In Chapter II of the Draft Manual, there seems to be some discrepency about the level of supervision required for certain services.  For PSR and MHSS, it appears that the language has been changed on pages 14 & 15 to indicate that services have to be supervised by LMHP-type individuals.  On page 15 of the manual, it states that, "DBHDS requires the supervision of services that are supportive in nature such as psychosocial rehabilitation or MHSS shall be provided an by a LMHP, LMHP-S, LMHP-R, LMHP-RP or QMHP-A."  As these programs are not inherently clinical in nature, there is a significant shortage of LMHP-types in many parts of the state and their level of compensation would not be feasible in a program such as PSR in which the reimbursement rate is so low, we support QMHP supervision of these programs.   These services are reviewed every six months by LMHP-types and LMHP-types are available to staff more clinical issues as they arise.  This should be sufficient for these services. 

Language in Chapter IV seems to state that LMHP-types can review services through a chart review for MHSS and PSR.  We would like some clarification around this making sure that we are understanding correctly that doing a documented chart review is sufficient for determining medical necessity. 

Thank you for your consideration of these comments.

Greetings,

The CMHRS Medicaid Provider Manual Drafts made available for public viewing, have provided helpful informative changes. Respectfully, I would like to ask for clarification addressing the below statements in regard to supervision for MHSS services. There is a discrepancy in the language relating to QMHP-A providing supervision for MHSS services. We would not support requiring LMHP types to solely conduct supervision for MHSS and PSR services. It would not be cost effective for the MHSS and PSR programs.  

Chapter II bullet 3 states, “Mental Health Skill-building Services providers must be licensed by DBHDS as a provider of Mental Health Community Support services. Mental Health Skill-Building services shall be provided by an LMHP, LMHP-S, LMHP-R, or LMHP-RP; a QMHP-A, QMHP-C, QMHP-E under the supervision of an LMHP, LMHP-R, LMHPRP or LMHP-S; or, a QPPMH under the supervision of a QMHP-A, a QMHP-C, QMHP-E, or an LMHP, LMHP-S, LMHP-R, or LMHP-RP”.

Chapter VI pg. 14, bullet 10 states “DBHDS requires the supervision of services that are supportive in nature such as psychosocial rehabilitation or MHSS shall be provided an “sic” LMHP, LMHP-S, LMHP-R, LMH-RP or QMHP-A”.  We would support Chapter VI pg 14 bullet 10

Thank you for your consideration

Best Regards

Norfolk supports the comments previously made by Lisa Snider of Loudoun County MHSADS.

Chap IV p. 14 - Required reviews & updates, including the annual review & update of the Comprehensive Needs Assessment are not billable. It is our understandinf that an annual assessment must be billed which would reuire a new Comprehensive Needs Assessment. Is it being suggested that an LMHP can just comlete an addendum for the annual assessment. This is not consistent with material presented on training for the Comprehensive Needs Assessment. 

DMAS’s willingness to streamline the assessment and intake process for individuals receiving services is greatly appreciated and we believe this will facilitate a more timely delivery of services.  Additional efficiency could be enacted for both providers and DMAS if a single assessment rate were established for all CMHR services with the exception of Mental Health Case Management, vs. billing as service delivery time for the highest paying service an individual receives.  This rate should be established with respect for the additional education, credentials, and clinical knowledge of the licensed/licensed eligible clinicians required to conduct these assessments and with recognition that the increasing expectations for involvement of LMHP/LMHP-types across a variety of services has impacted the pool of available clinical staff, with a ripple effect of impact on ability to offer services. The recommendation is to use CPT code 90791 or a similar code for this annual assessment.

We further recommend that the expectation for the quarterly review of an ISP not include the specification that this occur on the 90th calendar day.  Simply specifying that this is a quarterly requirement, with a 15 day grace period (other than for case management which requires a longer grace period) will increase uniformity across DMAS requirements (e.g. with DD Services) without any negative impact to individuals served.

