills, and stress management skills; (vi) family
education and family therapy; and (vii) individualized treatment planning.
"Comprehensive individual plan of care" or
"CIPOC" means a person centered plan of care that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Crisis" means a deteriorating or unstable
situation that produces an acute, heightened emotional, mental, physical,
medical, or behavioral event.
"Crisis management" means immediately provided
activities and interventions designed to rapidly manage a crisis. The
activities and interventions include behavioral health care to provide
immediate assistance to individuals experiencing acute behavioral health
problems that require immediate intervention to stabilize and prevent harm and
higher level of acuity. Activities shall include assessment and short-term
counseling designed to stabilize the individual. Individuals are referred to
long-term services once the crisis has been stabilized.
"Daily supervision" means the supervision
provided in a PRTF through a resident-to-staff ratio approved by the Office of
Licensure at the Department of Behavioral Health and Developmental Services
with documented supervision checks every 15 minutes throughout a 24-hour
period.
"Discharge planning" means family and
locality-based care coordination that begins upon admission to a PRTF or
therapeutic group home with the goal of transitioning the individual out of the
PRTF or therapeutic group home to a less restrictive care setting with
continued, clinically-appropriate, and possibly intensive, services as soon as
possible upon discharge. Discharge plans shall be recommended by the treating
physician, psychiatrist, or treating LMHP responsible for the overall supervision
of the plan of care and shall be approved by the DMAS contractor.
"DSM-5" means the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric
Association.
"Emergency admissions" means those admissions that
are made when, pending a review for the certificate of need, it appears that
the individual is in need of an immediate admission to a therapeutic group home
or PRTF and likely does not meet the medical necessity criteria to receive
crisis intervention, crisis stabilization, or acute psychiatric inpatient
services.
"Emergency services" means unscheduled and
sometimes scheduled crisis intervention, stabilization, acute psychiatric
inpatient services, and referral assistance provided over the telephone or
face-to-face if indicated, and available 24 hours a day, seven days per week.
"Family engagement" means a family-centered and
strengths-based approach to partnering with families in making decisions,
setting goals, achieving desired outcomes, and promoting safety, permanency,
and well-being for children, adolescents, and families. Family engagement
requires ongoing opportunities for an individual to build and maintain
meaningful relationships with family members, for example, frequent,
unscheduled, and noncontingent telephone calls and visits between an individual
and family members. Family engagement may also include enhancing or
facilitating the development of the individual's relationship with other family
members and supportive adults responsible for the individual's care and
well-being upon discharge.
"Family engagement activity" means an
intervention consisting of family psychoeducational training or coaching,
transition planning with the family, family and independent living skills, and
training on accessing community supports as identified in the plan of care.
Family engagement activity does not include and is not the same as family
therapy.
"Family therapy" means counseling services
involving the individual's family and significant others to advance the
treatment goals when (i) the counseling with the family member and significant
others is for the direct benefit of the individual, (ii) the counseling is not
aimed at addressing treatment needs of the individual's family or significant
others, and (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals. Family therapy shall be aligned with the goals of
the individual's plan of care. All family therapy services furnished are for
the direct benefit of the individual, in accordance with the individual's needs
and treatment goals identified in the individual's plan of care, and for the
purpose of assisting in the individual's recovery.
"FAPT" means the family assessment and planning
team.
"ICD-10" means International Statistical
Classification of Diseases and Related Health Problems, 10th Revision,
published by the World Health Organization.
"Independent certification team" means a team
that has competence in diagnosis and treatment of mental illness, preferably in
child psychiatry; has knowledge of the individual's situation; and is composed
of at least one physician and one LMHP. The independent certification team
shall be a DMAS-authorized contractor with contractual or employment
relationships with the required team members.
"Individual" means the child or adolescent
younger than 21 years of age who is receiving therapeutic group home or PRTF
services.
"Individual and group therapy" means the
application of principles, standards, and methods of the counseling profession
in (i) conducting assessments and diagnosis for the purpose of establishing
treatment goals and objectives and (ii) planning, implementing, and evaluating
plans of care using treatment interventions to facilitate human development and
to identify and remediate mental, emotional, or behavioral disorders and
associated distresses that interfere with mental health.
"Initial plan of care" or "IPOC" means
a person centered plan of care established at admission that meets all of the
requirements of this subsection and is specific to the individual's unique
treatment needs and acuity levels as identified in the clinical assessment and
information gathered during the referral process.
"Intervention" means scheduled therapeutic
treatment such as individual or group psychoeducation; skills restoration;
structured behavior support and training activities; recreation, art, and music
therapies; community integration activities that promote or assist in the
child's or adolescent's ability to acquire coping and functional or
self-regulating behavior skills; day and overnight passes; and family
engagement activities. Interventions shall not include individual, group, and
family therapy; medical or dental appointments; or physician services,
medication evaluation, or management provided by a licensed clinician or
physician and shall not include school attendance. Interventions shall be
provided in the therapeutic group home or PRTF and, when clinically necessary,
in a community setting or as part of a therapeutic pass. All interventions and
settings of the intervention shall be established in the plan of care.
"Plan of care" means the initial plan of care
(IPOC) and the comprehensive individual plan of care (CIPOC).
"Physician" means an individual licensed to
practice medicine or osteopathic medicine in Virginia, as defined in §
54.1-2900 of the Code of Virginia.
"Psychiatric residential treatment facility" or
"PRTF" means the same as defined in 42 CFR 483.352 and is a 24-hour,
supervised, clinically and medically necessary, out-of-home active treatment
program designed to provide necessary support and address mental health,
behavioral, substance abuse, cognitive, and training needs of an individual
younger than 21 years of age in order to prevent or minimize the need for more
intensive treatment.
"Recertification" means a certification for each
applicant or recipient for whom therapeutic group home or PRTF services are
needed.
"Room and board" means a component of the total
daily cost for placement in a licensed PRTF. Residential room and board costs
are maintenance costs associated with placement in a licensed PRTF and include
a semi-private room, three meals and two snacks per day, and personal care
items. Room and board costs are reimbursed only for PRTF settings.
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in a freestanding psychiatric hospital or PRTF that
are billed by the arranged practitioners separately from the freestanding
psychiatric hospital's or PRTF's per diem.
"Skills restoration" means a face-to-face service
to assist individuals in the restoration of lost skills that are necessary to
achieve the goals established in the beneficiary's plan of care. Services
include assisting the individual in restoring self-management, interpersonal,
communication, and problem solving skills through modeling, coaching, and
cueing.
"Therapeutic group home" means a congregate
residential service providing 24-hour supervision in a community-based home
having eight or fewer residents.
"Therapeutic pass" means time at home or
time with family consisting of partial or entire days of time away from the
therapeutic group home or psychiatric residential treatment facility as
clinically indicated in the plan of care and as paired with facility-based and
community-based interventions to promote discharge planning, community
integration, and family engagement activities. Therapeutic passes are not
recreational but are a therapeutic component of the plan of care and are
designed for the direct benefit of the individual.
"Treatment planning" means development of a
person centered plan of care that is specific to the individual's unique
treatment needs and acuity levels.
e. 2. Therapeutic behavioral group
home services (Level B) pursuant to 42 CFR 440.130(d).
(1) Such services must be therapeutic services rendered in
a residential setting. The residential services will provide structure for
daily activities, psychoeducation, therapeutic supervision, care coordination,
and psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual ® Criteria, or an equivalent standard authorized in advance by DMAS
shall be required for this service.
(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.
(3) a. Therapeutic group home services for children
and adolescents younger than 21 years of age shall provide therapeutic services
to restore or maintain appropriate skills necessary to promote prosocial
behavior and healthy living, including skills restoration, family living and
health awareness, interpersonal skills, communication skills, and stress
management skills. Therapeutic services shall also engage families and reflect
family-driven practices that correlate to sustained positive outcomes
post-discharge for youth and their family members. Each component of
therapeutic group home services is provided for the direct benefit of the
individual, in accordance with the individual's needs and treatment goals
identified in the individual's plan of care, and for the purpose of assisting
in the individual's recovery. These services are provided under 42 CFR
440.130(d) in accordance with the rehabilitative services benefit.
b. The plan of care shall include individualized
activities, including a minimum of one intervention per 24-hour period in
addition to individual, group, and family therapies. Daily interventions are
not required when there is documentation to justify clinical or medical reasons
for the individual's deviations from the plan of care. Interventions shall be
documented on a progress note and shall be outlined in and aligned with the
treatment goals and objectives in the IPOC and CIPOC. Any deviation from the
plan of care shall be documented along with a clinical or medical justification
for the deviation.
c. Medical necessity criteria for admission to a
therapeutic group home. The following requirements for severity of need and
intensity and quality of service shall be met to satisfy the medical necessity
criteria for admission.
(1) Severity of need required for admission. All of the
following criteria shall be met to satisfy the criteria for severity of need:
(a) The individual's behavioral health condition can only
be safely and effectively treated in a 24-hour therapeutic milieu with onsite
behavioral health therapy due to significant impairments in home, school, and
community functioning caused by current mental health symptoms consistent with
a DSM-5 diagnosis.
(b) The certificate of need must demonstrate all of the
following: (i) ambulatory care resources (all available modalities of treatment
less restrictive than inpatient treatment) available in the community do not
meet the treatment needs of the individual; (ii) proper treatment of the
individual's psychiatric condition requires services on an inpatient basis
under the direction of a physician; and (iii) the services can reasonably be
expected to improve the individual's condition or prevent further regression so
that the services will no longer be needed.
(c) The state uniform assessment tool shall be completed.
The assessment shall demonstrate at least two areas of moderate impairment in
major life activities. A moderate impairment is defined as a major or
persistent disruption in major life activities. A moderate impairment is
evidenced by, but not limited to (i) frequent conflict in the family setting
such as credible threats of physical harm, where "frequent" means
more than expected for the individual's age and developmental level; (ii)
frequent inability to accept age-appropriate direction and supervision from
caretakers, from family members, at school, or in the home or community; (iii)
severely limited involvement in social support, which means significant
avoidance of appropriate social interaction, deterioration of existing
relationships, or refusal to participate in therapeutic interventions; (iv)
impaired ability to form a trusting relationship with at least one caretaker in
the home, school, or community; (v) limited ability to consider the effect of
one's inappropriate conduct on others; and (vi) interactions consistently
involving conflict, which may include impulsive or abusive behaviors.
(d) Less restrictive community-based services have been
given a fully adequate trial and were unsuccessful or, if not attempted, have
been considered, but in either situation were determined to be unable to meet
the individual's treatment needs and the reasons for that are discussed in the
certificate of need.
(e) The individual's symptoms, or the need for treatment in
a 24 hours a day, seven days a week level of care (LOC), are not primarily due
to any of the following: (i) intellectual disability, developmental disability,
or autistic spectrum disorder; (ii) organic mental disorders, traumatic brain
injury, or other medical condition; or (iii) the individual does not require a
more intensive level of care.
(f) The individual does not require primary medical or
surgical treatment.
(2) Intensity and quality of service necessary for admission.
All of the following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The therapeutic group home service has been prescribed
by a psychiatrist, psychologist, or other LMHP who has documented that a
residential setting is the least restrictive clinically appropriate service
that can meet the specifically identified treatment needs of the individual.
(b) The therapeutic group home is not being used for
clinically inappropriate reasons, including (i) an alternative to incarceration
or preventative detention; (ii) an alternative to a parent's, guardian's, or
agency's capacity to provide a place of residence for the individual; or (iii)
a treatment intervention when other less restrictive alternatives are available.
(c) The individual's treatment goals are included in the
service specific provider intake and include behaviorally defined objectives
that require and can reasonably be achieved within a therapeutic group home
setting.
(d) The therapeutic group home is required to coordinate
with the individual's community resources, including schools and FAPT as
appropriate, with the goal of transitioning the individual out of the program
to a less restrictive care setting for continued, sometimes intensive, services
as soon as possible and appropriate.
(e) The therapeutic group home program must incorporate
nationally established, evidence-based, trauma-informed services and supports
that promote recovery and resiliency.
(f) Discharge planning begins upon admission, with concrete
plans for the individual to transition back into the community beginning within
the first week of admission, with clear action steps and target dates outlined
in the plan of care.
(3) Continued stay criteria. The following criteria shall
be met in order to satisfy the criteria for continued stay:
(a) All of the admission guidelines continue to be met and
continue to be supported by the written clinical documentation.
(b) The individual shall meet one of the following
criteria: (i) the desired outcome or level of functioning has not been restored
or improved in the timeframe outlined in the individual's plan of care or the
individual continues to be at risk for relapse based on history or (ii) the
nature of the functional gains is tenuous and use of less intensive services
will not achieve stabilization.
(c) The individual shall meet one of the following
criteria: (i) the individual has achieved initial CIPOC goals, but additional
goals are indicated that cannot be met at a lower level of care; (ii) the
individual is making satisfactory progress toward meeting goals but has not
attained plan of care goals, and the goals cannot be addressed at a lower level
of care; (iii) the individual is not making progress, and the plan of care has
been modified to identify more effective interventions; or (iv) there are
current indications that the individual requires this level of treatment to
maintain level of functioning as evidenced by failure to achieve goals
identified for therapeutic visits or stays in a nontreatment residential
setting or in a lower level of residential treatment.
(d) There is a written, up-to-date discharge plan that (i)
identifies the custodial parent or custodial caregiver at discharge; (ii)
identifies the school the individual will attend at discharge, if applicable;
(iii) includes individualized education program (IEP) and FAPT recommendations,
if necessary; (iv) outlines the aftercare treatment plan (discharge to another
residential level of care is not an acceptable discharge goal); and (v) lists
barriers to community reintegration and progress made on resolving these
barriers since last review.
(e) The active plan of care includes structure for combined
treatment services and activities to ensure the attainment of therapeutic
mental health goals as identified in the plan of care. Combined treatment
services reinforce and practice skills learned in individual, group, and family
therapy such as community integration skills, coping skills, family living and
health awareness skills, interpersonal skills, and stress management skills.
Combined treatment services may occur in group settings, in one-on-one
interactions, or in the home setting during a therapeutic pass. In addition to
the combined treatment services, the child or adolescent must also receive
psychotherapy services, care coordination, family-based discharge planning, and
locality-based transition activities. The child or adolescent shall receive
intensive family interventions at least twice per month, although it is recommended
that the intensive family interventions be provided at a frequency of one
family therapy session per week. Family involvement begins immediately upon
admission to therapeutic group home. If the minimum requirement cannot be met,
the reasons must be reported, and continued efforts to involve family members
must also be documented. Other family members or supportive adults may be
included as indicated in the plan of care.
(f) Less restrictive treatment options have been considered
but cannot yet meet the individual's treatment needs. There is sufficient
current clinical documentation or evidence to show that therapeutic group home
level of care continues to be the least restrictive level of care that can meet
the individual's mental health treatment needs.
(4) Discharge shall occur if any of the following applies:
(i) the level of functioning has improved with respect to the goals outlined in
the plan of care, and the individual can reasonably be expected to maintain
these gains at a lower level of treatment; (ii) the individual no longer
benefits from service as evidenced by absence of progress toward plan of care
goals for a period of 60 days; or (iii) other less intensive services may
achieve stabilization.
d. The following clinical activities shall be required for
each therapeutic group home resident:
(1) An assessment be performed by an LMHP, LMHP-R, LMHP-RP,
or LMHP-S.
(2) A face-to-face evaluation shall be performed by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days prior to admission with
a documented DSM-5 or ICD-10 diagnosis.
(3) A certificate of need shall be completed by an
independent certification team according to the requirements of subdivision D 4
of this section. Recertification shall occur at least every 60 calendar days by
an LMHP, LMHP-R, LMHP-RP, or LMHP-S acting within his scope of practice.
(4) An IPOC that is specific to the individual's unique
treatment needs and acuity levels. The IPOC shall be completed on the day of
admission by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be signed by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual and a family member or
legally authorized representative. The IPOC shall include all of the following:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Orders for medications, psychiatric, medical, dental,
and any special health care needs whether or not provided in the facilities,
treatments, restorative and rehabilitative services, activities, therapies,
therapeutic passes, social services, community integration, diet, and special
procedures recommended for the health and safety of the individual;
(f) Plans for continuing care, including review and
modification to the plan of care; and
(g) Plans for discharge.
