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Board of Medical Assistance Services
 

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4/18/21  7:20 pm
Commenter: Glenn Mathews

Telehealth, Silos
 

Will you outline the process and expectations around telehealth services for the programs?

When will you begin to better integrate mental health and SUD services. The regulations, language and expectations continue to separate MH and SUD. As we know, they are not separate. They are inextricably intertwined! 

CommentID: 97714
 

4/19/21  3:11 pm
Commenter: Janice A Hinkledire

Appendix C includes an outdated link
 

In the first draft Appendix C; bottom of page 3 to top of page 4 reference is made to a document called “CMHRS Provider Reference-Doing Business with CCC Plus MCO’s” located at https://www.dmas.virginia.gov/#/cmhrs.  This document includes outdated information. Are health plans able to submit updated information for correction?

CommentID: 97717
 

4/19/21  3:22 pm
Commenter: Janice A Hinkledire

Discharge Planning
 

Bottom of Page 1: Continued authorization requests must clearly document the above three bullets required for initial requests as well as the individual’s current status and the individual’s progress, or lack of progress toward goals and objectives in the ISP.

Would it also be appropriate to address the need for ongoing discharge planning to remain consistent with the IPS requirements?

 

CommentID: 97718
 

4/26/21  9:28 am
Commenter: Jennifer Sherman, LPC

Comments RE: MH-IOP
 

Pgs. 4-5, 7 of Appendix E; MH-IOP Level of Care Guidelines; Service Definition: “…A MH-IOP requires psychiatric oversight with at least weekly medication management included in the coordinated structure of the treatment program schedule.”

Comment: Please consider revising this service requirement to allow for psychiatric providers to schedule medication management appointments as medically necessary, but at minimum on a monthly basis. Additionally, individuals commonly express a preference to use their primary care physician instead of a psychiatric provider, or the individual declines a referral for a psychiatric evaluation and medication management. In these scenarios, please consider allowing individuals to continue participation in MH-IOP. Providers should document the individual’s choice and preferences and also engage in service coordination with any outside prescriber.

Pg. 8 of Appendix E; MH-IOP Level of Care Guidelines; Service Limitations: “MH-IOP may not be authorized or billed concurrently with…Mental Health Skill-building …”

Comment: Many individuals admitted to Mental Health Skill-building services would benefit from participation in a MH-IOP program. However, discontinuing the intervention and support provided through MHSS services would likely cause regression in the individual’s treatment progress. MHSS extends hands-on, practical, and real-time skill-training for individuals in their home and community setting, which is outside of the MH-IOP service scope. Please consider allowing concurrent service authorizations for MH-IOP and MHSS.

Pg. 8 of Appendix E; MH-IOP Level of Care Guidelines; Service Limitations: “MH-IOP may not be authorized or billed concurrently with…Therapeutic Day Treatment…”Pg. 9 of Appendix #; MH-IOP Provider Participation Requirements: “Regardless of setting, these programs should not be disruptive of the school day or provides as part of the school day structure for youth participants.”

Comment: Limiting concurrent MH-IOP and Therapeutic Day Treatment service authorizations will result in youth who lack the support and intervention needed to function well during the school day and could result in more restrictive service interventions or school placements as a result. MH-IOP aims to significantly increase the youth’s healthy ability to cope, relate interpersonally, and problem-solve. MH-IOP providers who coordinate services with TDT providers are more likely to see these skills generalized across service settings with the goal to successfully discharge from both programs.  Otherwise, the service limit will likely result in youth and guardians who decline MH-IOP in an effort to preserve TDT services, forfeiting MH-IOP a needed and beneficial service opportunity.

CommentID: 97732
 

4/26/21  11:03 am
Commenter: Kristina Turner Intercept Health

Mental Health – Intensive Outpatient Program (MH-IOP)
 

Extension of more mental health services to Virginia residents is always beneficial! Here are three proposals for amendments to the proposed language:

  1. Pgs. 4-5, 7 of Appendix E; MH-IOP Level of Care Guidelines; Service Definition: “…A MH-IOP requires psychiatric oversight with at least weekly medication management included in the coordinated structure of the treatment program schedule.”
    1. Please consider revising this section to allow individualization of med management appointments, maintain a minimum of a monthly requirement. 

