Some of the revisions within the ARTS manual are appreciated and positive; however, there are also some revisions that hinder clients access to care.  It is noted that the "CATP" definition has been revised to omit CSAC/CSAC-Supervisees.  With this revision CSAC/CSAC-Supervisees can no longer complete treatment planning and pieces of the assessment in some of the ASAM Levels of Care such as IOP and PHP.  This language also directly conflicts with the "Board of Counseling Scopes of Practice for Persons Regulated by the Board to provide Substance Abuse Treatment."  This document clearly states that CSAC/CSAC-Supervisees do have the ability to conduct pieces of the assessment and treatment planning.  It is also noted that CSAC/CSAC-Supervisees are able to conduct these pieces in the higher/more intensive ASAM levels of care.  If these revisions go through we will not be able to open individuals into treatment as quick as our CSAC/CSAC-Supervisees can no longer be supportive in this way.  It should also be noted that it is difficult to find licensed and licensed-eligible individuals that are trained and have experience in addiction treatment; whereas, CSAC/CSAC-Supervisees specialize in working with the SUD population.  

I am proposing that the language be revised and clearly define a CSAC/CSAC-Supervisee's ability to conduct pieces of the assessment and treatment planning under the direct supervision of a licensed professional for SUD Treatment in the ASAM levels of care such as IOP and PHP.  

Thank you!

I am writing to express my agreement and support for the comments from Crystal Grooms, LPC.  Given the difficulty in recruiting and retaining LMHPs, this unnecessary restriction on the scope of practice for CSACs is unreasonable and will limit the ability to provide needed services to consumers.  Please consider the recommendation to revise this.  Thank you.

Fairfax- Falls Church Community Services Board agrees and supports all the feedback/comments to date below:

1. Chapter II, Provider Participation Requirements, Page: 9 

Assure freedom of choice to individuals in seeking medical care from any institution, pharmacy, or practitioner qualified to perform the service(s) required and participating in the Medicaid Program at the time the service is performed;

• Comments/feedback: Further feedback is needed with this requirement as it pertains to, if clinical input will take precedence when an individuals judgement is impaired.

2. Chapter II, Provider Participation Requirements, Page: 23

Each therapy session must contain the dated co-signature of the supervising provider within three one business days from the date the service was rendered indicating that he or she has reviewed the note. The direct supervisor can be the licensed program supervisor/manager for the agency.

• Comments/feedback: Clear and concise direction is needed regarding whether this flexibility will affect only Licensed Residents and Supervisees, or if will extend to CSACs.

3. Chapter, IV, Covered Services, Page: 26

The Substance Abuse and Mental Health Services Administration (SAMHSA) describe the need for clinicians to use evidence-based screenings and assessments to appropriately and timely to identify individuals at risk for SUD and mental illnesses and be able to engage in treatment. The purpose of screenings for SUD are for individuals who do not have an established SUD diagnosis and to determine whether an individual needs further assessment. The purpose of assessments for SUD are to gather detailed information needed for defining or supporting a diagnosis and development of a treatment plan that is person-centered.

• Comments/feedback: Clarity is needed within this revision regarding if a screening is required for individuals whether or not they have a SUD diagnosis and will need an assessment.

4. Chapter, IV, Covered Services, Page: 30

The comprehensive ISP shall be developed and documented within 30 calendar days of the initiation of services to address needs specific to the member's unique treatment as identified in the multidimensional assessment as applicable to the ASAM Level of Care. If members are discharged from the service prior to 14 the initial 30 calendar days, the provider is still required to have the ISP documented in the member’s medical record.

• Comments/feedback: Additional clarity is needed regarding this revision and what is required from the provider. Please clarify what documentation is needed when an individual is discharged from services prior to 14 calendar days.

5. Chapter, IV, Covered Services, Page: 31

ASAM Level 3.5 to 3.1: The licensed CATPscredentialed addiction treatment professional including Residents in Counseling or Psychology and Supervisees in Social Work, as well as CSACs and CSAC-supervisees in collaboration with interdisciplinary team. The licensed CATPscredentialed addiction treatment professional must sign off on the ISP developed by a CSAC or CSAC-supervisee. CSACs and CSAC-supervisees may perform ISP reviews in Levels 3.1, 3.3, and 3.5 if the CATP signs and dates the ISP within one business day.