(5) A CIPOC shall be completed no later than 14 calendar
days after admission. The CIPOC shall meet all of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and shall reflect the need
for therapeutic group home care;
(b) Be based on input from school, home, other health care
providers, FAPT if necessary, the individual, and the family or legal guardian;
(c) Shall state treatment objectives that include
measurable short-term and long-term goals and objectives, with target dates for
achievement;
(d) Prescribe an integrated program of therapies,
activities, and experiences designed to meet the treatment objectives related
to the diagnosis; and
(e) Include a comprehensive discharge plan with necessary,
clinically appropriate community services to ensure continuity of care upon
discharge with the individual's family, school, and community.
(6) The CIPOC shall be reviewed, signed, and dated every 30
calendar days by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a
family member or primary caregiver. Updates shall be signed and dated by the
LMHP, LMHP-R, LMHP-RP, or LMHP-S and the individual or a family member or
legally authorized representative. The review shall include all of the
following:
(a) The individual's response to the services provided;
(b) Recommended changes in the plan as indicated by the
individual's overall response to the CIPOC interventions; and
(c) Determinations regarding whether the services being
provided continue to be required.
(7) Crisis management, clinical assessment, and
individualized therapy shall be provided to address both behavioral health and
substance use disorder needs as indicated in the plan of care to address
intermittent crises and challenges within the therapeutic group home setting or
community settings as defined in the plan of care and to avoid a higher level
of care.
(8) Care coordination shall be provided with medical,
educational, and other behavioral health providers and other entities involved
in the care and discharge planning for the individual as included in the plan
of care.
(9) Weekly individual therapy shall be provided in the
therapeutic group home, or other settings as appropriate for the individual's
needs, by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which shall be documented in
progress notes in accordance with the requirements in 12VAC30-60-61.
(10) Weekly (or more frequently if clinically indicated)
group therapy shall be provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, which
shall be documented in progress notes in accordance with the requirements in
12VAC30-60-61 and as planned and documented in the plan of care.
(11) Family treatment shall be provided as clinically
indicated, provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, and documented in
progress notes in accordance with the requirements in 12VAC30-60-61 and as
planned and documented in the plan of care.
(12) Family engagement activities shall be provided in
addition to family therapy or counseling. Family engagement activities shall be
provided at least weekly as outlined in the plan of care, and daily
communication with the family or legally authorized representative shall be
part of the family engagement strategies in the plan of care. For each
service authorization period when family engagement is not possible, the therapeutic
group home shall identify and document the specific barriers to the
individual's engagement with the individual's family or legally authorized
representatives. The therapeutic group home shall document on a weekly basis
the reasons why family engagement is not occurring as required. The therapeutic
group home shall document alternative family engagement strategies to be used
as part of the interventions in the plan of care and request approval of the
revised plan of care by DMAS. When family engagement is not possible, the
therapeutic group home shall collaborate with DMAS on a weekly basis to develop
individualized family engagement strategies and document the revised strategies
in the plan of care.
(13) Therapeutic passes shall be provided as clinically indicated
in the plan of care and as paired with facility-based and community-based
interventions to promote discharge planning, community integration, and family
engagement activities.
(a) The provider shall document how the family was prepared
for the therapeutic pass to include a review of the plan of care goals and
objectives being addressed by the planned interventions and the safety and
crisis plan in effect during the therapeutic pass.
(b) If a facility staff member does not accompany the
individual on the therapeutic pass and the therapeutic pass exceeds 24 hours,
the provider shall make daily contacts with the family and be available 24
hours per day to address concerns, incidents, or crises that may arise during
the pass.
(c) Contact with the family shall occur within seven
calendar days of the therapeutic pass to discuss the accomplishments and
challenges of the therapeutic pass along with an update on progress toward plan
of care goals and any necessary changes to the plan of care.
(d) Twenty-four therapeutic passes shall be permitted per
individual, per admission, without authorization as approved by the treating
LMHP and documented in the plan of care. Additional therapeutic passes shall
require service authorization. Any unauthorized therapeutic passes shall result
in retraction for those days of service.
(14) Discharge planning shall begin at admission and
continue throughout the individual's stay at the therapeutic group home. The
family or guardian, the community services board (CSB), the family assessment
and planning team (FAPT) case manager, and the DMAS contracted care manager
shall be involved in treatment planning and shall identify the anticipated
needs of the individual and family upon discharge and available services in the
community. Prior to discharge, the therapeutic group home shall submit an
active and viable discharge plan to the DMAS contractor for review. Once the
DMAS contractor approves the discharge plan, the provider shall begin actively
collaborating with the family or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The therapeutic
group home shall request permission from the parent or legally authorized
representative to share treatment information with these providers and shall
share information pursuant to a valid release. The therapeutic group home shall
request information from post-discharge providers to establish that the
planning of pending services and transition planning activities has begun,
shall establish that the individual has been enrolled in school, and shall
provide individualized education program recommendations to the school if
necessary. The therapeutic group home shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the therapeutic group home.
(15) Room and board costs shall not be reimbursed.
Facilities that only provide independent living services or nonclinical
services that do not meet the requirements of this subsection are not reimbursed
eligible for reimbursement. DMAS shall reimburse only for services
provided in facilities or programs with no more than 16 beds.
(4) These residential (16) Therapeutic group home
services providers must shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) under the Regulations
for Children's Residential Facilities (12VAC35-46).
(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include development or maintenance of daily living skills,
anger management, social skills, family living skills, communication skills,
and stress management. This service may be provided in a program setting or a
community-based group home.
(6) The individual must receive, at least weekly,
individual psychotherapy and, at least weekly, group psychotherapy that is
provided as part of the program.
(7) (17) Individuals shall be discharged from
this service when treatment goals are met or other less intensive
services may achieve stabilization.
(8) Service-specific provider intakes shall be required at
the onset of services and ISPs shall be required during the entire duration of
services. (18) Services that are based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs plans of care
shall be denied reimbursement. Requirements for intakes and ISPs are set out
in 12VAC30-60-61.
(9) These (19) Therapeutic group home services
may only be rendered by and within the scope of practice of an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH as
defined in 12VAC35-105-20.
(10) (20) The facility/group psychiatric
residential treatment facility or therapeutic group home shall coordinate
necessary services and discharge planning with other providers as
medically and clinically necessary. Documentation of this care coordination
shall be maintained by the facility/group facility or group home
in the individual's record. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted, and
recommended next steps.
(21) Failure to perform any of the items described in this
subsection shall result in a retraction of the per diem for each day of
noncompliance.
3. PRTF services are a 24-hour, supervised, clinically and
medically necessary out-of-home program designed to provide necessary support
and address mental health, behavioral, substance use, cognitive, or other
treatment needs of an individual younger than 21 years of age in order to
prevent or minimize the need for more inpatient treatment. Active treatment and
comprehensive discharge planning shall begin prior to admission. In order to be
covered for individuals younger than 21 years of age, these services shall (i)
meet DMAS-approved psychiatric medical necessity criteria or be approved as an
EPSDT service based upon a diagnosis made by an LMHP, LMHP-R, LMHP-RP, or
LMHP-S who is practicing within the scope of his license and (ii) be reflected
in provider records and on the provider's claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services.
a. PRTF services shall be covered for the purpose of
diagnosis and treatment of mental health and behavioral disorders when such
services are rendered by a psychiatric facility that is not a hospital and is
accredited by the Joint Commission on Accreditation of Healthcare
Organizations, the Commission on Accreditation of Rehabilitation Facilities,
the Council on Accreditation of Services for Families and Children, or by any
other accrediting organization with comparable standards that is recognized by
the state.
b. Providers of PRTF services shall be licensed by DBHDS.
c. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151 (a) and (b) and 42 CFR 441.152 through 42 CFR
441.156 and (ii) the Conditions of Participation in 42 CFR Part 483 Subpart G.
Each admission must be service authorized, and the treatment must meet DMAS
requirements for clinical necessity.
d. The PRTF benefit for individuals younger than 21 years
of age shall include services defined at 42 CFR 440.160 that are provided
under the direction of a physician pursuant to a certification of medical
necessity and plan of care developed by an interdisciplinary team of
professionals and shall involve active treatment designed to achieve the
child's discharge from PRTF services at the earliest possible time. The PRTF
services benefit shall include services provided under arrangement furnished by
Medicaid enrolled providers other than the PRTF, as long as the PRTF (i)
arranges for and oversees the provision of all services, (ii) maintains all
medical records of care furnished to the individual, and (iii) ensures that the
services are furnished under the direction of a physician. Services provided
under arrangement shall be documented by a written referral from the PRTF. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
e. PRTFs, as defined at 42 CFR 483.352, shall arrange for,
maintain records of, and ensure that physicians order these services: (i)
medical and psychological services, including those furnished by physicians,
licensed mental health professionals, and other licensed or certified health
professionals (i.e., nutritionists, podiatrists, respiratory therapists, and
substance abuse treatment practitioners); (ii) pharmacy services; (iii)
outpatient hospital services; (iv) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (v)
laboratory and radiology services; (vi) durable medical equipment; (vii) vision
services; (viii) dental, oral surgery, and orthodontic services; (ix)
nonemergency transportation services; and (x) emergency services.
f. PRTF services shall include assessment and
reassessment; room and board; daily supervision; combined treatment services;
individual, family, and group therapy; care coordination; interventions;
general or special education; medical treatment (including medication,
coordination of necessary medical services, and 24-hour onsite nursing);
specialty services; and discharge planning that meets the medical and clinical
needs of the individual.
g. Medical necessity criteria for admission to a PRTF. The
following requirements for severity of need and intensity and quality of
service shall be met to satisfy the medical necessity criteria for admission:
(1) Severity of need required for admission. The following
criteria shall be met to satisfy the criteria for severity of need:
(a) There is clinical evidence that the individual has a
DSM-5 disorder that is amenable to active psychiatric treatment.
(b) There is a high degree of potential of the condition
leading to acute psychiatric hospitalization in the absence of residential
treatment.
(c) Either (i) there is clinical evidence that the
individual would be a risk to self or others if the individual were not in a
PRTF or (ii) as a result of the individual's mental disorder, there is an
inability for the individual to adequately care for his own physical needs, and
caretakers, guardians, or family members are unable to safely fulfill these
needs, representing potential serious harm to self.
(d) The individual requires supervision seven days per
week, 24 hours per day to develop skills necessary for daily living; to assist
with planning and arranging access to a range of educational, therapeutic, and
aftercare services; and to develop the adaptive and functional behavior that
will allow the individual to live outside of a PRTF setting.
(e) The individual's current living environment does not
provide the support and access to therapeutic services needed.
(f) The individual is medically stable and does not require
the 24-hour medical or nursing monitoring or procedures provided in a hospital
level of care.
(2) Intensity and quality of service necessary for
admission. The following criteria shall be met to satisfy the criteria for
intensity and quality of service:
(a) The evaluation and assignment of a DSM-5 diagnosis must
result from a face-to-face psychiatric evaluation.
(b) The program provides supervision seven days per week,
24 hours per day to assist with the development of skills necessary for daily
living; to assist with planning and arranging access to a range of educational,
therapeutic, and aftercare services; and to assist with the development of the
adaptive and functional behavior that will allow the individual to live outside
of a PRTF setting.
(c) An individualized plan of active psychiatric treatment
and residential living support is provided in a timely manner. This treatment
must be medically monitored, with 24-hour medical availability and 24-hour
nursing services availability. This plan includes (i) at least once-a-week
psychiatric reassessments; (ii) intensive family or support system involvement
occurring at least once per week or valid reasons identified as to why such a
plan is not clinically appropriate or feasible; (iii) psychotropic medications,
when used, are to be used with specific target symptoms identified; (iv)
evaluation for current medical problems; (v) evaluation for concomitant
substance use issues; and (vi) linkage or coordination with the individual's
community resources, including the local school division and FAPT case manager,
as appropriate, with the goal of returning the individual to his regular social
environment as soon as possible, unless contraindicated. School contact should
address an individualized educational plan as appropriate.
(d) A urine drug screen is considered at the time of
admission, when progress is not occurring, when substance misuse is suspected,
or when substance use and medications may have a potential adverse interaction.
After a positive screen, additional random screens are considered and referral
to a substance use disorder provider is considered.
(3) Criteria for continued stay. The following criteria
shall be met to satisfy the criteria for continued stay:
(a) Despite reasonable therapeutic efforts, clinical
evidence indicates at least one of the following: (i) the persistence of
problems that caused the admission to a degree that continues to meet the
admission criteria (both severity of need and intensity of service needs); (ii)
the emergence of additional problems that meet the admission criteria (both
severity of need and intensity of service needs); or (iii) that disposition
planning or attempts at therapeutic reentry into the community have resulted in
or would result in exacerbation of the psychiatric illness to the degree that
would necessitate continued PRTF treatment. Subjective opinions without
objective clinical information or evidence are not sufficient to meet severity
of need based on justifying the expectation that there would be a
decompensation.
(b) There is evidence of objective, measurable, and
time-limited therapeutic clinical goals that must be met before the individual
can return to a new or previous living situation. There is evidence that
attempts are being made to secure timely access to treatment resources and
housing in anticipation of discharge, with alternative housing contingency
plans also being addressed.
(c) There is evidence that the plan of care is focused on
the alleviation of psychiatric symptoms and precipitating psychosocial
stressors that are interfering with the individual's ability to return to a
less-intensive level of care.
(d) The current or revised plan of care can be reasonably
expected to bring about significant improvement in the problems meeting the
criteria in subdivision 3 c (3) (a) of this subsection, and this is documented
in weekly progress notes written and signed by the provider.
(e) There is evidence of intensive family or support system
involvement occurring at least once per week, unless there is an identified
valid reason why it is not clinically appropriate or feasible.
(f) A discharge plan is formulated that is directly linked
to the behaviors or symptoms that resulted in admission and begins to identify
appropriate post-PRTF resources including the local school division and FAPT
case manager as appropriate.
(g) All applicable elements in admission-intensity and
quality of service criteria are applied as related to assessment and treatment
if clinically relevant and appropriate.
(4) Discharge criteria. Discharge shall occur if any of the
following applies: (i) the level of functioning has improved with respect to
the goals outlined in the plan of care, and the individual can reasonably be
expected to maintain these gains at a lower level of treatment; (ii) the
individual no longer benefits from service as evidenced by absence of progress
toward plan of care goals for a period of 30 days; or (iii) other less
intensive services may achieve stabilization.
h. The following clinical activities shall be required for
each PRTF resident:
(1) A face-to-face assessment shall be performed by an
LMHP, LMHP-R, LMHP-RS, or LMHP-S within 30 calendar days prior to admission and
weekly thereafter and shall document a DSM-5 or ICD-10 diagnosis.
(2) A certificate of need shall be completed by an independent
certification team according to the requirements of 12VAC30-50-130 D 4.
Recertification shall occur at least every 30 calendar days by a physician
acting within his scope of practice.
(3) The initial plan of care (IPOC) shall be completed
within 24 hours of admission by the treatment team. The IPOC shall
include:
(a) Individual and family strengths and personal traits
that would facilitate recovery and opportunities to develop motivational
strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and complications
indicating the need for admission;
(c) A description of the functional level of the
individual;
(d) Treatment objectives with short-term and long-term
goals;
(e) Any orders for medications, psychiatric, medical,
dental, and any special health care needs, whether or not provided in the
facility; education or special education; treatments; interventions; and
restorative and rehabilitative services, activities, therapies, social
services, diet, and special procedures recommended for the health and safety of
the individual;
(f) Plans for continuing care, including review and
modification to the plan of care;
(g) Plans for discharge; and
(h) Signature and date by the individual, parent, or
legally authorized representative, a physician, and treatment team members.
(4) The CIPOC shall be completed and signed no later than
14 calendar days after admission by the treatment team. The PRTF shall request
authorizations from families to release confidential information to collect information
from medical and behavioral health treatment providers, schools, FAPT, social
services, court services, and other relevant parties. This information shall be
used when considering changes and updating the CIPOC. The CIPOC shall meet all
of the following criteria:
(a) Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the individual's situation and must reflect the need
for PRTF care;
(b) Be developed by an interdisciplinary team of physicians
and other personnel specified in subdivision 3 d 4 of this subsection who are
employed by or provide services to the individual in the facility in
consultation with the individual, family member, or legally authorized representative,
or appropriate others into whose care the individual will be released after
discharge;
(c) Shall state treatment objectives that shall include
measurable, evidence-based, and short-term and long-term goals and objectives;
family engagement activities; and the design of community-based aftercare with
target dates for achievement;
(d) Prescribe an integrated program of therapies,
interventions, activities, and experiences designed to meet the treatment
objectives related to the individual and family treatment needs; and
(e) Describe comprehensive transition plans and
coordination of current care and post-discharge plans with related community
services to ensure continuity of care upon discharge with the recipient's
family, school, and community.