      Additionally, individuals commonly express a preference to use their primary care physician instead of a psychiatric provider, or the individual declines a referral for a psychiatric evaluation and medication management. In these scenarios, please consider allowing individuals to continue participation in MH-IOP. Providers should document the individual’s choice and preferences and also engage in service coordination with any outside prescriber.

  2. Pg. 8 of Appendix E; MH-IOP Level of Care Guidelines; Service Limitations: “MH-IOP may not be authorized or billed concurrently with…Mental Health Skill-building …”
    1. Please consider allowing individuals to receive MHSS and MH-IOP concurrently, as they target different skills in differing locations.
  3. Pg. 9 of Appendix #; MH-IOP Provider Participation Requirements: “Regardless of setting, these programs should not be disruptive of the school day or provides as part of the school day structure for youth participants.”
    1. Please consider allowing individuals to receive TDT and MH-IOP concurrently, as they target different skills in differing locations. The removal of TDT services from these individuals may result in change to more restrictive environments, including homebound instruction and movement to a private day placement. MH-IOP providers who coordinate services with TDT providers are more likely to see these skills generalized across service settings with the goal to successfully discharge from both programs. 
CommentID: 97733
 

4/27/21  9:42 am
Commenter: Fairfax-Falls Church Community Services Board

Draft-Mental Health Services Manual (formerly CMHRS)
 

1. App D-Intensive Community Based Support, Page 6:

Medication prescription monitoring must be provided by a psychiatrist or psychiatric nurse practitioner who completes an initial assessment at admission and has contact with individuals on a quarterly basis.

 

  • Requesting clarification on Intensive Community Based Support, Page 6:

Clarity around the time frame regarding completion of medication prescription monitoring. Will medication prescription monitoring need to be completed at admission. Does this mean day of admission, and if so, what is the time frame.

 

2. App D-Intensive Community Based Support, Page 2:

“Crisis treatment” means behavioral health care, available 24-hours per day, seven days per week, 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.

  • Requesting clarification – Intensive Community Based Support, Page 2:

Additional clarity is needed regarding the definition for crisis treatment. What are the specific expectations to meet this treatment requirement.

 

3. App D-Intensive Community Based Support, Page 7:

ACT may not be authorized or billed concurrently with Individual, Group or Family Therapy, Addiction and Recovery Treatment Services (ARTS) and Mental Health (MH) Intensive Outpatient, ARTS and MH Partial Hospitalization Program, Outpatient Medication Management, Therapeutic Day Treatment, Intensive In Home Services, Crisis Intervention, Crisis Stabilization, Mental Health Skill Building, Psychiatric Residential Treatment Facility (PRTF) and ARTS Level 3.3-3.7 or Peer Recovery Support Services, as the activities of these services are included in the per diem. Office based opioid treatment services (OBOT) and Office Based Addiction Treatment (OBAT) services are allowed simultaneously with ACT.

  • Requesting clarification on Intensive Community Based Support, Page 7:

Further clarity is needed surrounding whether the provider can/cannot bill for the identified services provided in question #3 while billing for ACT or can/cannot bill the same time during the day while billing for ACT.

 

4. App D-Intensive Community Based Support, Page 11:

  • Crisis intervention must be provided by a LMHP, LMHP-R, LMHP-RP or
    LMHP-S.

 

  • Crisis Treatment must be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, CATP, QMHP-A, QMHP-C, QMHP-E, CSAC* or CSAC-A*.

 

  • Requesting clarification on Intensive Community Based Support, Page 11:

 

Will a QMHP be able to provide crisis intervention. The second bullet point on crisis intervention references QMHP-type can provide crisis intervention. More specifics are needed on who can provide crisis intervention.

 

5. App D-Intensive Community Based Support, Page 17:

A minimum of 15 minutes face-to-face service, including one of the service components, is required in order to bill the per diem. Collateral contacts may only account for 25% of the team’s billed time. Licensed direct care staff shall provide services within the scope of practice for their license. Practitioners may not bill for services included in the ACT per diem (H0040) and also bill for the services outside of the per diem rate for individuals enrolled in ACT.

 

  • Requesting clarification on Intensive Community Based Support, Page 17:

Clarification is needed on how 25% is calculated for the team’s billed time. How is this amount defined and tracked. Will this be grouped together per team or individually by staff.