• Comments/feedback: Consider parody with other sections of the ARTS manual for this requirement, and allow Residents and Supervisees three business as opposed to one business day for signatures.

6. Chapter, IV, Covered Services, Page: 34

During months where a quarterly review is conducted, no additional documentation is necessary to meet 30 day ISP review requirements.

• Comments/feedback: Clear guidance is needed regarding documentation requirements during months where a quarterly review is due.

7. Chapter, IV, Covered Services, Pages: 39-40

Retroactive requests for authorizations will not be approved with the exception of retroactive Medicaid eligibility for the individual. When retroactive eligibility is obtained, the request for authorization must be submitted to the service authorization contractor no later than thirty (30) days from the date that the individual’s Medicaid was activated; if the request is submitted later than thirty (30) days from the date of activation, the request will be authorized beginning on the date it was received.

• Comments/feedback: Consider not limiting the retroactive request to within 30 days. We recommend the timeframe be extended to at least within 90 days to allow flexibilities to meet this requirement.

CATP  No longer includes:

• licensed marriage and family therapist
• and an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certified substance abuse counselor-assistant (CSAC-A) (18VAC115-30-10) under supervision of a licensed provider

CSAC 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.”

Recommendation:

1. CSACs should be able to prepare ASAM assessment and SUD ISPs at level 2.1 and 2.5 as well as the others listed.
2. Include LMFT in CATP
3. Include CSAC in CATP

Page 41 Peers: New Peers need chance to get credentialed, most do not apply for jobs already certified and registered. The requirement can hinder growth of peer support.

Delete requirement for Peers certification and registration with the Board. Allow peers to gain these expertise over a 15 month period, similar to the time frame given for STEP-VA peers to become certified before billing Medicaid.

Recommend: Not require physician/psychiatrist consult for ISPs or Service Authorizations

If a Licensed Mental Health Professional and/or CATP is completing a SUD assessment for SUD services, no need for a psychiatrist or physician to consult and sign off, nor for it to be required to list their name for a service authorization. This can delay service authorizations and getting into treatment. This is also a concern cost wise and staffing wise during work force shortages. As it is already required to provide a multidisciplinary team, their input would be considered.

We strongly encourage CSAC’s to be able to provide SUD services within their scope of practice as outlined by the Board of Counseling’s most recent guidance document dated January 23, 2020, which states, in part  

“A certified substance abuse counselor shall be (i) qualified to perform, under appropriate supervision or direction, the substance abuse treatment functions of screening, intake, orientation, the administration of substance abuse assessment instruments, recovery and relapse prevention planning, substance abuse treatment, case management, substance abuse or dependence crisis intervention, client education, referral activities, record keeping, and consultation with other professionals; (ii) qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence.”   

We are asking to review CSAC's providing ASAM 1.0 outpatient services that are aligned with the scope of practice of a CSAC, such as individual SUD counseling and psychoeducational groups.  Doing so would reduce barriers to treatment by creating more treatment opportunities for individuals, provide more staffing to serve our population, and increasing engagement.  

• CSAC no longer a CATP – we already have multiple positions for which we are unable to hire.  If the CSAC and CSAC supervisees are  no longer able to provide substance use disorder counseling and psychoeducational services within the scope of their practice, this has potential to significantly limit access to care in our region.
• CSAC cannot complete ASAM assmt or ISP for several service levels - same comment as above
• Peers must be certified and registered with the Board--  we have several open peer positions despite active recruitment efforts. Medicaid reimbursement for peer services and requirements surrounding their clinical work results in the inability for peer billing to sustain a peer position. This results in low salaries for peers. Increasing individual peer paperwork requirements is likely to result in even greater difficulty in recruitment of individuals to these positions.
• Requiring psychiatrist/physician to consult and include name on many service authorizations.  – we have many clients waiting to receive psychiatric services. If the psychiatrists time is diverted to consult and become involved in service authorizations, this has the potential to significantly impact access to care of clients. In addition, ancillary staff would need to be hired to coordinate this administrative burden, which will likely result in  decreased availability of other clinical staff such as nurses for clinical care.