(5) The CIPOC shall be reviewed every 30 calendar days by
the team specified in subdivision 3 d 4 of this subsection to determine that
services being provided are or were required from a PRTF and to recommend
changes in the plan as indicated by the individual's overall adjustment during
the time away from home. The CIPOC shall include the signature and date from
the individual, parent, or legally authorized representative, a physician, and
treatment team members.
(6) Individual therapy shall be provided three times
per week (or more frequently based upon the individual's needs) provided by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of care
and progress notes in accordance with the requirements in this subsection and
12VAC30-60-61.
(7) Group therapy shall be provided as clinically indicated
by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of
care and progress notes in accordance with the requirements in this subsection.
(8) Family therapy shall be provided as clinically
indicated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the
plan of care and progress notes in accordance with the individual and family or
legally authorized representative's goals and the requirements in this subsection.
(9) Family engagement shall be provided in addition to
family therapy or counseling. Family engagement shall be provided at least
weekly as outlined in the plan of care and daily communication with the
treatment team representative and the treatment team representative and the
family or legally authorized representative shall be part of the family
engagement strategies in the plan of care. For each service authorization
period when family engagement is not possible, the PRTF shall identify and
document the specific barriers to the individual's engagement with his family
or legally authorized representatives. The PRTF shall document on a weekly
basis the reasons that family engagement is not occurring as required. The PRTF
shall document alternate family engagement strategies to be used as part of the
interventions in the plan of care and request approval of the revised plan of
care by DMAS. When family engagement is not possible, the PRTF shall
collaborate with DMAS on a weekly basis to develop individualized family
engagement strategies and document the revised strategies in the plan of care.
(10) Three interventions shall be provided per 24-hour
period including nights and weekends. Family engagement activities are
considered to be an intervention and shall occur based on the treatment and
visitation goals and scheduling needs of the family or legally authorized
representative. Interventions shall be documented on a progress note and shall
be outlined in and aligned with the treatment goals and objectives in the plan
of care. Any deviation from the plan of care shall be documented along with a
clinical or medical justification for the deviation based on the needs of the
individual.
(11) Therapeutic passes shall be provided as clinically
indicated in the plan of care and as paired with community-based and
facility-based interventions to promote discharge planning, community
integration, and family engagement. Therapeutic passes include activities as
listed in subdivision 2 d (13) of this section. Twenty-four therapeutic passes
shall be permitted per individual, per admission, without authorization as
approved by the treating physician and documented in the plan of care.
Additional therapeutic passes shall require service authorization from DMAS.
Any unauthorized therapeutic passes not approved by the provider or DMAS shall
result in retraction for those days of service.
(12) Discharge planning shall begin at admission and
continue throughout the individual's placement at the PRTF. The parent or
legally authorized representative, the community services board (CSB), the
family assessment planning team (FAPT) case manager, if appropriate, and the
DMAS contracted care manager shall be involved in treatment planning and shall
identify the anticipated needs of the individual and family upon discharge and
identify the available services in the community. Prior to discharge, the PRTF
shall submit an active discharge plan to the DMAS contractor for review. Once
the DMAS contractor approves the discharge plan, the provider shall begin
collaborating with the parent or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for service-specific provider intakes as needed. The PRTF shall
request written permission from the parent or legally authorized representative
to share treatment information with these providers and shall share information
pursuant to a valid release. The PRTF shall request information from
post-discharge providers to establish that the planning of services and
activities has begun, shall establish that the individual has been enrolled in
school, and shall provide individualized education program recommendations to
the school if necessary. The PRTF shall inform the DMAS contractor of all
scheduled appointments within 30 calendar days of discharge and shall notify
the DMAS contractor within one business day of the individual's discharge date
from the PRTF.
(13) Failure to perform any of the items as described in
subdivisions 3 h (1) through 3 h (12) of this subsection up until the discharge
of the individual shall result in a retraction of the per diem and all other
contracted and coordinated service payments for each day of noncompliance.
i. The team developing the CIPOC shall meet the following
requirements:
(1) At least one member of the team must have expertise in
pediatric behavioral health. Based on education and experience, preferably
including competence in child or adolescent psychiatry, the team must be
capable of all of the following: assessing the individual's immediate and
long-range therapeutic needs, developmental priorities, and personal strengths
and liabilities; assessing the potential resources of the individual's family
or legally authorized representative; setting treatment objectives; and
prescribing therapeutic modalities to achieve the CIPOC's objectives.
(2) The team shall include one of the following:
(a) A board-eligible or board-certified psychiatrist;
(b) A licensed clinical psychologist and a physician
licensed to practice medicine or osteopathy; or
(c) A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases and a licensed clinical psychologist.
(3) The team shall also include one of the following: an
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
4. Requirements for independent certification teams
applicable to both therapeutic group homes and PRTFs:
a. The independent certification team shall certify the
need for PRTF or therapeutic group home services and issue a certificate of
need document within the process and timeliness standards as approved by DMAS
under contractual agreement with the DMAS contractor.
b. The independent certification team shall be approved by
DMAS through a memorandum of understanding with a locality or be approved under
contractual agreement with the DMAS contractor. The team shall initiate and
coordinate referral to the family assessment and planning team (FAPT) as
defined in §§ 2.2-5207 and 2.2-5208 of the Code of Virginia to facilitate care
coordination and for consideration of educational coverage and other supports
not covered by DMAS.
c. The independent certification team shall assess the
individual's and family's strengths and needs in addition to diagnoses,
behaviors, and symptoms that indicate the need for behavioral health treatment
and also consider whether local resources and community-based care are
sufficient to meet the individual's treatment needs, as presented within the
previous 30 calendar days, within the least restrictive environment.
d. The LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP, as
part of the independent certification team, shall meet with an individual and
the individual's parent or legally authorized representative within two
business days from a request to assess the individual's needs and begin the
process to certify the need for an out-of-home placement.
e. The independent certification team shall meet with an
individual and the individual's parent or legally authorized representative
within 10 business days from a request to certify the need for an out-of-home
placement.
f. The independent certification team shall assess the
treatment needs of the individual to issue a certificate of need (CON) for the
most appropriate medically necessary services. The certification shall include
the dated signature and credentials for each of the team members who rendered
the certification. Referring or treatment providers shall not actively
participate during the certification process but may provide supporting
clinical documentation to the certification team.
g. The CON shall be effective for 30 calendar days prior to
admission.
h. The independent certification team shall provide the
completed CON to the facility within one calendar day of completing the CON.
i. The individual and the individual's parent or legally
authorized representative shall have the right to freedom of choice of service
providers.
j. If the individual or the individual's parent or legally
authorized representative disagrees with the independent certification team's
recommendation, the parent or legally authorized representative may appeal the
recommendation in accordance with 12VAC30-110.
k. If the LMHP, as part of the independent certification
team, determines that the individual is in immediate need of treatment, the
LMHP shall refer the individual to an appropriate Medicaid-enrolled crisis
intervention provider, crisis stabilization provider, or inpatient psychiatric
provider in accordance with 12VAC30-50-226 or shall refer the individual for
emergency admission to a PRTF or therapeutic group home under subdivision 4 m
of this subsection and shall also alert the individual's managed care organization.
l. For individuals who are already eligible for Medicaid at
the time of admission, the independent certification team shall be a
DMAS-authorized contractor with competence in the diagnosis and treatment of
mental illness, preferably in child psychiatry, and have knowledge of the
individual's situation and service availability in the individual's local
service area. The team shall be composed of at least one physician and one
LMHP, including LMHP-S, LMHP-R, and LMHP-RP. An individual's parent or legally
authorized representative shall be included in the certification process.
m. For emergency admissions, an assessment must be made by
the team responsible for the comprehensive individual plan of care (CIPOC).
Reimbursement shall only occur when a certificate of need is issued by the team
responsible for the CIPOC within 14 calendar days after admission. The
certification shall cover any period of time after admission and before claims
are made for reimbursement by Medicaid. After processing an emergency
admission, the therapeutic group home, PRTF, or institution for mental diseases
(IMD) shall notify the DMAS contractor within five calendar days of the
individual's status as being under the care of the facility.
n. For all individuals who apply and become eligible for
Medicaid while an inpatient in a facility or program, the certification team
shall refer the case to the DMAS contractor for referral to the local FAPT to
facilitate care coordination and consideration of educational coverage and
other supports not covered by DMAS.
o. For individuals who apply and become eligible for
Medicaid while an inpatient in the facility or program, the certification shall
be made by the team responsible for the CIPOC and shall cover any period of
time before the application for Medicaid eligibility for which claims are made
for reimbursement by Medicaid. Upon the individual's enrollment into the
Medicaid program, the therapeutic group home, PRTF, or IMD shall notify the
DMAS contractor of the individual's status as being under the care of the
facility within five calendar days of the individual becoming eligible for
Medicaid benefits.
5. Service authorization requirements applicable to both
therapeutic group homes and PRTFs:
a. Authorization shall be required and shall be conducted
by DMAS using medical necessity criteria specified in this subsection.
b. An individual shall have a valid psychiatric diagnosis
and meet the medical necessity criteria as defined in this subsection to
satisfy the criteria for admission. The diagnosis shall be current, as
documented within the past 12 months. If a current diagnosis is not available,
the individual will require a mental health evaluation prior to admission by an
LMHP affiliated with the independent certification team to establish a
diagnosis and recommend and coordinate referral to the available treatment
options.
c. At authorization, an initial length of stay shall be
agreed upon by the individual and parent or legally authorized representative
with the treating provider, and the treating provider shall be responsible for
evaluating and documenting evidence of treatment progress, assessing the need
for ongoing out-of-home placement, and obtaining authorization for continued
stay.
d. Information that is required to obtain authorization for
these services shall include:
(1) A completed state-designated uniform assessment
instrument approved by DMAS;
(2) A certificate of need completed by an independent
certification team specifying all of the following:
(a) The ambulatory care and Medicaid or FAPT-funded
services available in the community do not meet the specific treatment needs of
the individual;
(b) Alternative community-based care was not successful;
(c) Proper treatment of the individual's psychiatric
condition requires services in a 24-hour supervised setting under the direction
of a physician; and
(d) The services can reasonably be expected to improve the
individual's condition or prevent further regression so that a more intensive
level of care will not be needed;
(3) Diagnosis as defined in the DSM-5 and based on (i) an
evaluation by a psychiatrist or LMHP that has been completed within 30 calendar
days of admission or (ii) a diagnosis confirmed in writing by an LMHP after
review of a previous evaluation completed within one year of admission;
(4) A description of the individual's behavior during the
seven calendar days immediately prior to admission;
(5) A description of alternate placements and community
mental health and rehabilitation services and traditional behavioral health
services pursued and attempted and the outcomes of each service;
(6) The individual's level of functioning and clinical
stability;
(7) The level of family involvement and supports available;
and
(8) The initial plan of care (IPOC).
6. Continued stay criteria requirements applicable to both
therapeutic group homes and PRTFs. For a continued stay authorization or a
reauthorization to occur, the individual shall meet the medical necessity
criteria as defined in this subsection to satisfy the criteria for continuing
care. The length of the authorized stay shall be determined by DMAS. A current
plan of care and a current (within 30 calendar days) summary of progress
related to the goals and objectives of the plan of care shall be submitted to
DMAS for continuation of the service. The service provider shall also submit:
a. A state uniform assessment instrument, completed no more
than 30 business days prior to the date of submission;
b. Documentation that the required services have been
provided as defined in the plan of care;
c. Current (within the last 14 calendar days) information
on progress related to the achievement of all treatment and discharge-related
goals; and
d. A description of the individual's continued impairment
and treatment needs, problem behaviors, family engagement activities,
community-based discharge planning and care coordination, and need for a
residential level of care.
7. EPSDT services requirements applicable to therapeutic
group homes and PRTFs. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT. EPSDT services may involve
service modalities not available to other individuals, such as applied
behavioral analysis and neuro-rehabilitative services. Individualized services
to address specific clinical needs identified in an EPSDT screening shall
require authorization by a DMAS contractor. In unique EPSDT cases, DMAS may
authorize specialized services beyond the standard therapeutic group home or
PRTF medical necessity criteria and program requirements, as medically and
clinically indicated to ensure the most appropriate treatment is available to
each individual. Treating service providers authorized to deliver medically
necessary EPSDT services in therapeutic group homes and PRTFs on behalf of a
Medicaid-enrolled individual shall adhere to the individualized interventions
and evidence-based progress measurement criteria described in the plan of care
and approved for reimbursement by DMAS. All documentation, independent
certification team, family engagement activity, therapeutic pass, and discharge
planning requirements shall apply to cases approved as EPSDT PRTF or
therapeutic group home service.
8. Inpatient psychiatric services shall be covered for
individuals younger than 21 years of age for medically necessary stays in
inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2)
for the purpose of diagnosis and treatment of mental health and behavioral
disorders identified under EPSDT when such services meet the requirements set
forth in subdivision 7 of this subsection.
a. Inpatient psychiatric services shall be provided under
the direction of a physician.
b. Inpatient psychiatric services shall be provided by (i)
a psychiatric hospital that undergoes a state survey to determine whether the
hospital meets the requirements for participation in Medicare as a psychiatric
hospital as specified in 42 CFR 482.60 or is accredited by a national
organization whose psychiatric hospital accrediting program has been approved
by the Centers for Medicare and Medicaid Services (CMS); or (ii) a hospital
with an inpatient psychiatric program that undergoes a state survey to
determine whether the hospital meets the requirements for participation in
Medicare as a hospital, as specified in 42 CFR part 482 or is accredited by a
national accrediting organization whose hospital accrediting program has been
approved by CMS.
c. Inpatient psychiatric admissions at general acute care
hospitals and freestanding psychiatric hospitals shall also be subject to the
requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25.
d. PRTF services are reimbursable only when the treatment
program is fully in compliance with (i) 42 CFR Part 441 Subpart D,
specifically 42 CFR 441.151(a) and 42 CFR 441.151 (b) and 42 CFR 441.152
through 42 CFR 441.156 and (ii) the Conditions of Participation in 42 CFR
Part 483 Subpart G. Each admission must be service authorized and the treatment
must meet DMAS requirements for clinical necessity.
e. The inpatient psychiatric benefit for individuals
younger than 21 years of age shall include services that are provided pursuant
to a certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the individual's discharge from inpatient status at the
earliest possible time. The inpatient psychiatric benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the individual,
and (iii) ensures that the services are furnished under the direction of a
physician. Services provided under arrangement shall be documented by a written
referral from the inpatient psychiatric facility. For purposes of pharmacy
services, a prescription ordered by an employee or contractor of the inpatient
psychiatric facility who is licensed to prescribe drugs shall be considered the
referral.
f. State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order pharmacy services
and emergency services. Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order the
following services: (i) medical and psychological services including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
outpatient hospital services; (iii) physical therapy, occupational therapy, and
therapy for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) nonemergency transportation services;
and (viii) emergency services. (Emergency services means the same as is set
forth in 12VAC30-50-310 B.)
f. E. Mental health family support partners.
(1) 1. Mental health family support partners are
peer recovery support services and are nonclinical, peer-to-peer activities
that engage, educate, and support the caregiver and an individual's self-help
efforts to improve health recovery resiliency and wellness. Mental health
family support partners is a peer support service and is a strength-based,
individualized service provided to the caregiver of a Medicaid-eligible
individual younger than 21 years of age with a mental health disorder that is
the focus of support. The services provided to the caregiver and individual
must be directed exclusively toward the benefit of the Medicaid-eligible
individual. Services are expected to improve outcomes for individuals younger
than 21 years of age with complex needs who are involved with multiple systems
and increase the individual's and family's confidence and capacity to manage
their own services and supports while promoting recovery and healthy
relationships. These services are rendered by a PRS who is (i) a parent of a
minor or adult child with a similar mental health disorder or (ii) an adult
with personal experience with a family member with a similar mental health
disorder with experience navigating behavioral health care services. The PRS
shall perform the service within the scope of his knowledge, lived experience,
and education.
(2) 2. Under the clinical oversight of the LMHP
making the recommendation for mental health family support partners, the peer
recovery specialist in consultation with his direct supervisor shall develop a
recovery, resiliency, and wellness plan based on the LMHP's recommendation for
service, the individual's and the caregiver's perceived recovery needs, and any
clinical assessments or service specific provider intakes as defined in this
section within 30 calendar days of the initiation of service. Development of
the recovery, resiliency, and wellness plan shall include collaboration with
the individual and the individual's caregiver. Individualized goals and
strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.