 

6. App D-Intensive Community Based Support, Page 18    

Case Management should be billed outside of the per diem rate.

 

  • Requesting clarification on Intensive Community Based Support, Page 18:

 

What is considered Case Management outside of ACT.

 

7. App E-Intensive Clinic Base Support, Pages 20-21:

At least three of the following service components shall be provided per day based on the treatment needs identified in the initial comprehensive assessment require:
1. Daily therapeutic interventions with a planned format including
individual, group or family therapy;
2. medication management (minimum of weekly);

3.Skill restoration/development
4.Health literacy counseling/psycho-education interventions; and
5. Occupational and/or other therapies performed by a professional
acting within the scope of their practice.

 

  • Requesting clarification - Intensive Clinic Base Support, Page 20:

 

What are the set number of hours for the three service components that are provided per day based on treatment needs.

 

8. App E-Intensive Clinic Base Support, Page 20:

The provider shall, with individual’s consent, collaborate with the individual’s primary care physician and other treatment providers such as psychiatrists, psychologists, and
substance abuse providers;

 

  • Requesting clarification - Intensive Clinic Base Support, Page 20:

Additional clarity regarding whether an individual may initiate or continue with a community-based psychiatrist.

 

 

 

 

CommentID: 97739
 

4/28/21  5:07 pm
Commenter: ICT Services, Inc

Mental Health Services (formerly CMHRS) App. D/ Provider Qualifications and ACT Billing Guidance
 

Provider Guidance

ACT Team Fidelity Standards

ACT Teams are required to undergo the standardized rating process using the Tool for Management of Assertive Community Treatment (TMACT) as specified in their DBHDS license.

  • ?  A new ACT team may obtain a conditional DBHDS license for ACT if their initial TMACT fidelity scores are in the low fidelity range of 2.7-3.3, but the team must rate at 3.4 or higher on the subsequent review to avoid losing this provisional license.

  • ?  ACT teams may reach full ACT certification status and a one-year DBHDS license if they obtain a TMACT score in the base fidelity range of 3.4-3.9.

  • ?  ACT providers scoring 4.0-5.0 are considered high fidelity (this category has two tiers: 4.0-4.3 are high fidelity and 4.4-5.0 are exemplary fidelity).

    ACT reimbursement rates are tiered based on the size of the team and fidelity rating status; information on these rates is available in the “Billing Guidance” section of this appendix.

If ACT Teams are to maintain fidelity ratings according to the TMACT model to not only keep their license but also to obtain the reimbursement rates shouldn't services required to meet fidelity within the TMACT Model be reflected in what we can bill under DMAS regulations?

 

Billing Guidance

The Per Diem Rate includes any of the following service components provided by a qualified provider:

  • ?  assessment

  • Billing Code -H0040 and Team Modifier
  • Unit- N/A
  • Description- Comprehensive Needs Assessment

Does this billing guidance for the "CNA" pertain to initial assessments for ACT? How does this apply for clients who are assessed at not meeting ACT admission criteria?

 
CommentID: 97752
 

4/30/21  7:19 am
Commenter: Natalie Handy

Comment
 

 

  1. Pgs. 4-5, 7 of Appendix E; MH-IOP Level of Care Guidelines; Service Definition: “…A MH-IOP requires psychiatric oversight with at least weekly medication management included in the coordinated structure of the treatment program schedule.”

 

Public Comment: Please consider revising this service requirement to allow for psychiatric providers to schedule medication management appointments as medically necessary, but at minimum on a monthly basis. Additionally, individuals commonly express a preference to use their primary care physician instead of a psychiatric provider, or the individual declines a referral for a psychiatric evaluation and medication management. In these scenarios, please consider allowing individuals to continue participation in MH-IOP. Providers should document the individual’s choice and preferences and also engage in service coordination with any outside prescriber.

 

  1. Pg. 8 of Appendix E; MH-IOP Level of Care Guidelines; Service Limitations: “MH-IOP may not be authorized or billed concurrently with…Mental Health Skill-building …”

 

Public Comment: Many individuals admitted to Mental Health Skill-building services would benefit from participation in a MH-IOP program. However, discontinuing the intervention and support provided through MHSS services would likely cause regression in the individual’s treatment progress. MHSS extends hands-on, practical, and real-time skill-training for individuals in their home and community setting, which is outside of the MH-IOP service scope. Please consider allowing concurrent service authorizations for MH-IOP and MHSS.