CSAC no longer considered CATP.  Short staffing is already an issue. If a CSAC or CSAC supervisee cannot provide SU counseling/psychoeducation services, it will hinder availability of services to the individuals.  It is difficult to find licensed or licensed eligible staff that have SU experience. CSAC could provide some of the services to close this gap.

Requiring a psychiatrist/physician consult and include name on the service authorizations would be another hinderance to providing services that are already limited in availability.  This would delay authorizations and individuals receiving treatment.

Giving the difficulties of finding both licensed and certified staff, I am disappointed that CSACs will no longer be considered credential addiction treatment professionals (CATP). Also with the additional responsibilities of a licensed staff, I propose that temporary rate increases become permanent. This may help with recruitment.

Please with the increase membership participation in groups. My major concern and a clarification that needs to be made is the conflict between the proposed DMAS regulation, as it relates to staffing, compared to the "draft" licensure regulations as it relates to 3.5 LOC (residential) staffing; especially, during i.e. midnight shifts.

DMAS: "Staff shall provide 24 hours per day awake supervision on site. The provider's staffing plan must be in compliance with DBHDS staffing plan regulations set forth in 12VAC35-105-590 and12VAC35-46-870. However, the DBHDS draft licensure reads: 12VAC35-107-980--clinically managed high-intensity residential services (ASAM LOC 3.5) staff criteria...offer onsite 24-hour a day clinical staffing by credentialed addiction treatment professionals..... Are saying licensed & certified need to be present on midnight shifts and shifts, usually after 8 pm when "treatment sessions" are not going on. Please note that I advocate for the application of the DMAS version versus the DBHDS licensure version.

Not allowing a CSAC to be considered a CATP: We are already struggling with staff shortage due to not being able to find qualified applicants that are licensed and/or licensed eligible that have the SU component experience in our area. Taking away the ability of a CSAC to provider SU services would hinder our services greatly.

Requiring a psychiatrist/physician to consult and be included on PAs could delay authorizations as well as individuals receiving treatment/services. We are already having difficulty with our psychiatrists being available.

I am submitting comment to strongly encourage that CSAC's continue to be considered CATP's.  The "Board of Counseling Scopes of Practice for Persons Regulated by the Board to provide Substance Abuse Treatment" states that CSAC/CSAC-Supervisees are able to conduct pieces of the assessment and treatment planning in various levels of care and these individuals specialize in SUD treatment. As a provider, this would significantly impact our ability to provide the necessary services for the population by individuals who are fully qualified, impact our ability to grow and expand services in process, and this would cause significant barriers in access to the care that is so desperately needed. 

I ask that you please consider CSAC/CSAC-Supervisees as CATP's. 

Thank you!

It is our intention to reiterate what has been stated by other providers regarding the limitations placed on CSAC/CSAC-Supervisee scope of practice.

It is with extreme concern that we strongly suggest the Department rethinks its plan to remove the CSAC as a CATP in our ARTS programs and requiring only  Licensed individuals or individuals under supervision for licensure. We have been effectively employing Bachelors and Masters level CSACs in primary roles, performing ISPs , multidimensional assessments, etc. - many are individuals in recovery, individuals from diverse backgrounds with years of experience , who should not be replaced with individuals just completing a Master’s degree. Our CSACS’s work under the supervision of licensed supervisors and we believe that should be  feasible going forward. They could work in the same capacity as a Masters level individual under supervision for licensure. The consequence for this change will likely create an equity staffing issue and possible termination of long term, quality  employees who are not licensed or currently license eligible. These qualified, experienced staff members would then be replaced with novice, Master's level clinicians who are not as competent to work with our population. Thus, this change would cause a reduction in the quality of services and likely a dramatic reduction in the number of patients able to be served.

We’ve reviewed the proposed chapters in depth and have feedback.

