Virginia Regulatory Town Hall View Comments

Department of Medical Assistance Services

Board of Medical Assistance Services

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5/2/22 1:18 pm

Commenter: Kim Boyd

Revision

In module 6, I think too much time is spent on reviewing the job descriptions. I would like to see more specific examples what peer support looks like in action. For example, how would a peer support someone who is experiencing an altered reality? A drug induced psychosis? Etc.

add more material on MAT and peer support. More material for veterans and FSP’s. Facilitating group peer support and problem gambling. Provide more information and role playing for MI .

CommentID: 121898

5/4/22 8:21 am

Commenter: Cindy

Ancillary and texting

In reading the information that states PRS is ancillary, I believe that in certain instances it can be utilized as a primary service. For those who go to drop in centers etc, that is strictly peer run, for instance. I personally have received referrals for those who are transitioning out of institutions, who are not on probation but need assistance and support from peers. And during the intake process has been assessed to meet the criteria of "medical necessity."Additionally, some people self-refer as noted in the manual, and they are not utilizing any other services within the agency.

I understand that texting is not billable, however, there should be some verbiage providing understanding that it can be utilized in a progress note. With the times of people who strictly text, it is still a form of communication in which they prefer. I believe in the future a percentage needs to be allocated for billing.

CommentID: 121906

5/5/22 6:55 pm

Commenter: Anonymous

CPRS should be REVIVE trained

All CPRS's should receive the REVIVE opioid overdose and Naloxone training and the REVIVE kits.

CommentID: 121913

5/6/22 12:35 pm

Commenter: Jalna Marie Harris

Additions

1.Mention of HIV/AIDS Support

2.Listing of available training that enhance Recovery Portfolio, Wellness, and Job Readiness

examples are: ECPR, APPR, Personal Medicine, Mental Health First Aid, Revive, MANDT, etc...

3.A page on Organizations that directly affect, relate, help and guide, such as...

Board of Counseling

VA Cert Board

DMAS

DBHDS

ORS

CommentID: 121921

5/6/22 4:03 pm

Commenter: Jesse Wysocki, The McShin Foundation

PRS Manual

I think the PRS training is great and glad we have it. The manual is good. Here are a few things that could possibly help with revised manual.

It would be helpful to the trainers if the manual had examples of role plays to utilize, time frames for modules, and training exercises associated with modules. If we are keeping SUD & MH combined then there should be more detailed training on a PRS role with those with MH. There are far more PRS with SUD then MH and think it would be beneficial to address more MH in the manual or talk in depth on the role the PRS has with those with MH.

Module 6 -- Important module and has good information. Maybe add more about MH here.

Module 7 -- Johari Window (great exercise but would be beneficial if there was some examples of it or more detail on it)

There are a few links that do not work. Should double check those. More information on how a PRS should conduct groups and an actual one on one session. The manual should reflect all information that will be on the CPRS exam. Should add a module on DEI. We should have a module on recovery capital and note taking or at least train on these two more in depth. I don't think there should be a separate module for advanced directives. Pearsons with the pencil/questions are helpful should keep them and have more.

Hope this information is beneficial. Thank you to those putting the time and effort into the PRS manual and helping us to be better trainers and CPRS.

CommentID: 121922

5/24/22 1:36 pm

Commenter: Nicky Fadley, Strength In Peers

Specific feedback on the draft Peer Recovery Support Services Supplement Provider Manual

Dear Acting Director Roberts:

Strength In Peers respectfully submits the following recommendations related to the Town Hall posting of the draft Peer Recovery Support Services Supplement Provider Manual.