In addition, there are a few points regarding which clarification is requested.  First, pages 21, 33-34, 49-50, and 56 specify a need for review and demonstration of continued need at the six month mark for the following services:  MHSS, PSR, and ICT.  In situations where a single provider provides more than one of these services to a particular individual, please clarify that a single review that speaks to the person’s need for the various services is acceptable; this is apparent in the FAQs, but not in the manual itself.  This would further streamline the time of LMHPs/LMHP-types, eliminate redundant documentation and potentially streamline time for individuals served (i.e. when a face-to-face review is indicated).

Second, page 49 of Chapter IV states that individuals who meet the medical necessity criteria to receive ICT services “may also simultaneously be approved for” Case Management services.  However, Licensure regulation 12VAC35-105-1410 clearly states that case management services are part of ICT/PACT service requirements and providers are held to that standard.

Inconsistent information is present regarding expectations for the content of ISPs.  Although page 23 of Chapter describes basic components of an ISP and then refers the reader to DBHDS Licensing requirements of 12VAC35-105-665, pages 7 and 24-25 articulate a series of requirements not wholly consistent with the Licensing requirements.  The effort to increase consistency with Licensing’s requirements is also appreciated and we request that there be further collaboration with DBHDS to ensure the two sets of expectations are consistent. 

Finally, although it is our understanding that credentials are now being defined by the Department of Health Professions, some of the definitions refer the reader to the Licensing regulations, which have not yet been completely updated to match those of the DHP. 

The Virginia Leadership Network proposes DMAS allow Certified Peer Recovery Specialists (CPRS) to bill for services offered at Psychosocial Rehabilitation (H2017). 

We propose Chapter IV, p. 44 to be amended as follows:

Service Requirements.

1. Psychosocial rehabilitation services may be provided by an LMHP, LMHP-S, LMHP-R, LMHP-RP, QMHP-A, QMHP-C, QMHP-E, QPPMH, or a Certified Peer Recovery Specialist under the supervision of a QMHP-A, QMHP-C, LMHP, LMHP-S, LMHP-R, or LMHP-RP. 

We propose similar language in Chapter II also be amended to ensure congruence in the language throughout the manual. 

Respectfully submitted,

Wanda L. Reese on behalf of Virginia Leadership Network

Chapter II and IV  -  A definition of a qualified mental health case manager is missing from the CMHRS manual.  All other qualified mental health provider types are defined.

Chapter IV, page 14  - please add clarification as to why SSPIs and or Psychiatric Diagnostic Interviews, (containing the 15 elements), completed prior to 1/1/19, cannot be used as a CNA.

Chapter II page 14  - PSR -  please add clarification regarding the added statement : under the supervision of an LMHP, LMHP-R, LMHP-RP or LMHP-S”…   What level of supervision is the LMHP type required to provide?

Chapter IV, page 49  -  This new statement is confusing and contradicts licensing regulation for ICT as case management is already a part of PACT/ICT.

Effective January 30, 2015 individuals who meet the medical necessity criteria to receive ICT services may also simultaneously be approved for either Mental Health Case Management or Treatment Foster Care Case Management services.

Thank you.

Chapter IV

1. Pg. 20 – Please clarify that a Comprehensive Needs Assessment is only “outdated” following a lapse of all (or the only) CMHRS service that are being provided within the same agency. A Comprehensive Needs Assessment can remain valid if providing multiple services and only one of those services has lapsed (see 11/20/19 Medicaid Memo, pg. 5 and training slides 42-44).
2. Pg. 20 – Please clarify the “annual review and update” requirement:

   • The language in the 11/20/18 Medicaid Memo reads “At a minimum, the Comprehensive Needs Assessment must be reviewed annually”. However, as written here it can be interpreted that an “annual review and update” is required every 365 days from the date of the initial Comprehensive Needs Assessment regardless of when the last face-to-face Review and Update (Reassessment) was completed. Our understanding from the Memo and training was that as long as the Comprehensive Needs Assessment has been reviewed and updated by a face-to-face reassessment within the last year, it remains a “valid” assessment.

   • Providers have been required by the BHSA and MCOs to bill for an assessment annually in order to continue services beyond 12 months. Will the BHSA and MCOs continue to reimburse for services after 12 months without receiving a claim for an Assessment?