The feedback for Chapter 1 is as follows:

• On page 3 under GENERAL SCOPE OF THE PROGRAM it reads “The determination of medical necessity may be made by the Utilization Review Committee in certain facilities, a peer review organization, DMAS professional staff or DMAS contractors.” How do we know which of these 4 methods will be used for our facility/programs?
• On page 7, the third to last bullet reads “Payment of deductible and coinsurance up to the Medicaid limit less any applicable payments for health care benefits paid in part by Title XVIII (Medicare) for services covered by Medicaid.” Could you please clarify what this means?
• On page 12 it reads “Additionally, some services for managed care enrolled individuals are covered through fee-for-service; these are referred to as managed care carved-out services.” Where can we find a list of common carved-out services as these are not clearly defined within the manual? In which contracts might we find this information?
• On page 14 it reads “A provider may bill a member only when the provider has provided advanced written notice to the member, prior to rendering services that their MCO/Medicaid will not pay for the service.” This language appears to indicate that providers can bill Medicaid patients as private pay if we let them know ahead of time, and it’s a denied service – is that correct?

We’ve reviewed the proposed chapters in depth and have feedback.

The feedback for Chapter 2 is as follows:

• On page 5 it reads “To participate with one of the DMAS-contracted managed care organizations, they must be credentialed and contracted in the MCO’s network.” In this sentence, who is “they?”
• On page 9, the second to last bullet reads “Accept as payment in full the amount reimbursed by DMAS or its contractor. 42 CFR § 447.15 provides that a ‘State Plan must provide that the Medicaid agency must limit participation in the Medicaid Program to providers who accept, as payment in full, the amount paid by the agency ...’” We would like to know how this applies to copays and patient responsibility regarding medications.
• Additionally, is it permissible to use donated funds for Medicaid members for services that are not covered by Medicaid? Are there any related laws or regulations we should consult?
• On page 11, under ADVERSE OUTCOMES it reads “ARTS providers must notify Magellan of Virginia (BHSA) or the appropriate MCO of member adverse outcomes or critical incidents within one business day following knowledge of the incident.” We are seeking operational definitions of “adverse outcomes” and “critical incidents.” How do you define these terms? Also, there isn’t sufficient clarification on the reporting mechanism. Will there be a portal or a specific point of contact?
• On page 22 it reads “[Providers] must also be qualified by training and experience as defined in the American Society of Addiction Medicine (ASAM) Criteria: Treatment Criteria for Addictive, Substance-Related and Co-occurring Conditions, Third Edition…” Please elaborate on the qualifications and documentation required.
• On page 23 we wanted to discuss changes to several items under the heading “Direct Supervision of Residents and Supervisees”
  • Please clarify the difference in definition of psychotherapy vs counseling services.
  • We are seeking a clear definition of “direct, personal” supervision.
  • We would like for you to reconsider the requirement of a licensed provider signing behind a resident or supervisee. Master’s level residents and supervisees have documented supervision and are trusted to work autonomously. The practice of signing-behind each qualified clinician is time-consuming and can cause billing delays.
• On page 27 there are several references to “Clinical Staff.” Now that the definition of CATP and Allied health professionals have been altered, we would like to have a clear definition of the term “Clinical Staff.”
• On page 27, item 5 indicates “Licensed physicians or physician extenders under supervision of a physician shall perform physical examinations for all individuals who are admitted…” Could this be done with a licensed provider over telehealth when a nurse (or other medical staff) is physically present with a patient in the treatment program?
• We've described our concerns regarding the limitation being placed on the CSAC role and its placement in the category of “Allied Health Professional” in a separate comment as this is a major change that is crippling and problematic in several ways.
• On page 40, there are some typographical concerns in the following sentence: “Collaborative, nonclinical, peer-to-peer services that engage, educate, and support an member’s self-help efforts to improve his health, recovery, resiliency, and wellness to assist members in achieving sustained recovery from the effects of mental illness, addiction or both.” It should say “a member” not “aN member.” In addition, it would be best practice to use non gender-specific language so in place of “his health” we should use “their health.”

The feedback for Chapter 4 is as follows:

• Page 10 contains the definition of Allied Health Professional which excludes a person who is a supervisee working toward their CSAC experiential hours. Can this be added to the definition (at the very least)?

We will further discuss our concerns about the placement of CSAC and CSAC Supervisees within this category in a different comment.

