7 comments
|
Proposed Changes |
|
|
12VAC30-60-181 |
Add in CSAC for 3.7- In 3.7, clients must see physician or extender for physical within 24 hours of admission. There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) This will increase availability as licensed staff are difficult to recruit and not available to work weekends. |
|
12VAC30-60-181 |
Add in CSAC for 3.7- In 3.7, clients must see physician or extender for physical within 24 hours of admission. There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) This will increase availability as licensed staff are difficult to recruit and not available to work weekends. |
|
12VAC30-60-181 |
This section is for an ISP. A Medication Assisted Treatment assessment does not belong here. It is not appropriate to have an assessment in an ISP. ISP is for client goals and must be in client language. Adding in an assessment here is inappropriate .
The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
|
|
|
"Credentialed addiction treatment
Segment above needs to be added back in. CSACs provide essential services and should be allowed to create a substance related ISP with oversight from licensed staff. If this is left in, must address that CSACs can perform ISP’s with oversight.
If CSACs cannot complete an ISP (with sign off by licensed provider) all “Primary Counselor” staff must be licensed. This would be cost prohibitive. All BH2s would need to be converted to senior clinicians. In addition, recruitment would be impossible. Statewide, there is already a shortage of licensed staff. By adding this requirement, it will make it impossible to recruit and hire essential staff, thus reducing services available during an opioid crisis. At the very least, allow CSACs with sign off by licensed to complete ISP and MDA assessment in 3.1, 3.3, 3.5, 3.7. In these setting, there are other credentialed staff on site an available ensure the client has his/her needs met.
Add in Licensed Nurse Practitioner with experience or training in addiction medicine- Across the State, many nurse practitioners (adult or family) have extensive training and experience in addiction medicine. They should be included. |
|
12VAC30-130-5040. Covered services: requirements; limits; standards. |
ARTS services require a primary substance use diagnosis, and the purpose for treatment shall be related to the substance use disorder.. A CATP or a CSAC under the supervision of a CATP shall complete the multidimensional assessments. A CATP must sign and date assessments performed by a CSAC within one business day.
Evidence based approaches ( to include David Mee-Lee/chief editor of the ASAM criteria) acknowledge that individuals with co-occurring disorders can have multiple primary disorders. One is not primary over the other. Clarify wording to reflect this. The individual must have a primary substance use disorder, but that does not mean he cannot also have another primary disorder. |
|
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services |
Leave it at 12 months versus one year. 12 month is more definitive |
|
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services |
5. Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.
Good |
|
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services |
9. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either onsite or through referral.
This says to test. The individual has the right to choose. This is too prescriptive. A test can be offered |
|
12VAC30-130-5140. Covered services: medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7). |
A. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) settings for services. The facility-based
3.7 has extensive additional requirements to include expensive medical personnel. Rates for this service need to be reviewed. |
|
12VAC30-130-5140. Covered services: medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7). |
1. Daily clinical services provided by an interdisciplinary team to involve appropriate medical and nursing services, as well as individual, group, and family activity services, as appropriate to the needs and current functioning level of the individual.
It is not clinically appropriate and may often be contraindicated to begin therapy during acute withdrawal. |
Other areas that need to be changed.
Take out treatment history from ISP
It does not belong here. It is not appropriate to have an assessment in an ISP. ISP is for client goals and must be in client language. Add treatment history as part of MDA assessment. Adding in an assessment is inappropriate.
The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
Discharge Planning sections for 3.3, 3.5, 3.7 are confusing and unrealistic. The time frames, especially for 3.7 is unrealistic and will result in lack on continuity of care. Programs cannot wait for the MCO to approve a discharge plan before talking to potential future providers in a short term 7 day program. This needs to be revamped.
Need to change time frame for the MDA Assessment in 3.7 programs to reflect that it is inappropriate to attempt to conduct a full psycho social history while the individual is in the acute phases of withdrawal. While the current regs allow the PDE to be delayed due to individual illness/withdrawal, the service authorization for is still expected in 24 hour but includes information that is gathered in the MDA. Specify that providers may complete service authorization form dimension 1 and 2 with 24 hours and complete the rest in 72 hours. Otherwise, the provider has to take the chance of not being paid or else must require a sick client to participate.
May 19, 2020
To Whom It May Concern,
On behalf of the VACSB MH and SUD Councils, thank you for the opportunity to comment on the potential impact of the proposed ARTS updates within the Virginia State Plan for Medical Assistance. The Council's comments reflect those of its members.
Sincerely,
Leslie Stephen, LCSW
Chair – VACSB Mental Health Council
12VAC30-60-181. Utilization review of addiction, and recovery, and treatment services
E2. All ISPs shall be completed and contemporaneously signed and dated by the credentialed addiction treatment professional CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.