 

  1. Pg. 8 of Appendix E; MH-IOP Level of Care Guidelines; Service Limitations: “MH-IOP may not be authorized or billed concurrently with…Therapeutic Day Treatment…”

Pg. 9 of Appendix #; MH-IOP Provider Participation Requirements: “Regardless of setting, these programs should not be disruptive of the school day or provides as part of the school day structure for youth participants.”

 

Public Comment: Limiting concurrent MH-IOP and Therapeutic Day Treatment service authorizations will result in youth who lack the support and intervention needed to function well during the school day and could result in more restrictive service interventions or school placements as a result. MH-IOP aims to significantly increase the youth’s healthy ability to cope, relate interpersonally, and problem-solve. MH-IOP providers who coordinate services with TDT providers are more likely to see these skills generalized across service settings with the goal to successfully discharge from both programs.  Otherwise, the service limit will likely result in youth and guardians who decline MH-IOP in an effort to preserve TDT services, forfeiting MH-IOP a needed and beneficial service opportunity.

CommentID: 97763
 

5/13/21  4:47 pm
Commenter: Tamara Starnes

MH IOP and PH, Appendix E
 

MH requirements are greatly above that for ARTS programs, allow little flexibility, and concerned will deter many from implementing these much needed services. Despite more requirements, rate is considerably less than ARTS. Suggest re-aligning closer to ARTS format. Recommend not passing this appendix without more review and input. What many understood as intended to be an alignment with ARTS IOP and PH, seems to be more of a creation of stand-alone program/clinic, versus a new ability to offer a similar group service structure for MH. With the numerous competing demands, changes and current requests, suspect many agencies have not had time to review thoroughly and give input.  

 

A few key point examples from the MH IOP draft regs:

  • Staffing requirements include Full time Clinical Director – Not in ARTS
  • Staffing requirements include Physician/NP/PA for weekly med management- Not in ARTS
  • Staffing ratio 1:5 clients- Not in ARTS
  • Supervisor ratio 1:6 staff  - Not in ARTS
  • Accreditation by CARF or Joint Commission (not required in ARTS, have heard may have 2 years to get this) There is no other specific MH service menu item that requires this in Virginia that I am aware of.
  • Three groups and 2 individual sessions per week- Individual sessions are available in ARTS as a separate service but not required/prescribed, recommend allowing for more individualized . treatment. This will create a 5 day a week program if need 3 groups (3 hours each), 2 individual sessions, and1 x weekly med management, equivalent with more of a partial hospitalization level of care. 

 

Reminder of rate differences:

ARTS IOP rate: $250 group

MH IOP rate: $141.50 per diem

 

ARTS PH: $500 group

MH PH: $120.58 ($220 if in a hospital) per diem

CommentID: 98521
 

5/13/21  4:51 pm
Commenter: Tamara Starnes

Appendix E
 

MH IOP regs equivalent to more of a partial hospital level of care. Requires 3 groups a week (three hours each), two individual sessions, weekly med management session= 5 day a week  program when capturing daily per diem. Recommend aligning more with ARTS and allowing individualized care versus prescriptive numbers of sessions, allows for no transitioning to lower level of care 

CommentID: 98522
 

5/13/21  4:54 pm
Commenter: Tamara Starnes

Registration and Authorization Appendix C
 

Recommend striking the section that requires a registration for a service. This appears redundant to what is required for billing of the service and sent to the insurer. There is no pre-authorization required and this creates a large unnecessary administrative burden.  

 

“ (i) the individual's name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code and begin date of the service; and (iii) the provider's name and NPI, a provider contact name and phone number, and email address.”

CommentID: 98523
 

5/13/21  4:56 pm
Commenter: Tamara Starnes

ACT Appendix D
 

Critical Features: Change “Team” to “Staff”. There are some ACT teams, especially in rural communities, and during work force shortages, that require additional (non team specific) staff to be used to cover 24/7. Its impossible in some places for the core “team” to screen calls 24/7. Unless the pool is widened, this requirement will increase staff turnover which is a determent to clients. This will be difficult for many CSBs to make happen with work force shortages. This could be a high fidelity measure versus regulation. Recommend keeping the need for 24 hour on call coverage, however less prescriptive about who that entails. 