• Page 18 contains the definition of Opioid Treatment Services which references “Preferred Office-Based Opioid Treatment (OBOT).” Should this be changed to reflect the new name of this service, “OBAT”?
• Page 23 contains the definition of Telemedicine which exclusively includes “the use of audio and video equipment.” Can a stipulation be added to this that in the event of a technical emergency (utility failure, internet outage, etc.) audio-only services will be accepted?
• Item 2 under MEDICAL NECESSITY CRITERIA on page 25 states that “The member shall be assessed by a CATP, as defined in 12VAC30-130-5020, acting within the scope of their practice…” According to the new definitions, this would exclude CSACs, CSAC Supervisees, and CSAC-As from completing assessments, however, page 38 reads “ARTS Services (as defined in 12VAC30-130-5000 et al) shall meet medical necessity criteria based upon the … multidimensional assessment completed by a CATP or CSAC/CSAC-Supervisee.” These appear to contradict one another, or at the very least, indicate a need for clearer language when referencing “assessments” as a whole. Can a CSAC, CSAC Supervisee, and/or CSAC-A complete a multidimensional biopsychosocial assessment at all levels of care?
  • Furthermore, page 37 and page 38 reference “Clinical Assessment” as distinct from “Multidimensional Assessment.” However, on page 57 it reads “Clinical assessments by the treatment team shall encompass factual, biopsychosocial data;” which overlaps with the definition of a Multidimensional Assessment. We need a clearer understanding of the terms Clinical Assessment and Multidimensional Assessment – how they differ, and who can conduct them.
• Page 26 contains a definition of screening, but does not clearly indicate who can and cannot complete screenings. Can screenings be done by Allied Health Professionals?
• On page29 under Discharge Planning within the ISP, there is a typographical error. The sentence reads “Discharges shall also be warranted when one of the below criteria is meet:” when it should say “is MET.”
• On page 38, we are wondering why a CATP or CSAC can complete progress notes, but a CSAC Supervisee or CSAC-A cannot do this at the residential levels of care (3.1 – 3.7).
• On page 44, it reads “Preferred OBAT services are allowable in ASAM Levels 1.0 through 3.7 excluding inpatient services.” Since level 3.7 is inherently inpatient, why are they included in this statement? In what ways can OBAT services be allowable at the Residential levels?
• On page 55, the second to last bullet states “Time not spent in skilled, clinically intensive treatment is not billable.” We are looking for an operational definition of “skilled, clinically intensive treatment. For example, if yoga group is provided at the PHP/IOP/OP levels of care as a mindfulness, stress reduction, or coping skills group, would this be considered “skilled, clinically intensive treatment”?
• On page 58, the final bullet reads “Clinically directed program activities by CATPs, constituting at least five hours per week of professionally directed treatment…” What is the difference in definition of clinically versus professionally directed treatment? Can a CSAC, CSAC Supervisee, or CSAC-A provide professionally directed treatment?
• On page 60, the third bullet reads “Medication education and management shall be provided.” This should include the same caveat as the preceding two bullets on page 60. We suggest adding the phrasing “Such services are provided either on-site or closely coordinated with an off-site provider.”
• On page 69, we suggest the inclusion of CSAC-As in the statement “Group substance use counseling by CATPs, CSACs and CSAC supervisees shall have a maximum of 12…”
• On page 73, the first bullet indicates that the MCOs and the BHSA now have “72 hours” to respond to the service authorization request. Does this mean that providers now have expanded time to submit service auth requests (especially considering that patients at 3.7 LOC are likely impaired upon initial assessment)?