--Allow CSACs to complete ISP for tx in ASAM Levels 1, 2, and 2.5.
--Add in CSAC for 3.7- In 3.7, clients must see physician or extender for physical within 24 hours of admission. There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) . This will increase availability as licensed staff are difficult to recruit and not available to work weekends.
F. This section is for an ISP. A Medication assisted Treatment assessment does not belong here. It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language. Adding in an assessment in appropriate.
---The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
12VAC30-130-5020. Definitions.
"Credentialed addiction treatment professionals" professional" or "CATP" means an individual licensed or registered with the appropriate board in the following roles: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) physician extenders with experience or training in addiction medicine; (iii) a licensed psychiatrist; (iii) (iv) a licensed clinical psychologist; (iv) (v) a licensed clinical social worker; (v) (vi) a licensed professional counselor; (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) a licensed marriage and family therapist; (ix) (x) a licensed substance abuse treatment practitioner; (x) residents (xi) a resident who is under the supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and in a residency approved by is registered with the Virginia Board of Counseling; (xi) residents (xii) a resident in psychology who is under supervision of a licensed clinical psychologist and in a residency approved by is registered with the Virginia Board of Psychology (18VAC125-20-10); (xii) supervisees or (xiii) a supervisee in social work who is under the supervision of a licensed clinical social worker approved by and is registered with the Virginia Board of Social Work (18VAC140-20-10); or (xiii) an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certification as a substance abuse counseling-assistant (CSAC-A) (18VAC115-30-10) under supervision of licensed provider and within his scope of practice, as described in §§ 54.1-3507.1 and 54.1-3507.2 of the Code of Virginia.
---Clarify that in case where the provider is both the CSAC and a LMHP, the provider is categorized as a CATP and does not require additional sign-off on multi-dimensional assessments or ISPs.
"Credentialed addiction treatment professionals" professional" or "CATP" means an individual licensed or registered with the appropriate board in the following roles: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) physician extenders with experience or training in addiction medicine; (iii) a licensed psychiatrist; (iii) (iv) a licensed clinical psychologist; (iv) (v) a licensed clinical social worker; (v) (vi) a licensed professional counselor; (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) a licensed marriage and family therapist; (ix) (x) a licensed substance abuse treatment practitioner; (x) residents (xi) a resident who is under the supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and in a residency approved by is registered with the Virginia Board of Counseling; (xi) residents (xii) a resident in psychology who is under supervision of a licensed clinical psychologist and in a residency approved by is registered with the Virginia Board of Psychology (18VAC125-20-10); (xii) supervisees or (xiii) a supervisee in social work who is under the supervision of a licensed clinical social worker approved by and is registered with the Virginia Board of Social Work (18VAC140-20-10); or (xiii) an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certification as a substance abuse counseling-assistant (CSAC-A) (18VAC115-30-10) under supervision of licensed provider and within his scope of practice, as described in §§ 54.1-3507.1 and 54.1-3507.2 of the Code of Virginia
-----Segment above needs to be added back in. CSACs provide essential services and should be allowed to create a substance related ISP with oversight from licensed staff. If this is left in, must address that CSACs can perform ISP’s with oversight.
---If CSACs cannot complete an ISP (with sign off by licensed) all “Primary Counselor” staff must be licensed. This would be cost prohibitive. All BH2s would need to be converted to senior clinicians. In addition, recruitment would be impossible. Statewide, there is already a shortage of licensed staff. By adding this requirement, it will make it impossible to recruit and hire essential staff, thus reducing services available during an opioid crisis. At the very least, allow CSACs with sign off by licensed to complete ISP and MDA assessment in 3.1, 3.3, 3.5, 3.7. In these setting, there are other credentialed staff on site an available ensure the client has his/her needs met.
---Add in Licensed Nurse practitioner with experience or training in addiction medicine- Across the State, many nurse practitioners (adult or family) have extensive training and experience in addiction medicine. They should be included.
---Adding Nurse Practitioners into the eligible providers is important. Not counting FNP's as LMHP's is limiting. While they do not have as much training as a MHNP or PNP, they clearly are on the front lines of providing treatment for BH conditions and shouldn't be excluded.
"Telemedicine" means the practice of the medical arts via electronic means rather than face-to-face the real-time, two-way transfer of medical data and information using an interactive audio-video connection for the purposes of medical diagnosis and treatment. The member is located at the originating site, while the provider renders services from a remote location via the audio-video connection. Equipment utilized for telemedicine shall be of sufficient audio quality and visual clarity as to be functionally equivalent to a face-to-face encounter for professional medical services.
---Allow for telehealth to be provided to a member located in the member’s home. This removes the barrier of transportation in rural and suburban communities. This change will increase client engagement (as demonstrated by increased engagement during COVID19). Engagement is the first ingredient for recovery.