(3) 3. Documentation of required activities
shall be required as set forth in 12VAC30-130-5200 A, C, and E through J.
(4) 4. Limitations and exclusions to service
delivery shall be the same as set forth in 12VAC30-130-5210.
(5) 5. Caregivers of individuals younger than 21
years of age who qualify to receive mental health family support partners shall
(i) care for an individual with a mental health disorder who requires recovery
assistance and (ii) meet two or more of the following:
(a) a. Individual and his caregiver need
peer-based recovery-oriented services for the maintenance of wellness and the
acquisition of skills needed to support the individual.
(b) b. Individual and his caregiver need
assistance to develop self-advocacy skills to assist the individual in
achieving self-management of the individual's health status.
(c) c. Individual and his caregiver need
assistance and support to prepare the individual for a successful work or
school experience.
(d) d. Individual and his caregiver need
assistance to help the individual and caregiver assume responsibility for
recovery.
(6) 6. Individuals 18 through, 19, and
20 years of age who meet the medical necessity criteria in 12VAC30-50-226 B 7
e, who would benefit from receiving peer supports directly and who choose to
receive mental health peer support services directly instead of through their
caregiver, shall be permitted to receive mental health peer support services by
an appropriate PRS.
(7) 7. To qualify for continued mental health family
support partners, medical necessity criteria shall continue to be met, and
progress notes shall document the status of progress relative to the goals
identified in the recovery, resiliency, and wellness plan.
(8) 8. Discharge criteria from mental health
family support partners shall be the same as set forth in 12VAC30-130-5180 E.
(9) 9. Mental health family support partners
services shall be rendered on an individual basis or in a group.
(10) 10. Prior to service initiation, a
documented recommendation for mental health family support partners services
shall be made by a licensed mental health professional (LMHP) who is acting
within his scope of practice under state law. The recommendation shall verify
that the individual meets the medical necessity criteria set forth in
subdivision 5 of this subsection. The recommendation shall be valid for no
longer than 30 calendar days.
(11) 11. Effective July 1, 2017, a peer recovery
specialist shall have the qualifications, education, experience, and
certification required by DBHDS in order to be eligible to register with the
Virginia Board of Counseling on or after July 1, 2018. Upon the promulgation of
regulations by the Board of Counseling, registration of peer recovery
specialists by the Board of Counseling shall be required. The PRS shall perform
mental health family support partners services under the oversight of the LMHP
making the recommendation for services and providing the clinical oversight of
the recovery, resiliency, and wellness plan.
(12) 12. The PRS shall be employed by or have a
contractual relationship with the enrolled provider licensed for one of the
following:
(a) a. Acute care general and emergency
department hospital services licensed by the Department of Health.
(b) b. Freestanding psychiatric hospital and
inpatient psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(c) c. Psychiatric residential treatment
facility licensed by the Department of Behavioral Health and Developmental
Services.
(d) d. Therapeutic group home licensed by the
Department of Behavioral Health and Developmental Services.
(e) e. Outpatient mental health clinic services
licensed by the Department of Behavioral Health and Developmental Services.
(f) f. Outpatient psychiatric services provider.
(g) g. A community mental health and
rehabilitative services provider licensed by the Department of Behavioral
Health and Developmental Services as a provider of one of the following
community mental health and rehabilitative services as defined in this section,
12VAC30-50-226, 12VAC30-50-420, or 12VAC30-50-430 for which the individual
younger than 21 years meets medical necessity criteria: (i) intensive in
home; (ii) therapeutic day treatment; (iii) day treatment or partial
hospitalization; (iv) crisis intervention; (v) crisis stabilization; (vi)
mental health skill building; or (vii) mental health case management.
(13) 13. Only the licensed and enrolled provider
as referenced in subdivision 5 f (12) 12 of this subsection shall
be eligible to bill and receive reimbursement from DMAS or its contractor
for mental health family support partner services. Payments shall not be
permitted to providers that fail to enter into an enrollment agreement with
DMAS or its contractor. Reimbursement shall be subject to retraction for
any billed service that is determined not to be in compliance with DMAS
requirements.
(14) 14. Supervision of the PRS shall meet the
requirements set forth in 12VAC30-50-226 B 7 l.
6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by: (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations or (ii) a
psychiatric facility that is accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.
a. The inpatient psychiatric services benefit for
individuals younger than 21 years of age shall include services defined at 42
CFR 440.160 that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active
treatment designed to achieve the child's discharge from inpatient status at
the earliest possible time. The inpatient psychiatric services benefit shall
include services provided under arrangement furnished by Medicaid enrolled
providers other than the inpatient psychiatric facility, as long as the
inpatient psychiatric facility (i) arranges for and oversees the provision of
all services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.
b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.
(1) State freestanding psychiatric hospitals shall arrange
for, maintain records of, and ensure that physicians order these services: (i)
pharmacy services and (ii) emergency services.
(2) Private freestanding psychiatric hospitals shall
arrange for, maintain records of, and ensure that physicians order these
services: (i) medical and psychological services including those furnished by
physicians, licensed mental health professionals, and other licensed or
certified health professionals (i.e., nutritionists, podiatrists, respiratory
therapists, and substance abuse treatment practitioners); (ii) outpatient
hospital services; (iii) physical therapy, occupational therapy, and therapy
for individuals with speech, hearing, or language disorders; (iv)
laboratory and radiology services; (v) vision services; (vi) dental, oral
surgery, and orthodontic services; (vii) transportation services; and (viii)
emergency services.
(3) Residential treatment facilities, as defined at 42 CFR
483.352, shall arrange for, maintain records of, and ensure that physicians
order these services: (i) medical and psychological services, including those
furnished by physicians, licensed mental health professionals, and other
licensed or certified health professionals (i.e., nutritionists, podiatrists,
respiratory therapists, and substance abuse treatment practitioners); (ii)
pharmacy services; (iii) outpatient hospital services; (iv) physical therapy,
occupational therapy, and therapy for individuals with speech, hearing, or
language disorders; (v) laboratory and radiology services; (vi) durable medical
equipment; (vii) vision services; (viii) dental, oral surgery, and orthodontic
services; (ix) transportation services; and (x) emergency services.
c. Inpatient psychiatric services are reimbursable only
when the treatment program is fully in compliance with (i) 42 CFR Part 441
Subpart D, specifically 42 CFR 441.151(a) and (b) and 42 CFR 441.152 through 42
CFR 441.156, and (ii) the conditions of participation in 42 CFR Part 483
Subpart G. Each admission must be preauthorized and the treatment must meet
DMAS requirements for clinical necessity.
d. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT.
7. F. Hearing aids shall be reimbursed for
individuals younger than 21 years of age according to medical necessity when
provided by practitioners licensed to engage in the practice of fitting or
dealing in hearing aids under the Code of Virginia.
8. G. Addiction and recovery treatment services
shall be covered under EPSDT consistent with 12VAC30-130-5000 et seq.
9. H. Services facilitators shall be required
for all consumer-directed personal care services consistent with the
requirements set out in 12VAC30-120-935.
10. I. Behavioral therapy services shall be
covered for individuals younger than 21 years of age.
a. 1. Definitions. The following words and terms
when used in this subsection shall have the following meanings unless the
context clearly indicates otherwise:
"Behavioral therapy" means systematic interventions
provided by licensed practitioners acting within the scope of practice defined
under a Virginia Department of Health Professions regulatory board and covered
as remedial care under 42 CFR 440.130(d) to individuals younger than 21 years
of age. Behavioral therapy includes applied behavioral analysis. Family
training related to the implementation of the behavioral therapy shall be
included as part of the behavioral therapy service. Behavioral therapy services
shall be subject to clinical reviews and determined as medically necessary.
Behavioral therapy may be provided in the individual's home and community
settings as deemed by DMAS or its contractor as medically necessary
treatment.
"Counseling" means a professional mental health
service that can only be provided by a person holding a license issued by a
health regulatory board at the Department of Health Professions, which includes
conducting assessments, making diagnoses of mental disorders and conditions,
establishing treatment plans, and determining treatment interventions.
"Individual" means the child or adolescent younger
than 21 years of age who is receiving behavioral therapy services.
"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.
b. 2. Behavioral therapy services shall be
designed to enhance communication skills and decrease maladaptive patterns of
behavior, which if left untreated, could lead to more complex problems and the
need for a greater or a more intensive level of care. The service goal shall be
to ensure the individual's family or caregiver is trained to effectively manage
the individual's behavior in the home using modification strategies. All
services shall be provided in accordance with the ISP and clinical assessment
summary.
c. 3. Behavioral therapy services shall be
covered when recommended by the individual's primary care provider or other
licensed physician, licensed physician assistant, or licensed nurse
practitioner and determined by DMAS or its contractor to be medically
necessary to correct or ameliorate significant impairments in major life
activities that have resulted from either developmental, behavioral, or mental
disabilities. Criteria for medical necessity are set out in 12VAC30-60-61 H
F. Service-specific provider intakes shall be required at the onset of
these services in order to receive authorization for reimbursement. Individual
service plans (ISPs) shall be required throughout the entire duration of
services. The services shall be provided in accordance with the individual
service plan and clinical assessment summary. These services shall be provided
in settings that are natural or normal for a child or adolescent without a
disability, such as the individual's home, unless there is justification in the
ISP, which has been authorized for reimbursement, to include service settings
that promote a generalization of behaviors across different settings to
maintain the targeted functioning outside of the treatment setting in the
individual's home and the larger community within which the individual resides.
Covered behavioral therapy services shall include:
(1) a. Initial and periodic service-specific
provider intake as defined in 12VAC30-60-61 H F;
(2) b. Development of initial and updated ISPs
as established in 12VAC30-60-61 H F;
(3) c. Clinical supervision activities. Requirements
for clinical supervision are set out in 12VAC30-60-61 H F;
(4) d. Behavioral training to increase the
individual's adaptive functioning and communication skills;
(5) e. Training a family member in behavioral
modification methods as established in 12VAC30-60-61 H F;
(6) f. Documentation and analysis of
quantifiable behavioral data related to the treatment objectives; and
(7) g. Care coordination.
C. J. School health services.
1. School health assistant services are repealed effective
July 1, 2006.
2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services, shall not be covered for school divisions. School divisions to
receive reimbursement for the screenings shall be enrolled with DMAS as clinic
providers.
a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.
b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act. These
services are necessary to correct or ameliorate defects of physical or mental
illnesses or conditions.
3. Providers shall be licensed under the applicable state
practice act or comparable licensing criteria by the Virginia Department of
Education, and shall meet applicable qualifications under 42 CFR Part 440.
Identification of defects, illnesses or conditions, and services
necessary to correct or ameliorate them shall be performed by practitioners
qualified to make those determinations within their licensed scope of practice,
either as a member of the IEP team or by a qualified practitioner outside the
IEP team.
a. Providers shall be employed by the school division or under
contract to the school division.
b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.
c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.
d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.
e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.
4. Covered services include:
a. Physical therapy, and occupational therapy
and services for individuals with speech, hearing, and language disorders,
performed by, or under the direction of, providers who meet the qualifications
set forth at 42 CFR 440.110. This coverage includes audiology services.
b. Skilled nursing services are covered under 42 CFR
440.60. These services are to be rendered in accordance to the licensing
standards and criteria of the Virginia Board of Nursing. Nursing services are
to be provided by licensed registered nurses or licensed practical nurses but
may be delegated by licensed registered nurses in accordance with the
regulations of the Virginia Board of Nursing, especially the section on
delegation of nursing tasks and procedures. The licensed practical nurse is
under the supervision of a registered nurse.
(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation, and evaluation) that is consistent with skilled nursing
services when performed by a licensed registered nurse or a licensed practical
nurse. These skilled nursing services shall include dressing changes,
maintaining patent airways, medication administration/monitoring administration
or monitoring, and urinary catheterizations.
(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant, or nurse practitioner for skilled nursing services. This
order shall be recertified on an annual basis.
c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient
services include individual medical psychotherapy, group medical psychotherapy
coverage, and family medical psychotherapy. Psychological and neuropsychological
testing are allowed when done for purposes other than educational diagnosis,
school admission, evaluation of an individual with intellectual or
developmental disability prior to admission to a nursing facility, or any
placement issue. These services are covered in the nonschool settings also.
School providers who may render these services when licensed by the state
include psychiatrists, licensed clinical psychologists, school psychologists,
licensed clinical social workers, professional counselors, psychiatric clinical
nurse specialists, marriage and family therapists, and school social workers.
d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner professional
develops a written plan for meeting the needs of the child individual,
which is implemented by the assistant. The assistant must have qualifications
comparable to those for other personal care aides recognized by the Virginia
Department of Medical Assistance Services. The assistant performs services such
as assisting with toileting, ambulation, and eating. The assistant may serve as
an aide on a specially adapted school vehicle that enables transportation to or
from the school or school contracted provider on days when the student is
receiving a Medicaid-covered service under the IEP. Children Individuals
requiring an aide during transportation on a specially adapted vehicle shall
have this stated in the IEP.
e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's an individual's
medical or other health related condition.
f. Transportation is covered as allowed under 42 CFR
431.53 and described at State Plan Attachment 3.1-D (12VAC30-50-530).
Transportation shall be rendered only by school division personnel or
contractors. Transportation is covered for a child an individual
who requires transportation on a specially adapted school vehicle that enables
transportation to or from the school or school contracted provider on days when
the student individual is receiving a Medicaid-covered service
under the IEP. Transportation shall be listed in the child's individual's
IEP. Children Individuals requiring an aide during transportation
on a specially adapted vehicle shall have this stated in the IEP.
g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's an individual's IEP and
shall be performed by any of the above licensed practitioners within the scope
of practice. Assessments and reassessments not tied to medical needs of the child
individual shall not be covered.
5. DMAS will ensure through quality management review that duplication
of services will be monitored. School divisions have a responsibility to ensure
that if a child an individual is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.
D. K. Family planning services and supplies for
individuals of child-bearing age.
1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing
arts.
2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.
3. Family planning services as established by § 1905(a)(4)(C)
of the Social Security Act include annual family planning exams; cervical
cancer screening for women; sexually transmitted infection (STI) testing; lab
services for family planning and STI testing; family planning education,
counseling, and preconception health; sterilization procedures; nonemergency
transportation to a family planning service; and U.S. Food and Drug Administration
approved prescription and over-the-counter contraceptives, subject to limits in
12VAC30-50-210.
12VAC30-50-226. Community mental health services.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:
"Activities of daily living" or "ADLs"
means personal care tasks such as bathing, dressing, toileting, transferring,
and eating or feeding. An individual's degree of independence in performing
these activities is a part of determining appropriate level of care and service
needs.
"Affiliated" means any entity or property in which
a provider or facility has a direct or indirect ownership interest of 5.0% or
more, or any management, partnership, or control of an entity.
"Behavioral health service" means the same as
defined in 12VAC30-130-5160.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS. DMAS' designated BHSA shall be
authorized to constitute, oversee, enroll, and train a provider network;
perform service authorization; adjudicate claims; process claims; gather and
maintain data; reimburse providers; perform quality assessment and improvement;
conduct member outreach and education; resolve member and provider issues; and
perform utilization management including care coordination for the provision of
Medicaid-covered behavioral health services. Such authority shall include
entering into or terminating contracts with providers in accordance with DMAS
authority pursuant to 42 CFR Part 1002 and § 32.1-325 D and E of the Code
of Virginia. DMAS shall retain authority for and oversight of the BHSA entity
or entities.
"Certified prescreener" means an employee of either
the local community services board/behavioral board or behavioral
health authority or its designee who is skilled in the assessment and treatment
of mental illness and who has completed a certification program approved by
DBHDS.
"Clinical experience" means, for the purpose of
rendering (i) mental health day treatment/partial hospitalization, (ii)
intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental
health skill building, (v) crisis stabilization, or (vi) crisis intervention
services, practical experience in providing direct services to individuals with
diagnoses of mental illness or intellectual disability or the provision of
direct geriatric services or special education services. Experience shall
include supervised internships, supervised practicums, or supervised field
experience. Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be
established by DBHDS in the document titled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Code" means the Code of Virginia.
"DBHDS" means the Department of Behavioral Health
and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.)
of Title 37.2 of the Code of Virginia.