 

“Critical features of ACT include:

? Team availability either directly or on-call 24 hours per day, seven

days per week and 365 days per year;

? Crisis response and intervention that is available 24 hours per day,

seven days per week, including telephone and face-to face contact;

? Team is to be the first line (and generally sole provider) of all the

services that individuals may need by providing individualized,

intensive treatment/rehabilitation and support services in the

community;”

CommentID: 98524
 

5/13/21  5:01 pm
Commenter: tamara starnes

ACT Appendix D additional
 

Lists Group as required activity: Recommend clarification that Group is available (not all will need this service, treatment should be individualized)

Notes “Will” provide Group and Individual modalities for people with co-occurring. This will depend on client preferences; reword to note “availability” versus will, treatment should be based on choice and individualized needs, not all do well in groups for example.

 

Recommend changing to “billed” only for the below excerpt: Person may have an authorization for ACT for example, then need MH Partial Hospital and the authorizations overlap because they are given in advanced time frames.  Also strike through Crisis Intervention as person may end up in ED and need Prescreening.

 

“ACT may not be authorized or billed concurrently with Individual, Group or Family Therapy, Addiction and Recovery Treatment Services (ARTS) and Mental Health (MH) Intensive Outpatient, ARTS and MH Partial Hospitalization Program, Outpatient Medication Management, Therapeutic Day Treatment, Intensive In Home Services, Crisis Intervention, Crisis Stabilization, Mental Health Skill Building, Psychiatric Residential Treatment Facility (PRTF) and ARTS Level 3.3-3.7 or Peer Recovery Support Services, as the activities of these services are included in the per diem.”

 

The above is especially important per this part of the manual: Continuation of services may be service authorized at one year intervals based on written service-specific provider re-assessment and certification of need by an LMHP.

 

Concerned the below will be taken as a regulation versus recommendation, does not seem needed/appropriate for regs. Have been on ACT teams that accepted many more than 4 per month in the first year. This recommendation would lead to only 12 cases total after 3 months, in some case, to a 1:1 staffing ratio.  “To ensure appropriate ACT team development, each new ACT team is recommended to titrate ACT intakes (no more than 4 total per month)”

 

Concerned this will be interpreted as must be updated every 30 days. Suggest using same standards as other outpatient services.  Reference: “The individualized treatment plan, updated every 30 days or as clinically appropriate”

 

Suggest taking out the words “vigorous” an “ongoing” as ACT is one of the longer- term treatment services available to help with sustained recovery. Transition from this level of service, compared to all others, should be slow and well thought out. “Coordination of care and vigorous, active discharge planning are documented and ongoing from the day of admission with the goal of transitioning individual to a less intensive level of care”. And especially considering the next section “Individuals should therefore not be discharged from the service due to perceived “lack of compliance” with a treatment plan or challenges integrating interventions into their lives towards recovery.”

 

CommentID: 98525
 

5/13/21  5:04 pm
Commenter: Tamara Starnes

Chapter IV: Paper work reduction, Comprehensive Needs Assessments
 

Recommend DMAS and DBHDS work together to align paperwork reduction efforts into draft regulations and manuals.

Gaps in service: currently require new Comprehensive Needs Assessment if no services in 31 days. Recommend changing this to need Comprehensive Needs Assessment Update. Many states use abbreviated Comprehensive Needs Assessment Update Form for people re-entering services any time less than 1 year.  Historical items on the assessment should not change.

Comprehensive Needs Assessment: If ISPs are reviewed every 90 days, quarterly reviews are required, and a new ISP is due every year, recommend discontinuing needing a new annual Comprehensive Needs Assessment due to duplication.

Additional Requirements for MHSS, PSR and ICT (is this ACT?): Recommend striking this section requiring 6 month reviews. Quarterly Reviews for ISPs are already required and the six month review is redundant. Service Authorizations also cover this aspect.

 

Additional Requirements for Day Treatment/Partial Hospitalization MH-PHP and MH-IOP: Recommend striking this section requiring evaluation and documentation of continued medical necessity. Quarterly Reviews for ISPs are already required at the 90 day mark. Service authorizations will likely already cover theses aspects.