3. Pg. 20-21 – Please clarify the need for a “new” Assessment verses just a “review and update” when services have not been provided for 31 calendar days.  Pg. 20 indicates that an Assessment is no longer valid when the provider has not provided a CMHRS service recommended by the Comprehensive Needs Assessment in the past 31 calendar days.  However, pg. 21 indicates that if services have not been initiated within the past 31 calendar days, they only need to “review and update” the Assessment as long as the Assessment is still valid.  When would the Assessment be valid in this scenario since you’ve already defined a lapse in service of 31 calendar days as rendering the Assessment "outdated" and "invalid"?  Is a “review and update” only allowed when more than one CMHRS service was recommended in the Comprehensive Needs Assessment and only one of those services was not initiated within the 31 days?

4. Pg. 21 – “A LMHP, LMHP-R, LMHP-RP or LMHP-S may update an existing, valid Comprehensive Needs Assessment as defined above to continue providing a CMHRS service after a member is discharged from the service”.  Does this only apply when 1) the individual is discharged for reasons other than a 31+ day lapse in service since that automatically invalidates the Assessment, or 2) if providing more than one CMHRS service and only discharged from one service?

The definition of qualified mental health case manager was not included in  the providers credential section chapter 2 page 10.

The activities/services provided by a case manager include assessment and planning of services and development of a person centered ISP.  Case manager’s play an integral role in assessing the functional needs of individuals served include  areas of daily living, coping skills, mental and physical health care practices, time management, money management ,  problem solving/counseling.  Therefore, after the initial CNA,    the MHCM should be able to complete the addendum for additional CMHRS services with review and certification by LMHP or LMHP-E, that the individual meets medical necessity.

Please provide clarification of CNA  after discharge.  Does this mean if an individual is discharged from a program, not receiving any other  CMHRS services and then decides they want to return to services, a new CNA  is not required as long as the current CNA  is valid?  How is this different then a lapse of 31 days?

Draft regulation states that a single CNA shall be used per provider.  We have received written communication they we may conduct separate CNAs per CMHRS based on our staffing and business operations.  Please clarify.

The DLA 20 is a functional assessment and Outcome measure proven to reliably estimate individual functioning in 20 different areas of daily living.  The DLA 20 should be allowed to serve as the assessment/addendum for CMHRS particularly MHSB and PSR.

1. Chapter IV, pg 9: There is no definition for a Qualified Mental Health Case Manager (QCM) provided. This omission should be corrected.

2. Chapter IV, pg 13: Assessments completed by a qualified mental health case manager may not be used as a Comprehensive Needs Assessment or updated by a LMHP, LMHP-R, LMHP-S, or LMHP-RP to be used as a Comprehensive Needs Assessment.

The proposed guideline should be revised, as it does not recognize the value of assessments completed by QCMs. Given the comprehensive nature of work completed by QCMs, especially in the identification and monitoring of services for individuals, the assessments and reassessments they complete are invaluable in service provision and contain information often unknown an unattainable by Providers with less frequent access/contact. As such, LMHPs and LMHP-types would be more than able to update an assessment or reassessment completed by a QCM to determine medical necessity in the CNA process. The inclusive nature of work done by QCMs would be beyond beneficial, time efficient and aid in effective treatment planning with the LMHP/LMHP-type when evaluating an individual’s need for continued care. This would also allow reciprocal use of assessments completed by QCMs across qualifying programs and DBHDS-licensed providers. The proposed guideline should be reworded to read (or follow as such):

Assessments completed by a qualified mental health case managers may not be used as a Comprehensive Needs Assessment or if updated by completed in conjunction with or under the supervision of an LMHP, LMHP-R, LMHP-S, or LMHP-RP to be used as a Comprehensive Needs Assessment.

3. Along with its ongoing efforts to align regulatory requirements, language, etc., DMAS should work with the DBHDS Office of Licensing to ensure applicable areas of regulation are updated expeditiously to coincide with all pertinent updates/changes (e.g., SSPI = CNA).