"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i)
shall have two consecutive years of documented practical experience rendering
peer support services or family support services, have certification training
as a PRS under a certifying body approved by DBHDS, and have documented
completion of the DBHDS PRS supervisor training; (ii) shall be a qualified
mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined in
12VAC35-105-20 with at least two consecutive years of documented experience as
a QMHP, and who has documented completion of the DBHDS PRS supervisor training;
or (iii) shall be an LMHP who has documented completion of the DBHDS PRS
supervisor training who is acting within his scope of practice under state law.
An LMHP providing services before April 1, 2018, shall have until April 1,
2018, to complete the DBHDS PRS supervisor training.
"DMAS" means the Department of Medical Assistance
Services and its contractor or 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.
"Human services field" means the same as the term
is defined by DBHDS the Department of Health Professions in the
guidance document entitled Human Services and Related Fields Approved
Degrees/Experience, issued March 12, 2013, revised May 3, 2013. Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018.
"Individual" means the patient, client, or
recipient of services described in this section.
"Individual service plan" or "ISP" means
a comprehensive and regularly updated treatment plan specific to the
individual's unique treatment needs as identified in the service-specific
provider intake. The ISP contains, but is not limited to, the individual's
treatment or training needs, the individual's goals and measurable objectives
to meet the identified needs, services to be provided with the recommended
frequency to accomplish the measurable goals and objectives, the estimated
timetable for achieving the goals and objectives, and an individualized
discharge plan that describes transition to other appropriate services. The
individual shall be included in the development of the ISP and the ISP shall be
signed by the individual. If the individual is a minor child, the ISP
shall also be signed by the individual's parent/legal parent or legal
guardian. Documentation shall be provided if the individual, who is a minor
child or an adult who lacks legal capacity, is unable or unwilling to sign the
ISP.
"Individualized training" means instruction and
practice in functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living skills,
and use of community resources; assistance with medical management; and
monitoring health, nutrition, and physical condition. The training shall be
rehabilitative and based on a variety of incremental (or cumulative) approaches
or tools to organize and guide the individual's life planning and shall reflect
what is important to the individual in addition to all other factors that
affect his the individual's functioning, including effects of the
disability and issues of health and safety.
"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the
same as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.
"LMHP-resident in psychology" or
"LMHP-RP" means the same as an individual in a residency, as that
term is defined in 18VAC125-20-10, program for clinical psychologists. An
LMHP-resident in psychology shall be in continuous compliance with the
regulatory requirements for supervised experience as found in 18VAC125-20-65
and shall not perform the functions of the LMHP-RP or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Psychology. For purposes of Medicaid reimbursement by supervisors for services
provided by such residents, they shall use the title "Resident in
Psychology" after their signatures to indicate such status.
"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" is defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered
a "supervisee" until the supervision for specific clinical duties at
a specific site is preapproved in writing by the Virginia Board of Social Work.
For purposes of Medicaid reimbursement to their supervisors for services
provided by supervisees, these persons shall use the title "Supervisee in
Social Work" after their signatures to indicate such status.
"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.
"Person centered" means the same as defined in
12VAC30-130-5160.
"Qualified mental health professional-adult" or
"QMHP-A" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-child" or
"QMHP-C" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20,
including a "QMHP-trainee" as defined by the Department of Health
Professions.
"Qualified paraprofessional in mental health" or
"QPPMH" means the same as defined in 12VAC35-105-20.
"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.
"Register" or "registration" means
notifying DMAS or its contractor that an individual will be receiving services
that do not require service authorization.
"Resiliency" means the same as defined in
12VAC30-130-5160.
"Review of ISP" means that the provider evaluates
and updates the individual's progress toward meeting the individualized service
plan objectives and documents the outcome of this review. For DMAS to determine
that these reviews are satisfactory and complete, the reviews shall (i) update
the goals, objectives, and strategies of the ISP to reflect any change in the
individual's progress and treatment needs as well as any newly identified
problems; (ii) be conducted in a manner that enables the individual to
participate in the process; and (iii) be documented in the individual's medical
record no later than 15 calendar days from the date of the review.
"Self-advocacy" means the same as defined in
12VAC30-130-5160.
"Service authorization" means the process to
approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS
individual by a DMAS service authorization contractor prior to service delivery
and reimbursement in order to validate that the service requested is medically
necessary and meets DMAS and DMAS contractor criteria for reimbursement.
Service authorization does not guarantee payment for the service.
"Service-specific provider intake" means the same
as defined in 12VAC30-50-130 and also includes individuals who are older than
21 years of age.
"Strength-based" means the same as defined in
12VAC30-130-5160.
"Supervision" means the same as defined in
12VAC30-130-5160.
B. Mental health services. The following services, with their
definitions, shall be covered: day treatment/partial hospitalization,
psychosocial rehabilitation, crisis services, intensive community treatment
(ICT), and mental health skill building. Staff travel time shall not be
included in billable time for reimbursement. These services, in order to be
covered, shall meet medical necessity criteria based upon diagnoses made by
LMHPs who are practicing within the scope of their licenses and are reflected
in provider records and on providers' claims for services by recognized
diagnosis codes that support and are consistent with the requested professional
services. These services are intended to be delivered in a person-centered
person centered manner. The individuals who are receiving these services
shall be included in all service planning activities. All services which do not
require service authorization require registration. This registration shall
transmit service-specific information to DMAS or its contractor in accordance
with service authorization requirements.
1. Day treatment/partial hospitalization services shall be
provided in sessions of two or more consecutive hours per day, which may be
scheduled multiple times per week, to groups of individuals in a nonresidential
setting. These services, limited annually to 780 units, include the major
diagnostic, medical, psychiatric, psychosocial, and psychoeducational treatment
modalities designed for individuals who require coordinated, intensive,
comprehensive, and multidisciplinary treatment but who do not require inpatient
treatment. One unit of service shall be defined as a minimum of two but less
than four hours on a given day. Two units of service shall be defined as at
least four but less than seven hours in a given day. Three units of service
shall be defined as seven or more hours in a given day. Authorization is
required for Medicaid reimbursement.
a. Day treatment/partial hospitalization services shall be
time limited interventions that are more intensive than outpatient services and
are required to stabilize an individual's psychiatric condition. The services
are delivered when the individual is at risk of psychiatric hospitalization or
is transitioning from a psychiatric hospitalization to the community. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual is at risk of
psychiatric hospitalization or is transitioning from a psychiatric
hospitalization to the community.
b. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Individuals must meet at least two of the following criteria
on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
hospitalization or homelessness or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that the individual
requires repeated interventions or monitoring by the mental health, social
services, or judicial system that have been documented; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
c. Individuals shall be discharged from this service when they
are no longer in an acute psychiatric state and other less intensive services
may achieve psychiatric stabilization.
d. Admission and services for time periods longer than 90
calendar days must be authorized based upon a face-to-face evaluation by a
physician, psychiatrist, licensed clinical psychologist, licensed professional
counselor, licensed clinical social worker, or psychiatric clinical nurse
specialist.
e. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
2. Psychosocial rehabilitation shall be provided at least two
or more hours per day to groups of individuals in a nonresidential setting.
These services, limited annually to 936 units, include assessment, education to
teach the patient about the diagnosed mental illness and appropriate
medications to avoid complication and relapse, and opportunities to
learn and use independent living skills and to enhance social and interpersonal
skills within a supportive and normalizing program structure and environment.
One unit of service is defined as a minimum of two but less than four hours on
a given day. Two units are defined as at least four but less than seven hours
in a given day. Three units of service shall be defined as seven or more hours
in a given day. Authorization is required for Medicaid reimbursement. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from mental, behavioral, or
emotional illness that results in significant functional impairments in major
life activities. Services are provided to individuals: (i) who without
these services would be unable to remain in the community or (ii) who meet at
least two of the following criteria on a continuing or intermittent basis:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that repeated
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, or a QPPMH.
3. Crisis intervention shall provide immediate mental health
care, available 24 hours a day, seven days per week, to assist individuals who
are experiencing acute psychiatric dysfunction requiring immediate clinical attention.
This service's objectives shall be to prevent exacerbation of a condition, to
prevent injury to the client or others, and to provide treatment in the context
of the least restrictive setting. Crisis intervention activities shall include
assessing the crisis situation, providing short-term counseling designed to
stabilize the individual, providing access to further immediate assessment and
follow-up, and linking the individual and family with ongoing care to prevent
future crises. Crisis intervention services may include office visits, home
visits, preadmission screenings, telephone contacts, and other client-related
activities for the prevention of institutionalization. The service-specific
provider intake, as defined at 12VAC30-50-130, shall document the individual's
behavior and describe how the individual meets criteria for this service. The
provision of this service to an individual shall be registered with either DMAS,
DMAS contractors, or the BHSA within one business day or the completion of
the service-specific provider intake to avoid duplication of services and to
ensure informed care coordination.
a. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a
psychiatric nature that puts the individual at risk of psychiatric
hospitalization. Individuals must meet at least two of the following criteria
at the time of admission to the service:
(1) Experience difficulty in establishing or maintaining
normal interpersonal relationships to such a degree that they are at risk of
psychiatric hospitalization, homelessness, or isolation from social supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by mental health, social services, or the judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or significantly inappropriate social
behavior.
b. The annual limit for crisis intervention is 720 units per
year. A unit shall equal 15 minutes.
c. These services may only be rendered by an LMHP, an
LMHP-supervisee, LMHP-resident, LMHP-RP, or a certified prescreener.
4. Intensive community treatment (ICT), initially covered for
a maximum of 26 weeks based on an initial service-specific provider intake and
may be reauthorized for up to an additional 26 weeks annually based on written
intake and certification of need by a licensed mental health provider (LMHP),
shall be defined by 12VAC35-105-20 or LMHP-S, LMHP-R, and LMHP-RP and shall
include medical psychotherapy, psychiatric assessment, medication management,
and care coordination activities offered to outpatients outside the clinic,
hospital, or office setting for individuals who are best served in the
community. Authorization is required for Medicaid reimbursement.
a. To qualify for ICT, the individual must meet at least one
of the following criteria:
(1) The individual must be at high risk for psychiatric
hospitalization or becoming or remaining homeless due to mental illness or
require intervention by the mental health or criminal justice system due to
inappropriate social behavior.
(2) The individual has a history (three months or more) of a
need for intensive mental health treatment or treatment for co-occurring
serious mental illness and substance use disorder and demonstrates a resistance
to seek out and utilize appropriate treatment options.
b. A written, service-specific provider intake, as defined at
12VAC30-50-130, that documents the individual's eligibility and the need for
this service must be completed prior to the initiation of services. This intake
must be maintained in the individual's records.
c. An individual service plan shall be initiated at the time
of admission and must be fully developed, as defined in this section, within 30
days of the initiation of services.
d. The annual unit limit shall be 130 units with a unit
equaling one hour.
e. These services may only be rendered by a team that meets
the requirements of 12VAC35-105-1370.
5. Crisis stabilization services for nonhospitalized
individuals shall provide direct mental health care to individuals experiencing
an acute psychiatric crisis which may jeopardize their current community living
situation. Services may be provided for up to a 15-day period per crisis
episode following a face-to-face service-specific provider intake by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP. Only one unit of service shall be
reimbursed for this intake. The provision of this service to an individual
shall be registered with either DMAS, DMAS contractors, or the BHSA
within one business day of the completion of the service-specific provider intake
to avoid duplication of services and to ensure informed care coordination.
a. The goals of crisis stabilization programs shall be to
avert hospitalization or rehospitalization, provide normative environments with
a high assurance of safety and security for crisis intervention, stabilize
individuals in psychiatric crisis, and mobilize the resources of the community
support system and family members and others for on-going maintenance and
rehabilitation. The services must be documented in the individual's records as
having been provided consistent with the ISP in order to receive Medicaid
reimbursement.
b. The crisis stabilization program shall provide to
individuals, as appropriate, psychiatric assessment including medication
evaluation, treatment planning, symptom and behavior management, and individual
and group counseling.
c. This service may be provided in any of the following
settings, but shall not be limited to: (i) the home of an individual who lives
with family or other primary caregiver; (ii) the home of an individual who
lives independently; or (iii) community-based programs licensed by DBHDS to
provide residential services but which are not institutions for mental disease
(IMDs).
d. This service shall not be reimbursed for (i) individuals with
medical conditions that require hospital care; (ii) individuals with a
primary diagnosis of substance abuse; or (iii) individuals with psychiatric
conditions that cannot be managed in the community (i.e., individuals who are
of imminent danger to themselves or others).
e. The maximum limit on this service is 60 days annually.
f. Services must be documented through daily progress notes
and a daily log of times spent in the delivery of services. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. Individuals qualifying for this service must demonstrate a
clinical necessity for the service arising from an acute crisis of a psychiatric
nature that puts the individual at risk of psychiatric hospitalization.
Individuals must meet at least two of the following criteria at the time of
admission to the service:
(1) Experience difficulty in establishing and maintaining
normal interpersonal relationships to such a degree that the individual is at
risk of psychiatric hospitalization, homelessness, or isolation from social
supports;
(2) Experience difficulty in activities of daily living such
as maintaining personal hygiene, preparing food and maintaining adequate
nutrition, or managing finances to such a degree that health or safety is
jeopardized;
(3) Exhibit such inappropriate behavior that immediate
interventions documented by the mental health, social services, or judicial
system are or have been necessary; or
(4) Exhibit difficulty in cognitive ability such that the
individual is unable to recognize personal danger or significantly
inappropriate social behavior.
g. These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, QMHP-E or a certified
prescreener.
6. Mental health skill-building services (MHSS) shall be
defined as goal-directed training to enable individuals to achieve and maintain
community stability and independence in the most appropriate, least restrictive
environment. Authorization is required for Medicaid reimbursement. Services
that are rendered before the date of service authorization shall not be
reimbursed. These services may be authorized up to six consecutive months as long
as the individual meets the coverage criteria for this service. The
service-specific provider intake, as defined at 12VAC30-50-130, shall document
the individual's behavior and describe how the individual meets criteria for
this service. These services shall provide goal-directed training in the
following areas in order to be reimbursed by Medicaid or the BHSA DMAS
contractor: (i) functional skills and appropriate behavior related to the
individual's health and safety, instrumental activities of daily living, and
use of community resources; (ii) assistance with medication management; and
(iii) monitoring of health, nutrition, and physical condition with goals
towards self-monitoring and self-regulation of all of these activities.
Providers shall be reimbursed only for training activities defined in the ISP
and only where services meet the service definition, eligibility, and service
provision criteria and this section. A review of MHSS services by an LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall be repeated for all individuals who have
received at least six months of MHSS to determine the continued need for this
service.
a. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Services are provided to individuals who
require individualized goal-directed training in order to achieve or maintain
stability and independence in the community.
b. Individuals ages 21 years of age and older
shall meet all of the following criteria in order to be eligible to receive
mental health skill-building services:
(1) The individual shall have one of the following as a
primary mental health diagnosis:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness; (ii)
results in severe and recurrent disability; (iii) produces functional
limitations in the individual's major life activities that are documented in the
individual's medical record; and (iv) requires individualized training for the
individual in order to achieve or maintain independent living in the community.
(2) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living
skills, such as symptom management; adherence to psychiatric and physical
health medication treatment plans; appropriate use of social skills and
personal support systems; skills to manage personal hygiene, food preparation,
and the maintenance of personal adequate nutrition; money management; and use
of community resources.
(3) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) (PRTF)
as a result of decompensation related to the individual's serious mental
illness; or (v) a temporary detention order (TDO) evaluation, pursuant to § 37.2-809
B of the Code of Virginia. This criterion shall be met in order to be initially
admitted to services and not for subsequent authorizations of service.
Discharge summaries from prior providers that clearly indicate (i) the type of
treatment provided, (ii) the dates of the treatment previously provided, and
(iii) the name of the treatment provider shall be sufficient to meet this
requirement. Family member statements shall not suffice to meet this
requirement.
(4) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications within the 12
months prior to the service-specific provider intake date. If a physician or
other practitioner who is authorized by his license to prescribe medications
indicates that antipsychotic, mood stabilizing, or antidepressant medications
are medically contraindicated for the individual, the provider shall obtain
medical records signed by the physician or other licensed prescriber detailing
the contraindication. This documentation shall be maintained in the
individual's mental health skill-building services record, and the provider
shall document and describe how the individual will be able to actively
participate in and benefit from services without the assistance of medication.