12VAC30-130-5040. Covered services: requirements; limits; standards.
A.1.In order to be covered, ARTS shall (i) meet medical necessity criteria based upon the multidimensional assessment completed by a credentialed addiction treatment professional within the scope of their practice CATP or a CSAC under the supervision of a CATP and (ii) be accurately reflected in provider medical record documentation and on providers' provider claims for services by recognized diagnosis codes that support and are consistent with the requested professional services. ARTS services require a primary substance use diagnosis, and the purpose for treatment shall be related to the substance use disorder. A CATP or a CSAC under the supervision of a CATP shall complete the multidimensional assessments. A CATP must sign and date assessments performed by a CSAC within one business day.
---Evidence based approaches (to include David Mee-Lee/chief editor of the ASAM criteria) acknowledge that individuals with co-occurring disorders can have multiple primary disorders. One is not primary over the other. Clarify wording to reflect this. The individual must have a primary substance use disorder, but that does not mean he cannot also have another primary disorder.
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services
D.1. Random urine drug screening, using either urine or blood serums, for all individuals, conducted at a minimum of eight times per year. Drug screenings include presumptive and definitive screenings and shall be accurately interpreted. Definitive screenings shall only be utilized when clinically indicated. Outcomes of the drug screening shall be used to support positive patient outcomes and recovery.
---Leave it at 12 months versus one year. 12 months is more definitive
D. 8. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either onsite or through referral.
---This says to test. The individual has the right to choose. This is too prescriptive. A test can be offered
12VAC30-130-5060. Covered services: clinic services - preferred office-based opioid treatment.
D.5. Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.
---Good
12VAC30-130-5080. Covered services: outpatient services - physician services (ASAM Level 1.0).
A.1. d. Group psychotherapy or substance use disorder counseling shall be provided by a credentialed addiction treatment professional, CATP with a maximum of 10 individuals in the group shall be provided. Such counseling and shall focus on the needs of the individuals served.
---Allow for groups to be provided via telehealth with the member who is at home.
12VAC30-130-5140. Covered services: medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7).
A. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) settings for services. The facility-based providers provider of ASAM Level 3.7 services shall be licensed by DBHDS as an inpatient psychiatric unit with a DBHDS medical detoxification license, (i) a freestanding psychiatric hospital or inpatient psychiatric unit with a DBHDS medical detoxification license or managed withdrawal license; (ii) a residential crisis stabilization unit with a DBHDS medical detoxification license or managed withdrawal license; (iii) a substance abuse residential treatment services (RTS) for adults/children service for women with children with a DBHDS medical detoxification managed withdrawal license or a residential crisis stabilization unit with DBHDS medical detoxification license; (iv) a Level C (psychiatric residential treatment facility) provider; (v) a "mental health residential-children" provider with a substance abuse residential license and a DBHDS managed withdrawal license; (vi) a "managed withdrawal-medical detox adult residential treatment" provider; or (vii) a "medical detox-chemical dependency unit" for adults and shall be contracted by the BHSA DMAS or its contractor or the MCO. ASAM Level 3.7 providers shall meet the service components and staff requirements in this section.
---3.7 has extensive additional requirements to include expensive medical personnel. Rates for this service need to be reviewed.
B1. Daily clinical services provided by an interdisciplinary team to involve appropriate medical and nursing services, as well as individual, group, and family activity services, as appropriate to the needs and current functioning level of the individual. Activities may include pharmacological, including medication assisted treatment that is provided onsite or through referral; withdrawal management, cognitive-behavioral, and other therapies psychotherapies and substance use disorder counseling administered on an individual or group basis and modified to meet the individual's level of understanding and assist in the individual's recovery.
---It is not clinically appropriate and may often be contraindicated to begin therapy during acute withdrawal.
Other areas that should be addressed
1. Take out treatment history from ISP
It does not belong here. It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language. Add treatment history as part of MDA assessment. Adding in an assessment in appropriate.
The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
2. Discharge Planning sections for 3.3, 3.5, 3.7 are confusing and unrealistic. The timeframes, especially for 3.7 is unrealistic and will result in lack on continuity of care. Programs cannot wait for the MCO to approve a discharge plan before talking to potential future providers in a short term 7-day program. This needs to be revamped where the provider.
3. Need to change timeframe for the MDA Assessment in 3.7 programs to reflect that it is inappropriate to attempt to conduct a full psycho social history while the individual is in the acute phases of withdrawal. While the current regulations allow the PDE to be delayed due to individual illness/withdrawal, the service authorization is still expected in 24 hours but includes information that is gathered in the MDA. Specify that providers may complete service authorization form dimension 1 and 2 with 24 hours and complete the rest in 72 hours. Otherwise, the provider has to take the chance of not being paid or else must require a sick client to participate.