The feedback for Chapter 5 is as follows:

• On page 5 it reads “Providers should refer to the MCO or the BHSA for information on services that allow span billing.” Is it possible for all MCOs and BHSA to have the same services that allow span billing?
• Page 10 begins the review of Timely Filing. Is it possible for all MCOs and BHSA to have the same timely filing requirements for all Medicaid services to improve ease of billing? In addition, other payers can take longer than the timely filing limit for the MCOs that do not allow 12 months which we believe bolsters the argument for the need for standardization of timely filing limit.
• On page 15, the table referencing Per Diem reimbursement mentions “non-psychotherapy interventions.” We are seeking a clear definition of what this term entails.
• On page 15, the second bullet reads “Other medical and psychological professional services including those furnished by licensed mental health professionals and other licensed or certified health professionals;” We request a clear definition of “psychological professional services.” Does this mean individual and group can now be billed if performed by a licensed person?
• On page 15, the list of services that may be billed separately includes “Non-Emergency Transportation services including transportation to appointments and Family Engagement;” Does this mean we may bill for transportation provided by our staff and/or transportation provided by 3rd party that we pay for? How would we go about billing for this? Is there a formal code or procedure?

The feedback for Chapter 6 is as follows:

• Page 11 reference reports regarding Provider fraud, however it is unclear if reports need to go to the MCOs in addition to Magellan as the language currently reads “Reports may be made to Magellan of Virginia via one of the following methods…”
• Page 12 reviews Member Fraud. If providers make every effort to confirm membership of an individual and do their due diligence, and member fraud is still found to have occurred, does this mean payment for services for this individual will be detracted?
• On page 17 it reads “Checklists and boilerplate or repeated language are not appropriate.” We ask that this be reconsidered in the event patients receive a large group lecture, or psychoeducational seminar as documentation is generally a brief summary of what was presented and an indication of participation level.
• On page 23 under the heading DOCUMENTATION REQUIREMENTS FOR ARTS it reads “Providers must use the Addiction and Recovery Treatment Services (ARTS) Service Authorization Extension Review Form for extension requests for the same ASAM level as the MCOs and the BHSA have agreed to utilize this one form for ARTS service authorization extension requests.” Not all of the MCOs use the ARTS Service Authorization Review Form. Will they be required to use it going forward?
• Page 25 reads “The multidimensional assessment documentation shall support an individualized, person-centered biopsychosocial assessment performed face-to-face…” Will the option to perform multidimensional assessments via telehealth no longer be available after the state of emergency ceases?
• Page 26 and 27 contain information about the Multidimensional Assessment Provider Requirements. We will further discuss our concerns about the limitations placed on CSAC and CSAC Supervisees in a different comment. Regardless we would like the language reflected in 3.5 Re: CSACs to be reflected for all levels of care and include at least CSAC Supervisees.
• On page 29 there is a typographical error in the final bullet, “ISP (s) should be reviewed on a consist basis to ensure treatment goals are being meet and are still applicable to the individual treatment needs of the member.” It should say “CONSISTENT basis.”
• On page 30, under the heading Individual Service Plan (ISP) Provider Requirements for Level 4.0 it appears the Licensed Substance Abuse Treatment Practitioner (LSATP) is missing. Was this done purposefully? We believe the LSATP needs to be explicitly identified among the list of appropriately credentialed clinical staff.

The feedback for the OBOT Supplement is as follows:

• This entire section appears to continuously reference the “OBOT” rather than the “OBAT” which is an overall change in the ARTS manual.
• On page 16 it reads “…Preferred OBOTs and OTPs are required to develop an Individual Service Plan (ISP) within 24 hours from intake…” Does the comprehensive ISP that is built in the coexistent counseling program, with the input of the OBOT staff, sufficiently meet this requirement?
• We are seeking clarification regarding the stated on page 17, “The CSACs and CSAC-Supervisees may not practice autonomously…” Please operationally define “practice autonomously” as the guidance regarding supervision from the Board of Counseling is not sufficient.
• Page 24 references avoiding arbitrary tapering. We feel this is an important addition to the manual and we fully support it.
• On page 25 it reads, “Provide home inductions for buprenorphine products when clinically indicated.” How would billing differ between a home induction versus a face-to-face induction?
• On page 26 it reads “Providers delivering services using telemedicine shall use the modifiers GT (interactive audio and video telecommunications system) or GQ (asynchronous telecommunications system). We ask that the following language be added at the end “to the extent that their systems are equipped to accept the modifiers,” as some MCO systems are not able to accept modifiers. Or will the MCO claim acceptance systems be ready for the GT modifiers?