This criterion shall be met upon admission to services and shall not be
required for subsequent authorizations of service. Discharge summaries from prior
providers that clearly indicate (i) the type of treatment provided, (ii) the
dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
c. Individuals aged 18 to 21 years of age shall
meet all of the following criteria in order to be eligible to receive mental
health skill-building services:
(1) The individual shall not be living in a supervised setting
as described in § 63.2-905.1 of the Code of Virginia. If the individual is
transitioning into an independent living situation, MHSS shall only be
authorized for up to six months prior to the date of transition.
(2) The individual shall have at least one of the following as
a primary mental health diagnosis.:
(a) Schizophrenia or other psychotic disorder as set out in
the DSM-5;
(b) Major depressive disorder;
(c) Recurrent Bipolar I or Bipolar II; or
(d) Any other serious mental health disorder that a physician
has documented specific to the identified individual within the past year and
that includes all of the following: (i) is a serious mental illness or serious
emotional disturbance; (ii) results in severe and recurrent disability; (iii)
produces functional limitations in the individual's major life activities that
are documented in the individual's medical record; and (iv) requires
individualized training for the individual in order to achieve or maintain
independent living in the community.
(3) The individual shall require individualized goal-directed
training in order to acquire or maintain self-regulation of basic living skills
such as symptom management; adherence to psychiatric and physical health
medication treatment plans; appropriate use of social skills and personal
support systems; skills to manage personal hygiene, food preparation, and the
maintenance of personal adequate nutrition; money management; and use of
community resources.
(4) The individual shall have a prior history of any of the
following: (i) psychiatric hospitalization; (ii) either residential or
nonresidential crisis stabilization; (iii) intensive community treatment (ICT)
or program of assertive community treatment (PACT) services; (iv) placement in
a psychiatric residential treatment facility (RTC-Level C) as a result
of decompensation related to the individual's serious mental illness; or (v)
temporary detention order (TDO) evaluation pursuant to § 37.2-809 B of the Code
of Virginia. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the treatment
provider shall be sufficient to meet this requirement. Family member statements
shall not suffice to meet this requirement.
(5) The individual shall have had a prescription for
antipsychotic, mood stabilizing, or antidepressant medications, within the 12
months prior to the assessment date. If a physician or other practitioner who
is authorized by his license to prescribe medications indicates that
antipsychotic, mood stabilizing, or antidepressant medications are medically
contraindicated for the individual, the provider shall obtain medical records
signed by the physician or other licensed prescriber detailing the
contraindication. This documentation of medication management shall be
maintained in the individual's mental health skill-building services record.
For individuals not prescribed antipsychotic, mood stabilizing, or
antidepressant medications, the provider shall have documentation from the
medication management physician describing how the individual will be able to
actively participate in and benefit from services without the assistance of
medication. This criterion shall be met in order to be initially admitted to
services and not for subsequent authorizations of service. Discharge summaries
from prior providers that clearly indicate (i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and (iii) the name of the
treatment provider shall be sufficient to meet this requirement. Family member
statements shall not suffice to meet this requirement.
(6) An independent clinical assessment, established in
12VAC30-130-3020, shall be completed for the individual.
d. Service-specific provider intakes shall be required at the
onset of services and individual service plans (ISPs) shall be required during
the entire duration of services. Services based upon incomplete, missing,
or outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in 12VAC30-50-130.
e. The yearly limit for mental health skill-building services
is 520 units. Only direct face-to-face contacts and services to the individual
shall be reimbursable. One unit is 1 to 2.99 hours per day, and two
units is 3 to 4.99 hours per day.
f. These services may only be rendered by an LMHP, LMHP-R,
LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or QPPMH.
g. The provider shall clearly document details of the services
provided during the entire amount of time billed.
h. The ISP shall not include activities that contradict or
duplicate those in the treatment plan established by the therapeutic
group home or assisted living facility. The provider shall coordinate mental
health skill-building services with the treatment plan established by the group
home or assisted living facility and shall document all coordination activities
in the medical record.
i. Limits and exclusions.
(1) Group Therapeutic group home (Level A or
B) and assisted living facility providers shall not serve as the mental
health skill-building services provider for individuals residing in the
provider's respective facility. Individuals residing in facilities may,
however, receive MHSS from another MHSS agency not affiliated with the owner of
the facility in which they reside.
(2) Mental health skill-building services shall not be
reimbursed for individuals who are receiving in-home residential services or
congregate residential services through the Intellectual Disability Waiver or
Individual and Family Developmental Disabilities Support Waiver.
(3) Mental health skill-building services shall not be
reimbursed for individuals who are also receiving services under the Department
of Social Services independent living program (22VAC40-151), independent living
services (22VAC40-131 and 22VAC40-151), or independent living arrangement
(22VAC40-131) or any Comprehensive Services Act-funded independent living
skills programs.
(4) Mental health skill-building services shall not be
available to individuals who are receiving treatment foster care
(12VAC30-130-900 et seq.).
(5) Mental health skill-building services shall not be
available to individuals who reside in intermediate care facilities for
individuals with intellectual disabilities or hospitals.
(6) Mental health skill-building services shall not be
available to individuals who reside in nursing facilities, except for up to 60
days prior to discharge. If the individual has not been discharged from the
nursing facility during the 60-day period of services, mental health
skill-building services shall be terminated and no further service
authorizations shall be available to the individual unless a provider can
demonstrate and document that mental health skill-building services are
necessary. Such documentation shall include facts demonstrating a change in the
individual's circumstances and a new plan for discharge requiring up to 60 days
of mental health skill-building services.
(7) Mental health skill-building services shall not be
available for residents of psychiatric residential treatment centers (Level
C facilities) except for the intake code H0032 (modifier U8) in the seven
days immediately prior to discharge.
(8) Mental health skill-building services shall not be
reimbursed if personal care services or attendant care services are being
received simultaneously, unless justification is provided why this is necessary
in the individual's mental health skill-building services record. Medical
record documentation shall fully substantiate the need for services when
personal care or attendant care services are being provided. This applies to
individuals who are receiving additional services through the Intellectual
Disability Waiver (12VAC30-120-1000 et seq.), Individual and Family
Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.), the
Elderly or Disabled with Consumer Direction Waiver (12VAC30-120-900 et seq.),
and EPSDT services (12VAC30-50-130).
(9) Mental health skill-building services shall not be
duplicative of other services. Providers shall be required to ensure that if an
individual is receiving additional therapeutic services that there will be
coordination of services by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A,
QMHP-C, QMHP-E, or QPPMH to avoid duplication of services.
(10) Individuals who have organic disorders, such as delirium,
dementia, or other cognitive disorders not elsewhere classified, will be
prohibited from receiving mental health skill-building services unless their
physicians issue signed and dated statements indicating that the individuals
can benefit from this service.
(11) Individuals who are not diagnosed with a serious mental
health disorder but who have personality disorders or other mental health
disorders, or both, that may lead to chronic disability shall not be excluded
from the mental health skill-building services eligibility criteria provided
that the individual has a primary mental health diagnosis from the list
included in subdivision B 6 b (1) or B 6 c (2) of this section and that the
provider can document and describe how the individual is expected to actively
participate in and benefit from mental health skill-building services.
7. Mental health peer support services.
a. Mental health peer support services are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support an individual's self-help efforts to improve health
recovery, resiliency, and wellness. Mental health peer support services for
adults is a person centered, strength-based, and recovery-oriented
rehabilitative service for individuals 21 years of age or older provided
by a peer recovery specialist successful in the recovery process with lived
experience with a mental health disorder, who is trained to offer support and
assistance in helping others in the recovery to reduce the disabling effects of
a mental health disorder that is the focus of support. Services assist the
individual with developing and maintaining a path to recovery, resiliency, and
wellness. Specific peer support service activities shall emphasize the
acquisition, development, and enhancement of recovery, resiliency, and
wellness. Services are designed to promote empowerment, self-determination,
understanding, and coping skills through mentoring and service coordination
supports, as well as to assist individuals in achieving positive coping
mechanisms for the stressors and barriers encountered when recovering from
their illnesses or disorders.
b. Under the clinical oversight of the LMHP making the
recommendation for mental health support services, the peer recovery specialist
in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's perceived recovery needs, and any clinical assessments or
service specific provider intakes as defined in this section within 30 calendar
days of the initiation of service. Development of the recovery, resiliency, and
wellness plan shall include collaboration with the individual. Individualized
goals and strategies shall be focused on the individual's identified needs for
self-advocacy and recovery. The recovery, resiliency, and wellness plan shall
also include documentation of how many days per week and how many hours per
week are required to carry out the services in order to meet the goals of the
plan. The recovery, resiliency, and wellness plan shall be completed, signed,
and dated by the LMHP, the PRS, the direct supervisor, and the individual
within 30 calendar days of the initiation of service. The PRS shall act as an
advocate for the individual, encouraging the individual to take a proactive
role in developing and updating goals and objectives in the individualized
recovery planning.
c. Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A, C, and E through J.
d. Limitations and exclusions to service delivery shall be the
same as set forth in 12VAC30-130-5210.
e. Individuals 21 years of age or older qualifying for
mental health peer support services shall meet the following requirements:
(1) Require recovery-oriented assistance and support services
for the acquisition of skills needed to engage in and maintain recovery; for the
development of self-advocacy skills to achieve a decreasing dependency on
formalized treatment systems; and to increase responsibilities, wellness
potential, and shared accountability for the individual's own recovery.
(2) Have a documented mental health disorder diagnosis.
(3) Demonstrate moderate to severe functional impairment
because of a diagnosis that interferes with or limits performance in at least
one of the following domains: educational (e.g., obtaining a high school or
college degree); social (e.g., developing a social support system); vocational
(e.g., obtaining part-time or full-time employment); self-maintenance (e.g.,
managing symptoms, understanding his illness, living more independently).
f. To qualify for continued mental health peer support
services, medical necessity criteria shall continue to be met, and progress
notes shall document the status of progress relative to the goals identified in
the recovery, resiliency, and wellness plan.
g. Discharge criteria from mental health peer support services
is the same as set forth in 12VAC30-130-5180 E.
h. Mental health peer support services shall be rendered
on an individual basis or in a group.
i. Prior to service initiation, a documented recommendation
for mental health peer support services shall be made by a licensed mental
health professional acting within the scope of practice under state law The
recommendation shall verify that the individual meets the medical necessity
criteria set forth in subdivision 7 e of this subsection. The recommendation
shall be valid for no longer than 30 calendar days.
j. Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification established
by DBHDS in order to be eligible to register with the Board of Counseling on or
after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health peer support
services under the oversight of the LMHP making the recommendation for services
and providing the clinical oversight of the recovery, resiliency, and wellness
plan. The PRS shall be employed by or have a contractual relationship with an
enrolled provider licensed for one of the following:
(1) Acute care general hospital licensed by the Department of
Health.
(2) Freestanding psychiatric hospital and inpatient
psychiatric unit licensed by the Department of Behavioral Health and
Developmental Services.
(3) Outpatient mental health clinic services licensed by the
Department of Behavioral Health and Developmental Services.
(4) Outpatient psychiatric services provider.
(5) Rural health clinics and federally qualified health
centers.
(6) Hospital emergency department services licensed by the
Department of Health.
(7) Community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services defined in this section or 12VAC30-50-420 for which the
individual meets medical necessity criteria:
(a) Day treatment or partial hospitalization;
(b) Psychosocial rehabilitation;
(c) Crisis intervention;
(d) Intensive community treatment;
(e) Crisis stabilization;
(f) Mental health skill building; or
(g) Mental health case management.
k. Only the licensed and enrolled provider referenced in
subdivision 7 j of this subsection shall be eligible to bill mental health peer
support services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor.
Reimbursement shall be subject to retraction for any billed service that is
determined to not to be in compliance with DMAS requirements.
l. Supervision of the PRS shall be required as set forth in
the definition of "supervision" in 12VAC30-130-5160. Supervision of
the PRS shall also meet the following requirements: the supervisor shall be
under the clinical oversight of the LMHP making the recommendation for
services, and the peer recovery specialist in consultation with his direct
supervisor shall conduct and document a review of the recovery, resiliency, and
wellness plan every 90 calendar days with the individual and the caregiver, as
applicable. The review shall be signed by the PRS and the individual and, as
applicable, the identified family member or caregiver. Review of the recovery,
resiliency, and wellness plan means the PRS evaluates and updates the
individual's progress every 90 days toward meeting the plan's goals and
documents the outcome of this review in the individual's medical record. For
DMAS to determine that these reviews are complete, the reviews shall (i) update
the goals and objectives as needed to reflect any change in the individual's
recovery as well as any newly identified needs, (ii) be conducted in a manner
that enables the individual to actively participate in the process, and (iii)
be documented by the PRS in the individual's medical record no later than 15 calendar
days from the date of the review.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, DSM-5, 2013, American Psychiatric Association
Length of Stay by Diagnosis and Operation, Southern Region,
1996, HCIA, Inc.
Guidelines for Perinatal Care, 4th Edition, August 1997,
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists
Virginia Supplemental Drug Rebate Agreement Contract and
Addenda
Office Reference Manual (Smiles for Children), prepared by
DMAS' Dental Benefits Administrator, copyright 2010, dated March 13, 2014 (http://www.dmas.virginia.gov/Content_atchs/dnt/VA_SFC_ORM_140313.pdf)
Patient Placement Criteria for the Treatment of
Substance-Related Disorders ASAM PPC-2R, Second Edition, copyright 2001,
American Society of Addiction Medicine
Human Services and Related Fields Approved
Degrees/Experience, Department of Behavioral Health and Developmental Services
(rev. 5/13)
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted on
November 3, 2017, revised on February 9, 2018
12VAC30-60-5. Applicability of utilization review requirements.
A. These utilization requirements shall apply to all Medicaid
covered services unless otherwise specified.
B. Some Medicaid covered services require an approved service
authorization prior to service delivery in order for reimbursement to occur.
1. To obtain service authorization, all providers' information
supplied to the Department of Medical Assistance Services (DMAS), service
authorization contractor, or the behavioral health service authorization
contractor or its contractor shall be fully substantiated throughout
individuals' medical records.
2. Providers shall be required to maintain documentation
detailing all relevant information about the Medicaid individuals who are in providers'
the provider's care. Such documentation shall fully disclose the extent
of services provided in order to support providers' the provider's
claims for reimbursement for services rendered. This documentation shall be
written, signed, and dated at the time the services are rendered unless
specified otherwise.
C. DMAS, or its designee contractor, shall
perform reviews of the utilization of all Medicaid covered services pursuant to
42 CFR 440.260 and 42 CFR Part 456.
D. DMAS shall recover expenditures made for covered services
when providers' documentation does not comport with standards specified in all
applicable regulations.
E. Providers who are determined not to be in compliance with
DMAS requirements shall be subject to 12VAC30-80-130 for the repayment of those
overpayments to DMAS.
F. Utilization review requirements specific to community
mental health services and residential treatment services, including
therapeutic group homes and psychiatric residential treatment facilities
(PRTFs), as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be as
follows:
1. To apply to be reimbursed as a Medicaid provider, the
required Department of Behavioral Health and Developmental Services (DBHDS)
license shall be either a full, annual, triennial, or conditional license.
Providers must be enrolled with DMAS or the BHSA its contractor
to be reimbursed. Once a health care entity has been enrolled as a provider, it
shall maintain, and update periodically as DMAS or its contractor
requires, a current Provider Enrollment Agreement for each Medicaid service
that the provider offers.
2. Health care entities with provisional licenses shall not be
reimbursed as Medicaid providers of community mental health services.
3. Payments shall not be permitted to health care entities
that either hold provisional licenses or fail to enter into a Medicaid
Provider Enrollment Agreement provider contract with DMAS or its
contractor for a service prior to rendering that service.
4. The behavioral health service authorization contractor
DMAS or its contractor shall apply a national standardized set of
medical necessity criteria in use in the industry, such as McKesson
InterQual Criteria, or an equivalent standard authorized in advance by
DMAS. Services that fail to meet medical necessity criteria shall be denied
service authorization.
5. For purposes of Medicaid reimbursement for services
provided by staff in residency, the following terms shall be used after their
signatures to indicate such status:
a. An LMHP-R shall use the term "Resident" after
his signature.
b. An LMHP-RP shall use the term "Resident in
Psychology" after his signature.
c. An LMHP-S shall use the term "Supervisee in Social
Work" after his signature.
12VAC30-60-50. Utilization control: Intermediate Care
Facilities care facilities for the Mentally Retarded (ICF/MR)
persons with intellectual and developmental disabilities and Institutions
institutions for Mental Disease (IMD) mental disease.
A. "Institution for mental disease" or
"IMD" means the same as that term is defined in § 1905(i) of the
Social Security Act.