12VAC30-60-181 D
Requesting alignment regarding CSAC as CATP between 12VAC30-60-181 & ARTS Manual Chapter IV
Regulation 12VAC30-60-181 states that CSACs can complete assessments and lists them as CATP. The ARTS manual, Chapter IV, Appendix 1 only allows for licensed CATPs to complete an assessment
12VAC30-60-181 2(ISP)- Add in CSAC for 3.7, 1.0,2.1- In 3.7, clients must see physician or extender for physical within 24 hours of admission. There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) This will increase availability as licensed staff are difficult to recruit and not available to work weekends
12VAC30-60-185- Add language re: telehealth can be included which will allow coverage if a client cannot come in person
12VAC30-60-185 CATP definition
Add back CSACs being able to create ISPs with oversight of Licensed Staff. CSACs provide essential services and should be allowed to create a substance related ISP with oversight from licensed staff. If this is left in, must address that CSACs can perform ISP’s with oversight.
If CSACs cannot complete an ISP (with sign off by licensed) all “Primary Counselor” staff must be licensed. This would be cost prohibitive and recruitment would be impossible. Statewide, there is already a shortage of licensed staff. By adding this requirement, it will make it impossible to recruit and hire essential staff, thus reducing services available during an opioid crisis. At the very least, allow CSACs with sign off by licensed to complete ISP and MDA in 3.1, 3.3, 3.5, 3.7. In these setting, there are other credentialed staff on site an available ensure the client has his/her needs met.
Add in Licensed Nurse practitioner with experience or training in addiction medicine- Across the State, many nurse practitioners (adult or family) have extensive training and experience in addiction medicine.
Add in LSATP-R who are under supervision
12VAC30-130-5040
Evidence based approaches ( to include David Mee-Lee/chief editor of the ASAM criteria) acknowledge that individuals with co-occurring disorders can have multiple primary disorders.One is not primary over the other. Clarify wording to reflect this. The individual must have a primary substance use disorder, but that does not mean he cannot also have another primary disorder.
For some individuals, there are two primary diagnoses that are being treated concurrently
12VAC30-130-5050 (1)
Leave it at 12 months versus one year. 12 months is more definitive than eight times per year
12VAC30-130-5050(9)
This says to test. The individual has the right to choose. This is too prescriptive. A test can be offered
12VAC30-130-5080 (ASAM Level 1.0) (A)
-Clarification is important regarding who can provide Outpatient Services
12VAC30-130-5140 (A)
3.7 has extensive additional requirements to include expensive medical personnel. Rates for this service need to be reviewed.
12VAC30-130-5140 (1)- It is not clinically appropriate and may often be contraindicated to begin therapy during acute withdrawal.
Other areas that need to be changed.
-Take out treatment history/ medication assisted treatment assessment from ISP- It does not belong here. It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language. Add treatment history as part of MDA. Adding in an assessment to ISP is inappropriate.
The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
-ISP requirements for CSACs:
“All ISPs shall be completed and contemporaneously signed and dated by the credentialed addiction treatment professional CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.”
Recommendation:
CSACs should be able to prepare ISPs at level 2.1 and 2.5 as well as others listed.
CSACs that meet CATP definition should not need to be signed off by others. Currently, CSACs complete their own ISPs without additional approval signatures. Having a licensed person needing to sign all ISPs would create a lot of additional work for the licensed staff and add to the already large amount of documentation and review needed to admissions. The Code of Virginia § 54.1-3507.1 indicates that CSACs are “qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence. Providing counseling to persons for a mental health diagnosis other than substance abuse or dependency is outside the scope of practice for CSACs.”
-ISP revision timelines
Recommendation: Clarify and require that the ISP be reviewed quarterly, every 90 calendar days, and updated as the member's progress and needs change to recommend changes in the plan as indicated by the member's overall adjustment during the placement.
-Discharge Planning sections for 3.3, 3.5, 3.7 are confusing and unrealistic. The timeframes, especially for 3.7 is unrealistic and will result in lack on continuity of care. Programs cannot wait for the MCO to approve a discharge plan before talking to potential future providers in a short term 7 day program. This needs to be changed.
-Need to change time frame for the MDA in 3.7 programs - it is inappropriate to attempt to conduct a full psychosocial history while the individual is in the acute phases of withdrawal. While the current regs allow the PDE to be delayed due to individual illness/withdrawal, the service authorization for is still expected in 24 hours but includes information that is gathered in the MDA. Specify that providers may complete service authorization form dimension 1 and 2 with 24 hours and complete the rest in 72 hours. Otherwise, the provider must take the chance of not being paid or else must require a sick client to participate.
-A CSAC should be able to review an assessment and update ASAM Levels, as well as complete an ISP under supervision.