The manual should clearly specify that peer support services can be billed under an individual's NPI and license from the Virginia Certification Board for services provided by Peer Recovery Specialists who are employed or contracted by the same entity. The original manual limits peer support billing to organizations licensed by DBHDS. This policy significantly reduces opportunities to sustain and expand access to peer support services. In particular, allowing billing under individuals' licenses and NPIs increases opportunities for non-clinical, peer-run Recovery Community Organizations to partner with clinical providers to offer integrated services supported by Medicaid. Many nonprofit behavioral treatment providers, including free clinics, bill Medicaid under their individual providers' NPIs and these entities represent key possible partners for Recovery Community Organizations wishing to access Medicaid reimbursement. There also is no inherent loss of quality, oversight or capacity in allowing billing under individuals' licenses compared with organizations' licenses.
A key aspect of peer support services is that they meet people where they are. This includes conducting outreach to potential participants and providing transportation. These services should be billable because they significantly help individuals overcome barriers to behavioral health services. To adhere to medical necessity requirements, outreach activities could be billed retroactively for individuals who are later diagnosed and recommended for peer support services. Transportation provided by Peer Recovery Specialists also could be billed at its own rate or in a manner similar to Medicaid transportation benefits.
Given the emergence of telehealth, particularly within behavioral health, the manual should specify that peer support services provided via telehealth are billable. There should be no restrictions on the percentage of total peer support time that can be provided via telehealth. This will increase access to services in rural and other underserved communities, and in the event of another public health emergency that affect's people ability to access in-person care.
Supervision of Peer Recovery Specialists via video conference should be allowed. Face-to-face supervisor should not be the only allowable format for supervision. There is significant evidence that quality supervision, and all manner of effective communication, can occur via video conference.
Peer recovery services delivered in hospital emergency department and crisis settings should be allowed to establish brief goals for immediate post-crisis recovery engagement instead of a full Recovery, Resilience and Wellness Plan due to the nature of the situation and needs of participants in crisis.
Similarly, hospital emergency department and crisis settings do not lend themselves to the requirement that provider submit a registration to the member's MCO or FFS contractor prior to starting services. The manual should provide an exception for these situations.
Although the rates for peer support services were removed from the manual, it should be noted that the $26/hour reimbursement rate is exceptionally low when compared with peer support reimbursement rates in other states. The current rate also is woefully insufficient to cover the costs of peer support services. A higher rate would foster the growth and retention of the peer support workforce, integration of peer support into more mental and behavioral health treatment models, and quality of services.

Strength In Peers is a nonprofit, peer-run Recovery Community Organization serving Harrisonburg City and Rockingham, Page and Shenandoah Counties. We offer peer-led, integrated recovery programs that combine peer support and clinical treatment provided by partners; comprehensive harm reduction; homeless street outreach and jail/prison in reach; and a Community Resource and Recovery Center.

We are grateful for the opportunity to submit public comments and the Commonwealth's continued efforts to strengthen and grow peer recovery support. Please feel free to contact us if you have any questions regarding our recommendations.

Sincerely,

Nicky Fadley, Executive Director

CommentID: 122098

5/27/22 9:03 am

Commenter: Heather Peck, Laurie Mitchell Empowerment & Career Center

Response on the Peer Recovery Support Services Supplement

TO: Department of Medical Assistance Services

FROM: Laurie Mitchell Empowerment & Career Center, Strength in Peers, Robin Hubert,

Becky Graser

DATE: May 27, 2022

SUBJECT: Response on the Peer Recovery Support Services Supplement

In response to the Town Hall posting of the draft Peer Recovery Support Services Supplement Provider Manual, this feedback is respectfully submitted to create the best possible Peer Support service benefit for Medicaid beneficiaries with behavioral health conditions. The comments should be received in the spirit of the authors, promoting recovery and early and meaningful intervention. Recovery Oriented Systems of Care activate Virginians in physical, emotional, mental, and spiritual self-care enriching families, communities, and workplaces. Peer and Family Supporters accompany Virginians to recover and live healthy lives with qualitative and financial ROI, thereby making Virginia the best place to live for everyone.

Comments:

Citation	Policy Statement	COMMENTARY	PROPOSED SOLUTION
General Language	Common use of the male gender references throughout, for instance, “Member and his caregiver need…”	A non-binary term is preferred for creating trusting and collaborative relationship between all persons served and the treatment network/providers. While it is understood that this language proposed here is in payer policy, this modeling of language is crucial for healthcare providers adopting this content into member-facing policy where health engagement and acceptance is crucial and aligned with principles of recovery.	Please use a non-binary pronoun of “their” instead of “his” or “his or her.”
General Language	Variability in the use of “member,” “person,” and “individual”	In some cases, “individual” is struck to be “member” and sometimes the reverse.	Suggested consistent use of either “member” (if that is standard language in other DMAS policy) or use “individual” as the best “person-first” alternative.
Definitions, Family Support Partners	PROPOSED ADDITION: “Services are expected to improve outcomes for youth with complex needs who are involved with multiple systems and…”	This statement implies that the target population is narrowed to “youth with complex needs who are involved with multiple systems.” Given the expectations of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) access expectations, the youth population who can access this service would be significantly broader. Even without the expectations set forth by EPSDT, it would be beneficial to youth who are experiencing an episodic, mild, or moderate behavioral health presentation to have this intervention early in the course of behavioral health treatment and support to promote the concepts of hope and recovery and family-driven self-management skills and understanding. The previous version did not have detail on the narrow target population.	Please remove this language to make Family Support Partner services more accessible to more youth and their families. If this is a priority population, then this writer suggest “Services are expected to improve behavioral health outcomes for youth, especially those youth with complex needs…”
Definitions, Family Support Partners	PROPOSED ADDITION: “Services are expected to improve outcomes for youth with complex needs who are involved with multiple systems and…”	See above and note that the target population is narrowed further by indicating that youth with “complex needs” must also be involved with “multiple systems” which implies child welfare, juvenile justice, school individualized education plan services (IEP), etc. Many youth may have complex clinical presentations and medical necessity for this service without having triggered multi-public agency response. The previous version did not have this detail which now proposes to narrow the target population.	Please remove this language to make Family Support Partner services more accessible to more youth and their families. If this is a priority population, then this writer suggests “Services are expected to improve behavioral health outcomes for youth, especially those youth with complex needs who may be involved with multiple systems…”
Definitions, Family Support Partners	PROPOSED ADDITION: These services are rendered by a PRS who is…(ii) an adult with personal experience with a family member with a similar a mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services.	This commenter supports this addition as PRS family members (such as siblings) increase the workforce numbers who may qualify to deliver services in this time when workforce is thin and play an observable role in Virginia families' seeking recovery pathways.	None recommended.
Provider Enrollment, ARTS	PROPOSED ADDITION: Adds Rural Health Centers, Federally Qualified Health Centers, and Hospital Emergency Rooms as provider types who can enroll.	The addition of these provider types greatly expands access and this commenter applauds these additions.	None recommended.
Provider Enrollment, MH Peer Support Services	PROPOSED ADDITION: Adds youth behavioral health provider-types and names additional behavioral health provider types	The addition of these provider types greatly expands access and this commenter applauds these additions.	None recommended.
Peer Recovery Specialists (header)	NO PROPOSED CHANGE: “The caseload assignment of a full time PRS shall not exceed 15 members at any one time allowing for new case assignments as those on the existing caseload begin to self-manage with less support. The caseload assignment of a part-time PRS shall not exceed 9 members at any one time.”	This proposed maximum member threshold is restrictive and does not give the workforce the opportunity to maximize service delivery in a time where there is an extreme behavioral health workforce crisis. A provider/supervising agency should be able to set case assignment based on the case mix for a PRS. Other state examples of one-to-one peer support include Georgia at a maximum 1:50, Nebraska 1:25, SC – max cap on groups only.	Recommend removing 1:1 maximum caseload altogether or at least raising to 25 members served to promote access.
Supervision of Peer Recovery Specialists , Items 1 and 2	NO PROPOSED CHANGE: “face-to-face, one-to-one supervision” is defined in both items 1 and 2.	Given the emergence of telehealth during the PHE, might the Medicaid agency consider the allowance of telehealth supervision (audio/visual) to reduce the demand on supervisors, promoting the ability to see more PRS back-to-back, increasing the supervision productivity and access for that workforce.	PROPOSED ADDITION to Items 1 and 2: The term face-to-face is inclusive of secure, confidential audio/visual telehealth modalities which allow the PRS and supervisor to freely yet confidentially engage in supervision.
Medical Necessity, ARTS Family Support Partners	PROPOSED CHANGE: “Individuals aged 18-20 who meet the medical necessity criteria for ARTS Peer Support Services may choose to receive ARTS Peer Support Services or Family Support Partners depending on their needs.”	For an emerging adult age 18 through 20, can it be possible for the family members to receive Family Support Partners (providing peer support to the family members who are assisting the emerging adult member towards mastery of his Recovery Plan) and the member to also receive Peer Support Services directly from a PRS who identifies as a “peer?” In this case, the two would be offered in a dyadic model with the family and the member receiving support, preparing the emerging young adult to embrace his own recovery management in the future.	Suggest removing the word “or” herein and replacing with “and/or:” “Individuals aged 18-20 who meet the medical necessity criteria for ARTS Peer Support Services may choose to receive ARTS Peer Support Services or *and/or* Family Support Partners depending on their needs.”