B. With respect to each Medicaid-eligible resident in
an ICF/MR intermediate care facility for persons with intellectual
and developmental disabilities (ICF/ID) or an IMD in Virginia, a
written plan of care must be developed prior to admission to or authorization
of benefits in such facility, and a regular program of independent professional
review (including a medical evaluation) shall be completed periodically for
such services. The purpose of the review is to determine: the adequacy of the
services available to meet his the resident's current health
needs and promote his the resident's maximum physical well being;
the necessity and desirability of his the resident's continued
placement in the facility; and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Long-term care of residents in such facilities will
be provided in accordance with federal law that is based on the resident's
medical and social needs and requirements.
B. C. With respect to each ICF/MR ICF/ID
or IMD, periodic on-site onsite inspections of the care being
provided to each person receiving medical assistance, by one or more
independent professional review teams (composed of a physician or registered
nurse and other appropriate health and social service personnel), shall be
conducted. The review shall include, with respect to each recipient, a
determination of the adequacy of the services available to meet his the
resident's current health needs and promote his the resident's
maximum physical well-being, the necessity and desirability of continued
placement in the facility, and the feasibility of meeting his the
resident's health care needs through alternative institutional or
noninstitutional services. Full reports shall be made to the state agency by
the review team of the findings of each inspection, together with any
recommendations.
C. D. In order for reimbursement to be made to
a facility for the mentally retarded persons with intellectual and
developmental disabilities, the resident must meet criteria for placement
in such facility as described in 12VAC30-60-360 and the facility must provide
active treatment for mental retardation intellectual or developmental
disabilities.
D. E. In each case for which payment for
nursing facility services for the mentally retarded persons with
intellectual or developmental disabilities or institution for mental
disease services is made under the State Plan:
1. A physician must certify for each applicant or recipient
that inpatient care is needed in a facility for the mentally retarded or an
institution for mental disease. A certificate of need shall be completed
by an independent certification team according to the requirements of
12VAC30-50-130 D 5. Recertification shall occur at least every 60 calendar days
by a physician, or by a physician assistant or nurse practitioner acting within
their scope of practice as defined by state law and under the supervision of a
physician. The certification must be made at the time of admission or, if an
individual applies for assistance while in the facility, before the Medicaid
agency authorizes payment; and
2. A physician, or physician assistant or nurse practitioner
acting within the scope of the practice as defined by state law and under the
supervision of a physician, must recertify for each applicant at least every 365
60 calendar days that services are needed in a facility for the
mentally retarded persons with intellectual and developmental
disabilities or an institution for mental disease.
E. F. When a resident no longer meets criteria
for facilities for the mentally retarded persons with intellectual
and developmental disabilities or for an institution for mental
disease, or no longer requires active treatment in a facility for the
mentally retarded persons with intellectual and developmental
disabilities then the resident must shall be discharged.
F. G. All services provided in an IMD and in
an ICF/MR ICF/ID shall be provided in accordance with guidelines
found in the Virginia Medicaid Nursing Home Manual.
H. All services provided in an IMD shall be provided with
the applicable provider agreement and all documents referenced therein.
I. Psychiatric services in IMDs shall only be covered for
eligible individuals younger than 21 years of age.
J. IMD services provided without service authorization
from DMAS or its contractor shall not be covered.
K. Absence of any of the required IMD documentation shall
result in denial or retraction of reimbursement.
L. In each case for which payment for IMD services is made
under the State Plan:
1. A physician shall certify at the time of admission, or
at the time the IMD is notified of an individual's retroactive eligibility status,
that the individual requires or required inpatient services in an IMD
consistent with 42 CFR 456.160.
2. The physician, or physician assistant or nurse
practitioner acting within the scope of practice as defined by state law and
under the supervision of a physician, shall recertify at least every 60
calendar days that the individual continues to require inpatient services in an
IMD.
3. Before admission to an IMD or before authorization
for payment, the attending physician or staff physician shall perform a medical
evaluation of the individual, and appropriate personnel shall complete a
psychiatric and social evaluation as described in 42 CFR 456.170.
4. Before admission to an IMD or before authorization for
payment, the attending physician or staff physician shall establish a written
plan of care for each individual as described in 42 CFR 441.155 and 42 CFR
456.180.
M. It shall be documented that the individual requiring
admission to an IMD who is younger than 21 years of age, that treatment is medically
necessary, and that the necessity was identified as a result of an independent
certification of need team review. Required documentation shall include the
following:
1. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition 2013, American Psychiatric
Association, and based on an evaluation by a psychiatrist completed within 30
calendar days of admission or if the diagnosis is confirmed, in writing, by a
previous evaluation completed within one year within admission.
2. A certification of the need for services as defined in
42 CFR 441.152 by an interdisciplinary team meeting the requirements of 42
CFR 441.153 or 42 CFR 441.156 and the Psychiatric Treatment of Minors Act (§
16.1-335 et seq. of the Code of Virginia).
N. The use of seclusion and restraint in an IMD shall be
in accordance with 42 CFR 483.350 through 42 CFR 483.376. Each use of a
seclusion or restraint, as defined in 42 CFR 483.350 through 42 CFR
483.376, shall be reported by the service provider to DMAS or its contractor
within one calendar day of the incident.
12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health and
behavioral therapy services for children.
A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:
"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian parent or
guardian is unable to manage the individual's mental, behavioral, or
emotional problems in the home and is actively, within the past two to four
weeks, seeking an out-of-home placement; (iii) a representative of either a
juvenile justice agency, a department of social services (either the state
agency or local agency), a community services board/behavioral health
authority, the Department of Education, or an LMHP, as defined in
12VAC35-105-20, and who is neither an employee of nor consultant to the
intensive in-home (IIH) services or therapeutic day treatment (TDT) provider,
has recommended an out-of-home placement absent an immediate change of
behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 calendar days; or
(v) the treatment team or family assessment planning team (FAPT) recommends IIH
services or TDT for an individual currently who is either: (a) transitioning
out of psychiatric residential treatment facility Level C (PRTF)
services, (b) transitioning out of a therapeutic group home Level A
or B services, (c) transitioning out of acute psychiatric hospitalization,
or (d) transitioning between foster homes, mental health case management,
crisis intervention, crisis stabilization, outpatient psychotherapy, or
outpatient substance abuse services.
"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the services did not treat or resolve the individual's mental
health or behavioral issues.
"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or and adolescents ages 12
through 20 years.
"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.
"Licensed behavior analyst" means a person who has
met the licensing requirements of 18VAC85-150 and holds a valid license issued
by the Department of Health Professions.
"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.
"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B therapeutic
group home; (ii) regular foster home if the individual is currently residing
with his the individual's biological family and, due to his
behavior problems, is at risk of being placed in the custody of the local
department of social services; (iii) treatment foster care if the individual is
currently residing with his the individual's biological family or
a regular foster care family and, due to the individual's behavioral problems,
is at risk of removal to a higher level of care; (iv) Level C psychiatric
residential treatment facility; (v) emergency shelter for the individual
only due either to his mental health or behavior or both; (vi) psychiatric
hospitalization; or (vii) juvenile justice system or incarceration.
"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized progress notes are part of the minimum documentation
requirements and shall convey the individual's status, staff interventions,
and, as appropriate, the individual's progress or lack of progress toward goals
and objectives in the plan of care. The progress notes shall also include, at a
minimum, the name of the service rendered, the date of the service rendered,
the signature and credentials of the person who rendered the service, the
setting in which the service was rendered, and the amount of time or units
required to deliver the service. The content of each progress note shall
corroborate the time or units billed. Progress notes shall be documented for
each service that is billed.
"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.
B. Utilization review requirements for all services in this
section.
1. The services described in this section shall be rendered
consistent with the definitions, service limits, and requirements described in
this section and in 12VAC30-50-130.
2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.
3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.
C. Utilization review of intensive in-home (IIH) services for
children and adolescents.
1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.
2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness that results in significant functional impairments in major life
activities. Individuals must meet at least two of the following criteria on a
continuing or intermittent basis to be authorized for these services:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.
3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.
4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian parent
or guardian within 30 calendar days of initiation of services. The
ISP shall meet all of the requirements as defined in 12VAC30-50-226.
5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.
6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered
in the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the
implementation of the ISP. For services provided outside of the home, there
shall be documentation reflecting therapeutic treatment as set forth in the ISP
provided for that date of service in the appropriately signed and dated
progress notes.
7. These services shall be provided when the clinical needs of
the individual put him the individual at risk for out-of-home
placement, as these terms are defined in this section:
a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,;
or
b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.
The service-specific provider intake shall describe how the
individual meets either subdivision 7 a or 7 b of this subdivision
7 subsection.
8. Services shall not be provided if the individual is no
longer a resident of the home.
9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual and
responsible parent/guardian parent or guardian shall be available
and in agreement to participate in the transition.
10. At least one parent/legal parent or legal
guardian or responsible adult with whom the individual is living must be
willing to participate in the intensive in-home services with the goal of
keeping the individual with the family. In the instance of this service, a
responsible adult shall be an adult who lives in the same household with the
child and is responsible for engaging in therapy and service-related activities
to benefit the individual.
11. The enrolled provider shall be licensed by the Department
of Behavioral Health and Developmental Services (DBHDS) as a provider of
intensive in-home services. The provider shall also have a provider enrollment
agreement with DMAS or its contractor in effect prior to the delivery of this
service that indicates that the provider will offer intensive in-home services.
12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.
13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family individual
or family per week in the initial phase of treatment. It is expected that
the pattern of service provision may show more intensive services and more
frequent contact with the individual and family initially with a lessening or
tapering off of intensity toward the latter weeks of service. Service plans
shall incorporate an individualized discharge plan that describes transition
from intensive in-home to less intensive or nonhome based services.
14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal members or legal
guardian or the individual with the provider, the provider shall discharge the
individual. If the individual continues to need services, then a new intake/admission
intake or admission shall be documented and a new service authorization
shall be required.
15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.
16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430,
the provider shall contact the case manager and provide notification of
the provision of services. In addition, the provider shall send monthly updates
to the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.
17. Emergency assistance shall be available 24 hours per day,
seven days a week.
18. Providers shall comply with DMAS marketing requirements at
12VAC30-130-2000. Providers that DMAS determines violate these marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him the primary care provider of the individual's receipt
of IIH services. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.
D. Utilization review of therapeutic day treatment for
children and adolescents.
1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.
2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following criteria:
a. Children and adolescents who require year-round treatment
in order to sustain behavior or emotional gains.
b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:
(1) This programming during the school day; or
(2) This programming to supplement the school day or school
year.
c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.
d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; or (iv) are extremely depressed or marginally
connected with reality.
e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral emotional or
behavioral problems are so severe that they the children
cannot function in these programs without additional services.
3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.
4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.
5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian parent or guardian within 30 calendar
days of initiation of services and shall meet all requirements of an ISP as
defined in 12VAC30-50-226. Individual progress notes shall be required for each
contact with the individual and shall meet all of the requirements as defined
in 12VAC30-50-130 this section.
6. Such services shall not duplicate those services provided
by the school.
7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. Individuals shall meet at least two of
the following criteria on a continuing or intermittent basis:
a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.
b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.
c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate social
behavior.
8. The enrolled provider of therapeutic day treatment for
child and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.
9. Services shall be provided by an LMHP, LMHP-supervisee,
LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E.
10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.
11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.
12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.
13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.
14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 calendar days of the service
discontinuation date. Providers and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
the individual's parent or legal guardian, shall inform the primary care
provider of the child's the individual's receipt of community
mental health rehabilitative services. The documentation shall include who was
contacted, when the contact occurred, and what information was transmitted. The
parent/legal parent or legal guardian shall be required to give
written consent that this provider has permission to inform the primary care
provider of the child's or adolescent's receipt of community mental health
rehabilitative services.
16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission intake
or admission documentation shall be prepared and a new service
authorization shall be required.
E. Utilization review of community-based services for
children and adolescents younger than 21 years of age (Level A).
1. The staff ratio must be at least one to six during the
day and at least one to 10 between 11 p.m. and 7 a.m. The program
director supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E
(as defined in 12VAC35-105-20). The program director must be employed full
time.
2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.
3. Authorization is required for Medicaid reimbursement.
All community-based services for children and adolescents younger than 21
(Level A) require authorization prior to reimbursement for these services.
Reimbursement shall not be made for this service when other less intensive
services may achieve stabilization.
4. Services must be provided in accordance with an
individual service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.
5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.
6. Such service-specific provider intakes shall be
performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
7. If an individual receiving community-based services for
children and adolescents younger than 21 years of age (Level A) is also
receiving case management services, the provider shall collaborate with the
case manager by notifying the case manager of the provision of Level A services
and shall send monthly updates on the individual's progress. When the
individual is discharged from Level A services, a discharge summary shall be
sent to the case manager within 30 days of the service discontinuation
date. Providers and case managers who are using the same electronic health
record for the individual shall meet requirements for the delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.
F. E. Utilization review of therapeutic behavioral
services group home for children and adolescents younger than 21
years of age (Level B).
1. The staff ratio must be at least one to four during the
day and at least one to eight between 11 p.m. and 7 a.m. approved
by the Office of Licensure at the Department of Behavioral Health and
Developmental Services. The clinical director must shall be a
licensed mental health professional. The caseload of the clinical director must
not exceed 16 individuals including all sites for which the same clinical
director is responsible.
2. The program director must shall be full time
and be a QMHP-C or QMHP-E with a bachelor's degree and at least one year's
clinical experience meet the requirements for a program director as
defined in 12VAC35-46-350.
3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the therapeutic group home shall
meet DBHDS paraprofessional staff qualified paraprofessional in
mental health (QPPMH) criteria, as defined in 12VAC35-105-20. The program/group
therapeutic group home must shall coordinate services with
other providers.
4. All therapeutic behavioral group home
services (Level B) shall be authorized prior to reimbursement for these
services. Services rendered without such prior authorization shall not be
covered.
5. Services must be provided in accordance with an ISP a
comprehensive individual plan of care as defined in 12VAC30-50-130, which
shall be fully completed within 30 calendar days of authorization for
Medicaid reimbursement.
6. Prior to admission, a service-specific provider intake
an assessment shall be performed using all elements specified by DMAS in
12VAC30-50-130.
7. Such service-specific provider intakes assessments
shall be performed by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.
8. If an individual receiving therapeutic behavioral group
home services for children and adolescents younger than 21 years of age (Level
B) is also receiving case management services, the therapeutic behavioral
group home services provider must collaborate with the care
coordinator/case manager by notifying him of the provision of Level B therapeutic
group home services and the Level B therapeutic group home
services provider shall send monthly updates on the individual's treatment
status. When the individual is discharged from Level B services, a discharge
summary shall be sent to the care coordinator/case manager within 30 days of
the discontinuation date.
9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian parent or legally authorized representative, shall inform
the primary care provider of the individual's receipt of these Level B therapeutic
group home services. The documentation shall include who was contacted,
when the contact occurred, and what information was transmitted. If these
individuals are children or adolescents, then the parent/legal guardian parent
or legally authorized representative shall be required to give written
consent that this provider has permission to inform the primary care provider
of the individual's receipt of community mental health rehabilitative services.
G. Utilization review. Utilization reviews for
community-based services for children and adolescents younger than 21 years of
age (Level A) and therapeutic behavioral services for children and adolescents
younger than 21 years of age (Level B) shall include determinations whether
providers meet all DMAS requirements, including compliance with DMAS marketing
requirements. Providers that DMAS determines have violated the DMAS marketing
requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.
H. F. Utilization review of behavioral therapy
services for children individuals younger than 21 years of age.
1. In order for Medicaid to cover behavioral therapy services,
the provider shall be enrolled with DMAS or its contractor as a Medicaid
provider. The provider enrollment agreement shall be in effect prior to the
delivery of services for Medicaid reimbursement.
2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.
3. Behavioral therapy services require service authorization.
Services shall be authorized only when eligibility and medical necessity
criteria are met.
4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), LMHP,
LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
behaviors targeted for treatment with their frequency, duration, and intensity)
and describing how service needs can best be met through behavioral therapy.
The service-specific provider intake shall be conducted face-to-face in the
individual's residence with the individual and parent or guardian.
5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP as defined in
12VAC30-50-130 shall be fully completed, signed, and dated by an LBA, LABA,
LMHP, LMHP-R, LMHP-RP, or LMHP-S. Every three months, the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S shall review the ISP, modify the ISP as appropriate,
and update the ISP, and all of these activities shall occur with the individual
in a manner in which the individual may participate in the process. The ISP
shall be rewritten at least annually.