-CSAC versus CATP- Confused about the multiple references differentiating CSACs from CATPs (Credentialed Addiction Treatment Professionals). We have been operating all of the time with the understanding that a CSAC is a CATP based on the definition given in the initial ARTS rollout:
Recommendation: references should be for CATP only, in other words, CSAC should not be differentiated from CATPs in the document
- Face to face definition:
"Face-to-face" means encounters that occur in person or through telemedicine.
“Individual psychotherapy or substance use disorder counseling between the individual and shall be provided by a credentialed addiction treatment professional shall be provided CATP. Services shall be provided face to face in person or by telemedicine”
"Telemedicine" means the practice of the medical arts via electronic means rather
than face-to-face the real-time, two-way transfer of medical data and information
using an interactive audio-video connection for the purposes of medical diagnosis
and treatment. The member is located at the originating site, while the provider
renders services from a remote location via the audio-video connection.
Equipment utilized for telemedicine shall be of sufficient audio quality and visual
clarity as to be functionally equivalent to a face-to-face encounter for professional
medical services.”
Recommendation: Resolve inconsistencies in the above definitions
Change “telemedicine” to “telehealth” language throughout. Or, change to “video telehealth”.
Recommend deleting the line about originating site. This would allow for members to join services from their homes vs having to come in the clinic due to transportation or childcare barriers. This has proven to recently help with retention and engage rates. Or, add a client’s home as a viable remote origination site for telehealth.
Highly recommend allowing group counseling options via telehealth. COVID-19 experiences have resulted in significant increased engagement (50% to 80%) and is ideal for some who have barriers to treatment such as transportation or childcare.
- Maximum Individuals allowed in Group
Recommendation: In addition to the ASAM 1.0 levels of care, have a maximum requirement for number of individuals served in ASAM 2.1 and 2.5 levels of care to be 12
Confused about the multiple references differentiating CSACs from CATPs (Credentialed Addiction Treatment Professionals). We have been operating all of the time with the understanding that a CSAC is a CATP based on the definition given below in the initial ARTS rollout:
[1] “Credentialed Addiction Treatment Professionals” include licensed clinical psychologists, licensed clinical social workers, licensed professional counselors, licensed psychiatric clinical nurse specialists, licensed psychiatric nurse practitioners, licensed marriage and family therapists, licensed substance abuse treatment practitioners, licensed substance abuse treatment practitioners, or individuals with certification as a substance abuse counselors (CSAC) who are under the direct supervision of one of the licensed practitioners listed above.
Recommendation: references should be for CATPS only, in other words, CSAC should not be differentiated from CATPs in the document
"Face-to-face" means encounters that occur in person or through telemedicine.
“Individual psychotherapy or substance use disorder counseling between the individual and the provider shall be provided by a credentialed addiction treatment professional/CATP. Services shall be provided face to face in person or by telemedicine”
"Telemedicine" means the practice of the medical arts via electronic means rather
than face-to-face the real-time, two-way transfer of medical data and information
using an interactive audio-video connection for the purposes of medical diagnosis
and treatment. The member is located at the originating site, while the provider
renders services from a remote location via the audio-video connection.
Equipment utilized for telemedicine shall be of sufficient audio quality and visual
clarity as to be functionally equivalent to a face-to-face encounter for professional
medical services.”
Recommend: Resolve inconsistencies in the above definitions.
“All ISPs shall be completed and contemporaneously signed and dated by the credentialed addiction treatment professional CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.”
Recommendation:
A) CSACs should be able to prepare ISPs at level 2.1 and 2.5 as well as others listed.
B) CSACs that meet CATP definition should not need to be signed off by others! Currently, CSACs complete their own ISPs without additional approval signatures. Having a licensed person have to sign all ISPs would create a lot of additional work for the licensed staff and add to the already large amount of documentation and review needed to admissions. The Code of Virginia § 54.1-3507.1 indicates that CSACs are “qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence. Providing counseling to persons for a mental health diagnosis other than substance abuse or dependency is outside the scope of practice for CSACs.”
“Reimbursement for substance use outpatient services shall be made for medically necessary services provided in accordance with an ISP or the treatment plan and include withdrawal management as necessary. Services can be provided face-to-face in person or by telemedicine. Outpatient services shall meet the ASAM Level 1.0 service components and staff requirements as follows:”
Recommendation: In addition to the OBOT, psychiatric, medical and ASAM 1.0 levels of care;
expand access to care by including ASAM levels 2.1 and 2.5 levels of care in the provision of in person or telemedicine services.
”The provider shall include the individual and the family or caregiver, as may be appropriate, in the development of the ISP or treatment plan. To the extent that the individual's condition requires assistance for participation, assistance shall be provided. The ISP shall be updated at least annually and as the individual's needs and progress change. An ISP that is not updated either annually or as the individual's needs and progress change shall be considered outdated.