 

CommentID: 98526
 

5/13/21  5:05 pm
Commenter: Tamara Starnes

Registrations Chapter IV
 

Recommend striking the section that requires registration for a service. This appear redundant to what is required for billing of the service. There is no pre-authorization required and this creates a large administrative burden.

 

“All services which do not require service authorization require registration. This registration*shall transmit to DMAS or its contractor (i) the individual's name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code and begin date of the service; and (iii) the provider's name and NPI, a provider contact name and phone number, and email address.”

 

CommentID: 98527
 

5/13/21  5:06 pm
Commenter: Tamara Starnes

Chapter IV Comprehensive Needs Assessment
 

PG 19. Valid Comprehensive Needs Assessment is required prior to initiating Crisis Intervention and Crisis Stabilization: do not recommend this for Crisis Services as it is not always possible, can delays treatment, and some items potentially escalating. Recommend CNA be completed by the fourth visit for these services (and Pre-screening can qualify as CNA for crisis services)

Rules of when a new Comprehensive Needs Assessment is needed and can be billed are confusing. Recommend if doing and assessment, including a comprehensive needs assessment, or CNA update, that assessment code is appropriate to bill.

Previously allowed Pre-screeners (extremely well trained) to complete Comprehensive Needs Assessment, this has been struck through, recommend keeping.

CommentID: 98528
 

5/13/21  5:08 pm
Commenter: Tamara Starnes

Chapter VI: Allowing Master's Level Interns
 

Page 10- directive on who can render services: Recommend explicitly including wording to allow Master’s level Social Work, Counseling, and Marriage and Family Therapy students to provide services under guidance of LPC, LCSW, or LMFT (even if not able to be reimbursed). This will help allow more internship opportunities and grow the work force. Current regs the way they are worded prevent using interns in many settings even under supervision. 

CommentID: 98529
 

5/13/21  5:10 pm
Commenter: Tamara Starnes

Chapter VI Easy Access To Crisis Services
 

Make Crisis Services (Crisis Intervention, Crisis Stabilization, future Mobile Crisis) easily accessible by not requiring prior authorization or comprehensive needs assessment prior to the first service. This cannot always be completed with clients in active crisis. 

CommentID: 98530
 

5/13/21  5:11 pm
Commenter: Tamara Starnes

Chapter VI Comprehensive Needs Assessment
 

Gaps in service: currently require new Comprehensive Needs Assessment if no services in 31 days. Recommend changing this to need Comprehensive Needs Assessment Update. Many states use abbreviated CNA Update Form for people re-entering services any time less than 1 year.  Historical items on the assessment should not change. Using an "Update" to the assessment is used in several other states for any clients re-entering services within one year. 

Comprehensive Needs Assessment: If ISPs are reviewed every 90 days, quarterly reviews are required, and a new ISP is due every year, recommend discontinuing needing a new annual Comprehensive Needs Assessment due to duplication.

CommentID: 98531
 

5/13/21  5:13 pm
Commenter: Tamara Starnes

Requiring document number of people in groups Chapter VI
 

*Required that documentation includes the number of clients in group- do not see need to add this, can be monitored by billing, claims data, or audits. Some EHRs may not be able to capture this and creates additional paper work for numerous therapists with no benefit to the client.

CommentID: 98532
 

5/13/21  5:15 pm
Commenter: Tamara Starnes

Chapter VI New Manual - old psych services and CMHRS
 

Can it be clarified if the Psychiatric Services Manual outpatient therapy portions and Community Mental Health Rehabilitative Services were/will be combined, and will this be the new manual for both?

Recommend DMAS and DBHDS work together to align paperwork reduction and streamlining efforts into draft regulations and manuals during this drafting and review process.

CommentID: 98533
 

5/14/21  9:29 am
Commenter: Rebecca Cash, Valley Community Services Board

MH Services Manual draft
 

Ch. II p. 8 regarding adverse outcomes. Language does not reflect current standardized guidance regarding critical incident reporting to MCOs. Language is not clearly defined for what meets criteria for reporting. Language surrounding incidents of violence initiated by the member has been removed critical incident reporting guidance document. Language should be consistent with critical incident reporting guidance.