6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.
7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision of unlicensed staff shall
occur at least weekly. As documented in the individual's medical record,
clinical supervision shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. Clinical supervision shall be documented by, at a
minimum, the contemporaneously dated signature of the clinical supervisor.
8. Family training involving the individual's family and
significant others to advance the treatment goals of the individual shall be
provided when (i) the training with the family member or significant other is
for the direct benefit of the individual, (ii) the training is not aimed at
addressing the treatment needs of the individual's family or significant
others, (iii) the individual is present except when it is clinically
appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.
9. The following shall not be covered under this service:
a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.
b. Services other than the initial service-specific provider intake
that are provided but are not based upon the individual's ISP or linked to a
service in the ISP. Time not actively involved in providing services directed
by the ISP shall not be reimbursed.
c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.
d. Sessions that are conducted for family support, education,
recreational, or custodial purposes, including respite or child care.
e. Services that are provided by a provider but are rendered
primarily by a relative or guardian who is legally responsible for the
individual's care.
f. Services that are provided in a clinic or provider's office
without documented justification for the location in the ISP.
g. Services that are provided in the absence of the individual
or a parent or other authorized caregiver identified in the ISP with the
exception of treatment review processes described in subdivision 12 e of this
subsection, care coordination, and clinical supervision.
h. Services provided by a local education agency.
i. Provider travel time.
10. Behavioral therapy services shall not be reimbursed
concurrently with community mental health services described in 12VAC30-50-130 B
5 C or 12VAC30-50-226, or behavioral, psychological, or psychiatric
therapeutic consultation described in 12VAC30-120-756, 12VAC30-120-1000,
or 12VAC30-135-320.
11. If the individual is receiving targeted case management
services under the Medicaid state plan State Plan (defined in
12VAC30-50-410 through 12VAC30-50-491 12VAC30-50-491), the
provider shall notify the case manager of the provision of behavioral therapy
services unless the parent or guardian requests that the information not be
released. In addition, the provider shall send monthly updates to the case
manager on the individual's status pursuant to a valid release of information.
A discharge summary shall be sent to the case manager within 30 days of the
service discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.
12. Other standards to ensure quality of services:
a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.
b. Individual-specific services shall be directed toward the
treatment of the eligible individual and delivered in the family's residence
unless an alternative location is justified and documented in the ISP.
c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.
d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.
e. Billable time is permitted for the LBA, LABA, LMHP, LMHP-R,
LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision 12 c of this subsection.
13. Failure to comply with any of the requirements in
12VAC30-50-130 or in this section shall result in retraction.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)
Department of Medical Assistance Services Provider Manuals (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManuals):
Virginia Medicaid Nursing Home Manual
Virginia Medicaid Rehabilitation Manual
Virginia Medicaid Hospice Manual
Virginia Medicaid School Division Manual
Development of Special Criteria for the Purposes
of Pre-Admission Screening, Medicaid Memo, October 3, 2012, Department of
Medical Assistance Services
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association
Patient Placement Criteria for the Treatment of
Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001,
American Society on Addiction Medicine, Inc.
Medicaid Special Memo, Subject: New Service
Authorization Requirement for an Independent Clinical Assessment for Medicaid
and FAMIS Children's Community Mental Health Rehabilitative Services, dated
June 16, 2011, Department of Medical Assistance Services
Medicaid Special Memo, Subject: Changes to Children
Community Mental Health Rehabilitative Services - Children's Services, July 1,
2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Medicaid Special Memo, Subject: Changes to
Community Mental Health Rehabilitative Services - Adult-Oriented Services, July
1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical
Assistance Services
Approved
Degrees in Human Services and Related Fields for QMHP Registration, adopted
November 3, 2017, revised February 9, 2018
Part XIV
Residential Psychiatric Treatment for Children and Adolescents (Repealed)
12VAC30-130-850. Definitions. (Repealed.)
The following words and terms when used in this part shall
have the following meanings, unless the context clearly indicates otherwise:
"Active treatment" means implementation of a
professionally developed and supervised individual plan of care that must be
designed to achieve the recipient's discharge from inpatient status at the
earliest possible time.
"Certification" means a statement signed by a
physician that inpatient services in a residential treatment facility are or
were needed. The certification must be made at the time of admission, or, if an
individual applies for assistance while in a mental hospital or residential
treatment facility, before the Medicaid agency authorizes payment.
"Comprehensive individual plan of care" or
"CIPOC" means a written plan developed for each recipient in
accordance with 12VAC30-130-890 to improve his condition to the extent that
inpatient care is no longer necessary.
"Emergency services" means a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.
"Individual" or "individuals" means a
child or adolescent younger than 21 years of age who is receiving a service
covered under this part of this chapter.
"Initial plan of care" means a plan of care established
at admission, signed by the attending physician or staff physician, that meets
the requirements in 12VAC30-130-890.
"Inpatient psychiatric facility" or
"IPF" means a private or state-run freestanding psychiatric hospital
or psychiatric residential treatment center.
"Recertification" means a certification for each
applicant or recipient that inpatient services in a residential treatment
facility are needed. Recertification must be made at least every 60 days by a
physician, or physician assistant or nurse practitioner acting within the scope
of practice as defined by state law and under the supervision of a physician.
"Recipient" or "recipients" means the
child or adolescent younger than 21 years of age receiving this covered
service.
"RTC-Level C" means a psychiatric residential
treatment facility (Level C).
"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in an IPF that are billed by the arranged
practitioners separately from the IPF per diem.
12VAC30-130-860. Service coverage; eligible individuals;
service certification. (Repealed.)
A. Residential treatment programs (Level C) shall be
24-hour, supervised, medically necessary, out-of-home programs designed to
provide necessary support and address the special mental health and behavioral
needs of a child or adolescent in order to prevent or minimize the need for
more intensive inpatient treatment. Services must include, but shall not be
limited to, assessment and evaluation, medical treatment (including drugs),
individual and group counseling, and family therapy necessary to treat the child.
B. Residential treatment programs (Level C) shall provide
a total, 24 hours per day, specialized form of highly organized, intensive and
planned therapeutic interventions that shall be utilized to treat some of the
most severe mental, emotional, and behavioral disorders. Residential treatment
is a definitive therapeutic modality designed to deliver specified results for
a defined group of problems for children or adolescents for whom outpatient day
treatment or other less intrusive levels of care are not appropriate, and for
whom a protected, structured milieu is medically necessary for an extended
period of time.
C. Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B) and Community-Based Services for Children and
Adolescents under 21 (Level A) must be therapeutic services rendered in a
residential type setting such as a group home or program that provides
structure for daily activities, psychoeducation, therapeutic supervision and
mental health care to ensure the attainment of therapeutic mental health goals
as identified in the individual service plan (plan of care). The child or
adolescent must have a medical need for the service arising from a condition
due to mental, behavioral or emotional illness that results in significant functional
impairments in major life activities.
D. Active treatment shall be required. Residential
Treatment, Therapeutic Behavioral and Community-Based Services for Children and
Adolescents under age 21 shall be designed to serve the mental health needs of
children. In order to be reimbursed for Residential Treatment (Level C),
Therapeutic Behavioral Services for Children and Adolescents under 21 (Level
B), and Community-Based Services for Children and Adolescents under 21 (Level
A), the facility must provide active mental health treatment beginning at
admission and it must be related to the recipient's principle diagnosis and
admitting symptoms. To the extent that any recipient needs mental health
treatment and his needs meet the medical necessity criteria for the service, he
will be approved for these services. These services do not include
interventions and activities designed only to meet the supportive nonmental
health special needs, including but not limited to personal care, habilitation
or academic educational needs of the recipients.
E. An individual eligible for Residential Treatment
Services (Level C) is a recipient under the age of 21 years whose treatment
needs cannot be met by ambulatory care resources available in the community,
for whom proper treatment of his psychiatric condition requires services on an
inpatient basis under the direction of a physician.
An individual eligible for Therapeutic Behavioral Services
for Children and Adolescents under 21 (Level B) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a Licensed Mental Health Professional.
An individual eligible for Community-Based Services for
Children and Adolescents under 21 (Level A) is a child, under the age of 21
years, for whom proper treatment of his psychiatric condition requires less
intensive treatment in a structured, therapeutic residential program under the
direction of a qualified mental health professional. The services for all three
levels can reasonably be expected to improve the child's or adolescent's
condition or prevent regression so that the services will no longer be needed.
F. In order for Medicaid to reimburse for Residential
Treatment (Level C), Therapeutic Behavioral Services for Children and
Adolescents under 21 (Level B), and Community-Based Services for Children and
Adolescents under 21 (Level A), the need for the service must be certified
according to the standards and requirements set forth in subdivisions 1 and 2
of this subsection. At least one member of the independent certifying team must
have pediatric mental health expertise.
1. For an individual who is already a Medicaid recipient
when he is admitted to a facility or program, certification must:
a. Be made by an independent certifying team that includes
a licensed physician who:
(1) Has competence in diagnosis and treatment of pediatric
mental illness; and
(2) Has knowledge of the recipient's mental health history
and current situation.
b. Be signed and dated by a physician and the team.
2. For a recipient who applies for Medicaid while an
inpatient in the facility or program, the certification must:
a. Be made by the team responsible for the plan of care;
b. Cover any period of time before the application for
Medicaid eligibility for which claims for reimbursement by Medicaid are made;
and
c. Be signed and dated by a physician and the team.
12VAC30-130-870. Preauthorization. (Repealed.)
A. Authorization for Residential Treatment (Level C) shall
be required within 24 hours of admission and shall be conducted by DMAS or its
utilization management contractor using medical necessity criteria specified by
DMAS. At preauthorization, an initial length of stay shall be assigned and the
residential treatment provider shall be responsible for obtaining authorization
for continued stay.
B. DMAS will not pay for admission to or continued stay in
residential facilities (Level C) that were not authorized by DMAS.
C. Information that is required in order to obtain
admission preauthorization for Medicaid payment shall include:
1. A completed state-designated uniform assessment
instrument approved by the department.
2. A certification of the need for this service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the recipient;
b. Proper treatment of the recipient's psychiatric
condition requires services on an inpatient basis under the direction of a
physician; and
c. The services can reasonably be expected to improve the
recipient's condition or prevent further regression so that the services will
not be needed.
3. Additional required written documentation shall include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental Retardation,
Axis III (General Medical Conditions), Axis IV (Psychosocial and Environmental
Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the seven
days immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
D. Continued stay criteria for Residential Treatment
(Level C): information for continued stay authorization (Level C) for Medicaid
payment must include:
1. A state uniform assessment instrument, completed no more
than 90 days prior to the date of submission;
2. Documentation that the required services are provided as
indicated;
3. Current (within the last 30 days) information on
progress related to the achievement of treatment goals. The treatment goals
must address the reasons for admission, including a description of any new
symptoms amenable to treatment;
4. Description of continued impairment, problem behaviors,
and need for Residential Treatment level of care.
E. Denial of service may be appealed by the recipient
consistent with 12VAC30-110-10 et seq.; denial of reimbursement may be appealed
by the provider consistent with the Administrative Process Act (§ 2.2-4000 et
seq. of the Code of Virginia).
F. DMAS will not pay for services for Therapeutic
Behavioral Services for Children and Adolescents under 21 (Level B), and
Community-Based Services for Children and Adolescents under 21 (Level A) that
are not prior authorized by DMAS.
G. Authorization for Level A and Level B residential
treatment shall be required within three business days of admission.
Authorization for services shall be based upon the medical necessity criteria
described in 12VAC30-50-130. The authorized length of stay must not exceed six
months and may be reauthorized. The provider shall be responsible for documenting
the need for a continued stay and providing supporting documentation.
H. Information that is required in order to obtain
admission authorization for Medicaid payment must include:
1. A current completed state-designated uniform assessment
instrument approved by the department. The state designated uniform assessment
instrument must indicate at least two areas of moderate impairment for Level B
and two areas of moderate impairment for Level A. A moderate impairment is
evidenced by, but not limited to:
a. Frequent conflict in the family setting, for example,
credible threats of physical harm.
b. Frequent inability to accept age appropriate direction
and supervision from caretakers, family members, at school, or in the home or
community.
c. Severely limited involvement in social support; which
means significant avoidance of appropriate social interaction, deterioration of
existing relationships, or refusal to participate in therapeutic interventions.
d. Impaired ability to form a trusting relationship with at
least one caretaker in the home, school or community.
e. Limited ability to consider the effect of one's
inappropriate conduct on others, interactions consistently involving conflict,
which may include impulsive or abusive behaviors.
2. A certification of the need for the service by the team
described in 12VAC30-130-860 that:
a. The ambulatory care resources available in the community
do not meet the specific treatment needs of the child;
b. Proper treatment of the child's psychiatric condition
requires services in a community-based residential program; and
c. The services can reasonably be expected to improve the
child's condition or prevent regression so that the services will not be
needed.
3. Additional required written documentation must include
all of the following:
a. Diagnosis, as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV, effective October 1, 1996),
including Axis I (Clinical Disorders), Axis II (Personality Disorders/Mental
Retardation), Axis III (General Medical Conditions), Axis IV (Psychosocial and
Environmental Problems), and Axis V (Global Assessment of Functioning);
b. A description of the child's behavior during the 30 days
immediately prior to admission;
c. A description of alternative placements tried or
explored and the outcomes of each placement;
d. The child's functional level and clinical stability;
e. The level of family support available; and
f. The initial plan of care as defined and specified at
12VAC30-130-890.
I. Denial of service may be appealed by the child
consistent with 12VAC30-110; denial of reimbursement may be appealed by the
provider consistent with the Administrative Process Act (§ 2.2-4000 et seq. of
the Code of Virginia).
J. Continued stay criteria for Levels A and B:
1. The length of the authorized stay shall be determined by
DMAS or its contractor.
2. A current Individual Service Plan (ISP) (plan of care)
and a current (within 30 days) summary of progress related to the goals and
objectives on the ISP (plan of care) must be submitted for continuation of the
service.
3. For reauthorization to occur, the desired outcome or
level of functioning has not been restored or improved, over the time frame
outlined in the child's ISP (plan of care) or the child continues to be at risk
for relapse based on history or the tenuous nature of the functional gains and
use of less intensive services will not achieve stabilization. Any one of the
following must apply:
a. The child has achieved initial service plan (plan of
care) goals but additional goals are indicated that cannot be met at a lower
level of care.
b. The child is making satisfactory progress toward meeting
goals but has not attained ISP goals, and the goals cannot be addressed at a
lower level of care.
c. The child is not making progress, and the service plan
(plan of care) has been modified to identify more effective interventions.
d. There are current indications that the child requires
this level of treatment to maintain level of functioning as evidenced by
failure to achieve goals identified for therapeutic visits or stays in a
nontreatment residential setting or in a lower level of residential treatment.
K. Discharge criteria for Levels A and B.
1. Reimbursement shall not be made for this level of care
if either of the following applies:
a. The level of functioning has improved with respect to
the goals outlined in the service plan (plan of care) and the child can reasonably
be expected to maintain these gains at a lower level of treatment; or
b. The child no longer benefits from service as evidenced
by absence of progress toward service plan goals for a period of 60 days.
12VAC30-130-880. Provider qualifications. (Repealed.)
A. Providers must provide all Residential Treatment
Services (Level C) as defined within this part and set forth in 42 CFR Part 441
Subpart D.
B. Providers of Residential Treatment Services (Level C)
must be:
1. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric hospital
accredited by the Joint Commission on Accreditation of Healthcare
Organizations;
2. A residential treatment program for children and
adolescents licensed by DMHMRSAS that is located in a psychiatric unit of an
acute general hospital accredited by the Joint Commission on Accreditation of
Healthcare Organizations; or
3. A psychiatric facility that is (i) accredited by the
Joint Commission on Accreditation of Healthcare Organizations, the Commission
on Accreditation of Rehabilitation Facilities, the Council on Quality and
Leadership in Supports for People with Disabilities, or the Council on
Accreditation of Services for Families and Children and (ii) licensed by DMHMRSAS
as a residential treatment program for children and adolescents.
C. Providers of Community-Based Services for Children and
Adolescents under 21 (Level A) must be licensed by the Department of Social
Services, Department of Juvenile Justice, or Department of Education under the
Standards for Interdepartmental Regulation of Children's Residential Facilities
(22VAC42-10).
D. Providers of Therapeutic Behavioral Services (Level