Recommendation: Clarify and require that the ISP be reviewed quarterly, every 90 calendar days, and updated as the member's progress and needs change to recommend changes in the plan as indicated by the member's overall adjustment during the placement.
Recommendation: For OBOT treatment, discontinue required monthly ISP reviews and continue Quarterly reviews as is congruent with the standard for substance use treatment.
Support the increased references to telehealth options
12VAC30-60-181
Henrico Area Mental Health & Developmental Services (HAMHDS) suggests DMAS consider continuing to allow groups to be provided via telehealth as we have seen that this option reaches a whole new subgroup. It is very beneficial to those that have limited transportation and to those with childcare and/or work obligations. It is easy for people to participate in a group during a lunch break, etc. Thank-you for this consideration.
12VAC30-130-5020 Definitions:
"Credentialed addiction treatment professional" or "CATP" means an individual licensed or registered with the appropriate board in the following roles: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) …… the Virginia Board of Social Work (18VAC140-20-10); or (xiii) an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certification as a substance abuse counseling-assistant (CSAC-A) (18VAC115-30-10) under supervision of licensed provider and within his scope of practice, as described in §§ 54.1-3507.1 and 54.1-3507.2 of the Code of Virginia.
Recommendation: It is confusing to have the multiple references differentiating CSACS from CATPs. We have been operating all of the time with the understanding that a CSAC is a CATP based on the definition given in the current DMAS ARTS Manual.
CSAC should be returned to the list of credentialed individuals who meet criteria to be a CATP. These individuals have completed significant didactic training and supervision as well as have passed a competency exam indicating knowledge of the population being served in order to become certified. By scope of practice and credentialing, CSAC are unable to provide services without a licensed supervisor thereby inherently including supervision/oversight within the role they fill within their agency. Therefore, CSAC should be able to write and implement ISPs and complete the Multidimensional Assessment without the need for a co-signature of a licensed person. Additionally, there are sufficient safeguards in regulations to ensure that individuals’ needs are being noted and/or addressed by other licensed professions required as members of the treatment team with the levels of care, especially at ASAM 3.1-3.7. Finally, Service Request Authorizations require the signature of a team member that is licensed or license-type (Resident/Supervisee) in order to be submitted for review so there is already someone reviewing appropriateness for the level of care based on medical necessity so requiring co-signatures on CSAC documentation is duplicative and excessive.
CSAC should be returned to the definition of credentialed staff who meet CATP requirements and all references within the proposed changes should be removed.
Recommendation: CSAC-Supervisee should be added to the list of credentialed individuals who meet criteria to be a CATP, just as Residents in Counseling and Supervisees in Social Work are. In order to be a Supervisee, there needs to be an identified certified/licensed supervisor and the required hours of didactic training must already be completed. If necessary, require a co-signature for Supervisees as they are still in their training process and have not yet become completed supervised experience or passed the credentialing exam.
Recommendation: “Psychiatric” type NP program is not needed or required to treat SUD or become a buprenorphine waivered practitioner. All references to Nurse Practitioners should have additional specifiers deleted, both in CATP definitions and throughout the document- examples “psychiatric” or “family” nurse practitioner. Could simply note “licensed Nurse Practitioners” instead. Using the more specific language decreases available qualified workforce.
12VAC30-60-181 UR
D. Multidimensional Assessment – if completed by CSAC, must be co-signed by CATP (new definition) Recommendation: See recommendation to return CSAC to CATP definition above.
E.1 “… The ISP shall be updated at least annually and as the individual's needs and progress change. An ISP that is not updated either annually or as the individual's needs and progress change shall be considered outdated.”
Recommendation: This language should be clarified to include the need for review every 90 days, should be changed to REWRITTEN (rather than updated) or should be combined with F below where it outlines the need for “review every 90 days calendar days and shall be modified as the needs and progress of the individual change.”
E.2 “All ISPs shall be completed and contemporaneously signed and dated by the CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.”
Recommendation: See recommendation to return CSAC to CATP definition above.
F. (vi) The comprehensive ISP … shall include: …, Medication Assisted Treatment Assessment, which shall be provided onsite or through referral
Recommendation: A MAT assessment contains data determining eligibility for the service. Assessment data drives development of the ISP. It is more appropriate to require different documentation that a MAT assessment was offered. If the client receives MAT, the ISP would reflect the on-going MAT service at that time.
F… CSACs may perform the ISP reviews in ASAM Levels 3.1, 3.3, and 3.5 if a CATP signs and dates the ISP review
Recommendation: See return of CSAC to CATP definition above. CSACs should be considered CATP and be qualified to write and implement ISPs for all levels of care without the need for co-signature of licensed or license-type staff.