Ch IV p. 14 regarding DLA-20 may be used as CNA if it covers all 15 elements or addendum can be done to cover elements. This could potentially assist to streamline documentation. However, is DBHDS Office on Licensing going to recognize DLA-20 standard assessment as meeting all requirements for assessment under 12VAC35-105-650.

Appendix D p. 15 #4: “The individualized treatment plan, updated every 30 days or as clinically appropriate…” Please clarify if the requirement is that each individual’s treatment plan will be updated at least every 30 days? Requiring treatment plan update every 30 days at a minimum places additional administrative burden on ACT teams. Recommend that treatment plan updates should occur as clinically appropriate or at least every 90 days.

Current regulations require new CNA to be completed if no CMHRS services were provided in 31 days. Recommend that an addendum be considered as sufficient in these circumstances as long as there is a full CNA that has been completed within the last year. In general, language around when a new CNA is to be completed and when an addendum is sufficient is confusing and appears to contradict itself within the regulations. Requiring a new CNA if gap in service of 31 days places additional administrative burden on both employees, individuals, and families. 

 

 

 

CommentID: 98538
 

5/14/21  12:47 pm
Commenter: Morgan Ketner-White

Mental Health Services (formerly CMHRS) App. D Pg. 11
 

*CSACs and CSAC-As may only provide services related to substance use disorder treatment

The wording is a little confusing, is there a way for the wording to become more specific? i.e.

Can individuals under supervision for either CSAC and/or CSAC-A provide services related to substance abuse disorder?

Are Certified addiction treatment professionals not allowed to provide substance use disorder treatment anymore?

Can individuals with CSAC and/or CSAC-A that also hold other license and certifications only provide substance use disorder treatment?

CommentID: 98542
 

5/15/21  4:44 pm
Commenter: Leslie Sharp, NRVCS

App. E
 

Pg. 4 weekly psych oversight; weekly med mgmt. and Pg. 6- requires psych/medical consult within 72 hours of admission.  - Would like for a NP to be considered as a credential for this service.

Pg. 5 -The inclusion of rigorous quality assurance mechanisms that focus on achieving individual outcomes through monitoring treatment fidelity and progress and adjusting treatment goals and plans to address individual needs and barriers as they arise.  Can you further clarify the outcomes?

Pg. 10- Interdisciplinary Team includes Occupational Therapist - is this option or a requirement?

CommentID: 98557
 

5/16/21  8:12 pm
Commenter: Virginia Association of Community-Based Providers (VACBP)

MH-IOP Provider Manual Input
 

BACKGROUND

The Virginia Association of Community-Based Providers (VACBP) was an early supporter of the enhancement of Virginia’s community-based behavioral health Medicaid services.  As the association and our members have participated in the process, our focus has been on ensuring that the behavioral health system offers a continuum of care that:

  • Includes strong prevention and recovery components,
  • Is trauma-informed and evidence-based where possible, and
  • Enables individuals to easily move from service to service without gaps in coverage so that the most appropriate care can be accessed.

 

PROVIDER MANUAL INPUT

As we approach the implementation of those phase one services that will be implemented on July 1, 2021, the VACBP offers the following input on the proposed provider manual changes currently under consideration. Thank you for the opportunity to have our input considered. Please note that all the comments provided are related to Mental Health – Intensive Outpatient (MH-IOP).

 

Medication managementThe VACBP requests that the provider manual more clearly define what “medication management” means and that the requirement that psychiatric oversight include a minimum of weekly medication management be adjusted to a minimum of monthly medication management.

 

Rationale: This change will ensure there is a clear understanding of the specific expectations with respect to medication management and will provide flexibility so the provider can determine what is needed for and in the best interest of each individual patient.

 

Patient choice for primary care physicianThe VACBP requests that an adjustment be made to allow individuals to continue participation in MH-IOP in cases where an individual may prefer to use their primary care physician or an external, established psychiatric provider instead of the psychiatric provider included within the MH-IOP staffing plan, or where the individual declines a referral for a psychiatric evaluation and medication management.

 

Rationale: This will reduce the barriers to receiving this service for those who may benefit from it but are more comfortable seeing an existing primary care physician. This also would enable those who decline a psychiatric evaluation or medication management to participate in MH-IOP. In these cases, the clinician should be required to document the individual’s choice and preferences and engage in service coordination with any outside prescriber.