• CSAC no longer considered a CATP (credentialed addiction treatment professional)-we are already short staffed and if CSAC/ CSAC supervisee cannot provide SU counseling/psychoeducation services, it will hinder availability of services to our clients. It is difficult already to find licensed or licensed eligible staff that have SU experience whereas a CSAC has this experience and has been able to provide SU services before this suggested change.

• Requiring psychiatrist/physician to consult and include name on service authorizations- our psychiatrists are already limited on availability and having to find time to do this would limit their time even more. It would also delay the authorizations and client getting into treatment.

Page 16:

“Please note that Preferred OBOTs and OTPs are required to develop an Individual Service Plan (ISP) within 24 hours from intake and an Interdisciplinary Plan of Care (IPOC) within 30 calendar days an updated at a minimum every 90 calendar days.”

VS.

Page 24:

“Develop and maintain the DMAS Individualized Plan of Care (IPOC) within 30 calendar days from the ISP assessment date if billing Substance Use Care Coordination and ongoing every 90 calendar days. Providers may use the DMAS IPOC form but not required.”

Comments: Clarification is needed between these 2 statements as current standards require updates to IPOC every 30 days. Does this effect billing being limited to every 90 days or 30-90 days? Programs should not be limited to only providing this service every 90 days as evidence shows that we are able to provide a better level of care when care coordination includes IPOC review monthly. 

Page 26:

“o DMAS requires individualized substance use disorder counseling and/or psychotherapy to be provided along with pharmacotherapy. However, DMAS recognizes not all members are ready to engage in counseling or psychotherapy. Providers shall document continuous efforts to engage members in treatment utilizing motivational interviewing techniques, relapse prevention strategies, etc. and are not required to discharge members from pharmacotherapy during this period.”

Comments: Clearer definition is needed as it stated as a requirement, but programs are also not required to discharge members if not engaging. Is there a time frame for which members are given the opportunity to participate in counseling or is it just not a requirement at all if the member prefers not to? How is a program supposed to encourage a member to participate in counseling if they cannot be discharged or referred to a higher level of care- then it is not a requirement.  Isn’t this also part of the ”evidence based” treatment model?  We fear members will understand this to say that therapy is optional, and many will decide not to participate, simple human nature of “I am too busy” etc.  We fear this then could lead to higher relapse rates.  As suggestion would be to allow for a longer time to enroll in counseling, a new member shall enroll, participate within perhaps 30 to 90 days of starting the program.

It is also noted in accordance with other commenters that changes in the definition to CATP’s exclude CSAC’s and throughout the manual CSAC’s have been restricted in services they are able to provide. In acknowledging that staffing requirements are one of the largest obstacles in expanding services and programs, we urge that CSAC’s not be limited in this way so that they may be fully utilized by providers.

Under Medical Necessity Criteria section, it indicates that the patient must have a primary diagnosis of OUD.  That means that patients who are being treated here for other substance use disorders, other than Opioids, don't get reimbursed for ARTS covered services, such as Care Coordination G9012.  We perform the care coordination services on patients with Opioid Use Disorders as well as other Substance Use Disorders and this diagnosis should be expanded to cover services for providers who treat a variety of drug abuse.  Suggestion to modify this section and update from OUD diagnosis to SUD diagnosis to meet the coverage guidelines.  Thank you for your consideration. 

Clear distinction between screening and assessment in terms of timelines.  Screening and assessments are not always completed in the same setting.  In Chapter 4, it states that the Comprehensive ISP is to be completed 30 days from initiation of services, is this at the screening or assessment, or first visit? 

Clarification on functions a CSAC and CSAC-Supervise can perform. Recommended that CSACs/S been given additional functions as long as it fits into their scope.  There is contradictory language on page 25 and 28 concerning function of CSAC.  Page 25 states that  “The member shall be assessed by a CATP, as defined in 12VAC30-130-5020, acting within the scope of their practice…”, however on page 38 it states that the member meets medical necessity based on “multidimensional assessment completed by a CATP or CSAC/CSAC-Supervisee.” However, the new definition of the CATP, does not include CSAC or CSAC-S.

Clarification or revision should be consistent in utilizing terms clinical assessment and multidimensional assessment. Are these being used interchangeably or do they differ based on who can perform them?