12VAC30-70-418. Reimbursement for residential and inpatient substance use treatment services.
Recommendation: Due to the significant staffing requirements in the above indicated levels of care for residential settings, it is recommended to consider re-evaluation of reimbursement rates for these services. These are residential levels of care which require 24 hour supervision and services provided by medical and clinical staff that reimburse at a lower rate than that of ASAM 2.5 on a daily basis.
12VAC30-130-5020 Definitions
"Face-to-face" means encounters that occur in person or through telemedicine
Recommendation: Clarification may be needed as this would seem to imply that any service indicated as being provided as “face-to-face” would be allowable as “telemedicine.” (See telemedicine recommendation.)
"Individual service plan" or "ISP" means an initial and comprehensive treatment plan … An ISP includes documentation if the individual is a minor child or an adult who lacks legal capacity and is unable or unwilling to sign the ISP.
Recommendation: Update language to include “if the individual is a minor or incapacitated adult, the ISP is also signed by the individual’s parent or legal guardian.”
"Psychotherapy" or "therapy" means the use of psychological methods in a professional relationship to assist a person to acquire great human effectiveness or to modify feelings, …
Recommendation: Provide clarification (quantify or qualify) what “acquire great human effectiveness” means as this is not clear.
"Telemedicine" means the practice of the medical arts via electronic means rather than face-to-face the real-time, two-way transfer of medical data and information using an interactive audio-video connection for the purposes of medical diagnosis and treatment. The member is located at the originating site, while the provider renders services from a remote location via the audio-video connection. Equipment utilized for telemedicine shall be of sufficient audio quality and visual clarity as to be functionally equivalent to a face-to-face encounter for professional medical services.
Recommendations: Resolve inconsistencies in definitions of “Telemedicine,” “face-to-face” and within ASAM 1.0 level of services (“Services shall be provided face to face in person or by telemedicine.”)
12VAC30-130-5040. A. Addiction and recovery treatment services.
1. In order to be covered, ARTS shall (i) meet medical necessity criteria based upon the multidimensional assessment completed by a CATP or a CSAC under the supervision of a CATP and … professional services. ARTS services require a primary substance use diagnosis, and the purpose for treatment shall be related to the substance use disorder. Individuals may have a secondary, co-occurring diagnosis. A CATP or a CSAC under the supervision of a CATP shall complete the multidimensional assessments. A CATP must sign and date assessments performed by a CSAC within one business day.
Recommendation: See return of CSAC to CATP definition above. CSACs should be considered CATP and be qualified to write and implement ISPs for all levels of care without the need for co-signature of licensed or license-type staff.
Recommendation: Where the regulations indicate, “ARTS services require a primary substance use diagnosis, and the purpose for treatment shall be related to the substance use disorder. Individuals may have a secondary, co-occurring diagnosis” delete the word “primary” from all references of this language within the proposed changes. Requiring “primary substance use diagnosis” discriminates against those with mental health disorders. Most people with SUD also have co-occurring disorders. This language would rule out people with primary MH disorders who also validly need SUD treatment. It would also rule out people with true co-occurring disorders. It is often difficult to separate out which diagnoses are primary, especially without a period of prolonged sobriety. All people with SUD should have access to covered treatment.
12VAC30-130-5060. B.OBOT service components
10. Provision of onsite screening or referral for screening for clinically indicated infectious disease testing for diseases such as HIV; hepatitis A, B, and C; syphilis; and tuberculosis at treatment initiation and then at least annually or more often based on risk factors and the ability to provide or refer for treatment of infectious diseases as necessary.
Recommendation: Clarify what “at initiation” of services means. Is a screening (verbal questions) sufficient or are labs required? Is it that we need to perform or order labs and receive results before MAT induction can occur? What if an individual refuses the testing as they have a right to do – are we to not allow prescribing of medications for MAT? This would also hold true for any places that it references the “ability to provide pregnancy testing for women of childbearing age.”(#12) Again, we cannot force an individual to complete a pregnancy test and/or do we need to ensure we have results before we can initiate MAT services?
C. OBOT staff requirements
2. CATPs are required and shall work in collaboration with the buprenorphine-waivered practitioner who is prescribing buprenorphine products or naltrexone products to individuals with moderate to severe a primary opioid use disorder. This collaboration can be in person or via telemedicine as long as it meets the department's requirements for the OBOT setting and for telemedicine. CSACs, CSAC-supervisees, and CSAC-As are also recognized in the preferred OBOT setting as well as registered peer recovery specialists. A registered peer recovery specialist shall meet the definition in § 54.1-3500 of the Code of Virginia.
Recommendation: See return of CSAC to CATP definition above. CSAC is recognized as an appropriate provider at this level of service and should be considered a CATP based on training and experience.