 

Concurrent MH-IOP and MHSSThe VACBP requests that the prohibition on an individual’s ability to receive both MH-IOP and MHSS concurrently be removed.

 

Rationale: Many individuals admitted to MHSS could benefit from participation in a MH-IOP program. There are concerns that discontinuing the MHSS services would likely cause regression in the individual’s treatment progress. It’s also important to note that the hands-on, practical, and real-time skill-training provided to individuals in their home and community setting through MHSS is outside of the MH-IOP service scope. This may not apply to all patients, but flexibility should be provided to accommodate those cases where both treatments would be beneficial to the individual.

 

Concurrent MH-IOP and TDTThe VACBP requests that the prohibition on an individual’s ability to receive both MH-IOP and TDT concurrently be removed.

 

Rationale: There is concern that limiting concurrent MH-IOP and TDT service authorizations will result in youth who lack the support and intervention needed to function well during the school day and could result in more restrictive service interventions or school placements as a result. MH-IOP aims to significantly increase the youth’s healthy ability to cope, relate interpersonally, and problem-solve. MH-IOP providers who coordinate services with TDT providers are more likely to see these skills generalized across service settings with the goal to successfully discharge from both programs.  The inability to receive MH-IOP and TDT concurrently will likely result in youth and guardians who decline MH-IOP in an effort to preserve TDT services, forfeiting MH-IOP which may be a needed and beneficial service opportunity.

 

90-day assessmentsThe VACBP requests that additional information regarding what is expected to be documented in the assessment required every 90 days be provided and that providers are able to appropriately bill for the assessments.

 

Rationale: It is important that there be a clear understanding of what the expectations are with respect to these assessments and that providers can be reimbursed to provide it. This clarity can also help providers understand how the 90-day assessments will be used and the relationship between this assessment and other required service planning.

 

Accreditation requirementsIn order to better prepare for continued enhancement of Virginia’s Medicaid behavioral health services, it’s important to understand DMAS’s vision with respect to accreditation.

 

Rationale: While a requirement that providers be accreditted is proposed in the case of MH-IOP, there is uncertainty as to whether the vision for the system is likely to include required accreditation for other services as enhancement continues. Given the long timeline and significant cost to becoming and maintaining accreditation, the VACBP requests greater transparency and clarity regarding potential future requirements with which providers will need to comply to provide services.

 

The VACBP urges the elimination or significant reduction of licensing regulations in those cases where a provider is accredited.

 

Rationale: With the requirement that agencies be accreditted in order to provide service, yet another layer of compliance requirements will be added to existing licensing and other related regulations. The VACBP and its members are committed to compliance with all applicable regulations and implementation of best practices to ensure providers are operating at the highest of levels. That being said, multiple layers of requirements are significantly increasing the administrative burden on providers and setting the stage for duplicative and potentially conflicting standards and requirements.

 

Where accreditation is required, the VACBP requests that the rates include all the associated costs, both direct and indirect.

 

Rationale: Even in the case of the rates for MH-IOP, the VACBP is concerned that the true and complete costs to obtain and maintain accreditation are not included in the rates. As there are further requirements imposed on providers, the true and complete costs should be accommodated in the rates.

 

 

The Virginia Association of Community-Based Providers (VACBP) is an association of private-sector organizations that provide community-based behavioral health and substance use disorder treatment to Virginia’s most vulnerable populations. The VACBP is among largest associations representing the interests of private-sector behavioral health providers In Virginia, with more than 50 agencies that have more than 160 facilities across the Commonwealth.

 

The association’s members range from providers with less than 10 employees to more than 500, from agencies with one location to more than 30, serving the behavioral health needs of individuals in all regions of the Commonwealth. Members of the VACBP provide a wide range of behavioral health and SUD services, including Intensive In-Home (IIH), Mental Health Skill Building Services (MHSS), Therapeutic Day Treatment (TDT), Crisis Stabilization (CS), Crisis Intervention (CI), Crisis hotline/texting services, Outpatient (OP), Applied Behavior Analysis (ABA), Psychosocial Rehabilitation (PSR), Supported Employment, Permanent Supportive Housing (PSH), Comprehensive Services Act (CSA)-funded services and Addiction and Recovery Treatment Services (ARTS).

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