D. OBOT risk management shall be documented in each individual’s record and shall include: (Subsections 1, 6, 7, 8, 9 specifically)
Recommendation: What if an individual refuses the testing as they have a right to do – are we to not allow prescribing of medications for MAT? This would also hold true for any places that it references the “ability to provide pregnancy testing for women of childbearing age. Again, we cannot force an individual to complete a pregnancy test and/or do we need to ensure we have results before we can initiate or continue MAT services?
12VAC30-130-5080.
1. Outpatient services (ASAM Level 1.0) service components:
b. … The multidimensional assessment shall include a physical examination and laboratory testing necessary for substance use disorder treatment as necessary.
Recommendation: Remove the language “ shall include a physical examination and laboratory testing” or update to say “may include” as it is less prescriptive and could allow for exam but not require it.
c. Individual psychotherapy or substance use disorder counseling shall be provided CATP. Services shall be provided face to face in person or by telemedicine.
Recommendation: clarification needed in language indicating that services shall be provided in person or by telemedicine. See comment related to telemedicine definition.
d. Group psychotherapy or substance use disorder counseling shall be provided by a CATP with a maximum of 10 individuals in the group and shall focus on the needs of the individuals served.
Recommendation: Expand the group size to allow for a maximum of 12 individuals in the group setting to expand capacity to provide services and allow for scheduling of 12 participants to take into account no-shows or absences.
Recommendation: Allow group services as ASAM Level 1.0 to be provided via telehealth, not just individual services. Telehealth has increased retention and engagement by up to 30% during the COVID-19 period; telehealth allows for a reduction in barriers to treatment such as childcare and transportation.
e. Family psychotherapy or substance use disorder counseling shall be provided by a CATP to facilitate the individual's recovery and support for the family's recovery.
Recommendation: “Shall be provided” is too prescriptive and would be better described as “encouraged” or “allowed.” Often, clients have dysfunctional and unhealthy relationships with their family and it would be inappropriate, and not therapeutic, to require participation in such activity. Furthermore, we cannot force a client to participate in services they object to nor can we force a family member to participate in family therapy against their will.
2. Outpatient services (ASAM Level 1.0) staff requirements shall include:
a. A CATP; or b. A registered nurse or a practical nurse who is licensed by the Commonwealth with at least one year of clinical experience involving medication management.
Recommendation: It is unclear how an RN or LPN with one year of clinical experience involving medication management would meet the criteria to provide “professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services” as described in regulations for ASAM Level 1.0 when they are not designated at a CATP. CSAC, who has specialized training and experience in SUD related services, should be allowed to provide services at this level and be considered a CATP.
12VAC30-130-5090. (ASAM Level 2.1).
A. The following service components shall be provided weekly as directed by the ISP for reimbursement)
Recommendation: Update language to indicate “may be provided weekly…” All items are not appropriate for every client. For example, family therapy, MAT, psychopharmacological consultation, addiction medication management, psychiatric consultation, etc. are not required for each and every client.
B. 2. Generalist physicians or physicians with experience in addiction medicine are permitted to provide general medical evaluations and concurrent or integrated general medical care.
Recommendation: Clarification of what is included in “general medical evaluations and concurrent or integrated general medical care.” If supports are in place for members to be referred for primary care services and/or evaluation is consultation sufficient to meet this need or does the physician need to be an employee/contractor of the agency? Are these physicians consultants to the team or are they providing actual medical care to individuals? Is it allowable to use Physician Extenders for this purposed as they are allowed in subsection 3 as long as they have a DEA-X number for buprenorphine prescribing?
12VAC30-130-5100. partial hospitalization services (ASAM Level 2.5).
A. Partial hospitalization services (ASAM Level 2.5) components…shall include the following, … provided on a weekly basis:
3. Family psychotherapy and substance use disorder counseling involving family members, guardians, or significant others in the assessment, treatment, and continuing care of the individual.
Recommendation: “Shall be provided” is too prescriptive and would be better described as “encouraged” or “allowed.” Often, clients have dysfunctional and unhealthy relationships with their family and it would be inappropriate, and not therapeutic, to require participation in such activity. Furthermore, we cannot force a client to participate in services they object to nor can we force a family member to participate in family therapy against their will.
General Feedback:
Highly recommend allowing group counseling options via telehealth. COVID-19 experiences have resulted in significant increased engagement (from prior levels of approximately 50% to current levels of approximately 80%) and is ideal for some who have barriers to treatment such as transportation and child care needs.
There is no indication in the proposed regulations for maximum group size for levels of care other than ASAM Level 1.0. Current regulations cap group size for 2.1, 2.5, 3.5, and 3.7 at 10 participants for group. If it is recommended that if there will be a group size maximum for these other levels of care that it be expanded to 12 participants to allow for increased capacity for services as well as to account for no shows/absences.