Medical Necessity, MH Family Support Partners	NO PROPOSED CHANGE: “Members 18-20 years old who meet the medical necessity criteria stated above for MH Peer Support Services, who would benefit from receiving peer supports directly, and who choose to receive MH Peer Support Services directly instead of through MH Family Support Partners shall be permitted to receive MH Peer Support Services by an appropriate PRS.”	For an emerging adult age 18 through 20, can it be possible for the family members to receive Family Support Partners (providing peer support to the family members who are assisting the emerging adult member towards mastery of his Recovery Plan) and the member to also receive Peer Support Services directly from a PRS who identifies as a “peer?” In this case, the two would be offered in a dyadic model with the family and the member receiving support, preparing the emerging young adult to embrace his own recovery management in the future.	PROPOSED CHANGE (to mirror ARTS Family Support Partners statement in the row above): “Individuals aged 18-20 who meet the medical necessity criteria for MH Peer Support Services may choose to receive MH Peer Support Services or *and/or* Family Support Partners depending on their needs.”
Language Confusion between the term “Referral” and “Recommendation”	See citations from several sections of the Proposed Supplement: Section titled Referral for Peer Support Services and Family Support Partners: “There are no limits to who can refer members for Peer Support Services and Family Support Partners.” Section titled Assessment and Recommendation for Services and Clinical Oversight ARTS Peer Support Services and Family Support Partners - ARTS Peer Support Services and Family Support Partners shall be rendered following a documented assessment from a referring provider. Referrals must be made by a practitioner who meets the definition of Credentialed Addiction Treatment Professional (CATP) acting within their scope of practice under state law and who is recommending PRS for the member. Section titled: Assessment for Services Any person involved in the member’s treatment, caregiver or community partner can make a referral for services. The member may also self-refer. Once a referral for services is received an assessment for Peer Support Services or Family Support Partners shall be completed and must include the dated signature of the LMHP,…”	While bullets 1 and 2 in column 2 seem clear about the expectation that referral can emanate from any source, the second bullet seems to blend the definition of “referral” with the function of a practitioner recommending a member for a service.	PROPOSED CHANGE (strikethrough deletions and additions in bold/italics): Assessment and Recommendation for Services and Clinical Oversight - ARTS Peer Support Services and Family Support Partners - ARTS Peer Support Services and Family Support Partners shall be rendered following a documented assessment from a ~~referring~~ provider *as defined below. ~~Referrals~~ Recommendations for the service* must be *based upon the assessment and* made by a practitioner who meets the definition of Credentialed Addiction Treatment Professional (CATP) acting within their scope of practice under state law and who is recommending PRS for the member.
Recovery, Resiliency, and Wellness Plan	NO PROPOSED CHANGE: Services with a length of stay fewer than 30 calendar days still require a Recovery, Resiliency, and Wellness Plan. Members receiving Peer Support Services or Family Support Partners within a short-term program require a Recovery, Resiliency, and Wellness Plan as described above during the provision of services that focuses on the identified recovery goals. Providers are to ensure the timely completion of the Recovery, Resiliency, and Wellness Plan while a member is receiving services of durations that are fewer than 30 calendar days.”	With the addition of Hospital Emergency Departments are provider enrollment types being added to the provider network, there should likely be added an accommodation to the Recovery, Resiliency, and Wellness Plan which is modified to reflect the nature of that brief intervention, understanding the stabilization nature of the ED.	PROPOSED CHANGE: Add sentence, “Given the quick turn-around of a PRS-delivered intervention in a Hospital Emergency Department, an abridged Recovery, Resiliency, and Wellness Plan may be utilized, documenting 1-2 brief goals for immediate post-emergency recovery engagement.”
SERVICE AUTHORIZATION AND BILLING LIMITATIONS: ARTS and MH Peer Recovery Support Services	PROPOSED CHANGE: “Providers must submit a registration to the member’s MCO or FFS contractor prior to starting services.”	Generally, Peer Support Services provided in Emergency Departments, in Crisis Stabilization Units, and via Mobile Crisis do not require a registration prior to the start of services. Can DMAS consider this in what will become the final supplement (in accordance with other crisis authorization policy)?	PROPOSED CHANGE (additions in bold/italics): “Providers must submit a registration to the member’s MCO or FFS contractor prior to starting services *(except for Crisis Response services which include Emergency Department-based intervention, Crisis Stabilization Unit services, and Mobile Crisis Services)*.”
RATES	PROPOSED DELETION of Rates	While rates are being removed from this supplement and to be memorialized in on the DMAS or MCO website, it is important to denote the sub-par reimbursement for PRSs via this benefit. This commenters fear is that service access will never increase if the reimbursement, and directly linked wages for the PRS are not competitive for employing providers. For instance, $26/hour with a stellar productive billing time of 30/hours week only yields an agency $40,460/year. Assuming an industry norm for billing time, CEU time, PTO, indirect costs such as EHRs access, Internet access, office space, travel reimbursement, etc. at 25-40%, a PRS would make $30K, a wage which is not competitive in current work markets. Other state rates are provided here as a benchmark: Georgia Medicaid - ~$81/hour, Ohio Medicaid - $62/hour, West Virginia Medicaid - $60/hour, Arizona - ~$68/hour.	If access to PRS-provided supports is to thrive, a livable wage must be supported by the reimbursement rate. Please consider a cost-study for this service in the near term.
Provider Participation and Setting Requirements	PROPOSED CHANGE: “Providers must meet the criteria set forth in Chapter II of this provider manual in addition to the requirements below, etc.”	Non-clinical, peer-run Recovery Community Organization face significant barriers to accessing Medicaid reimbursement, yet they provide critical services to the Medicaid population. These organizations should be allowed to partner with clinical providers that bill Medicaid under their individual licenses and NPIs. Many free clinics and other nonprofit behavioral health providers bill Medicaid under the licenses and NPIs of individual providers. Specifying that billing can occur under a licensed individual’s NPI (as opposed to limiting billing to DBHDS licensed organizations) would foster partnerships among Recovery Community Organization and clinical partners to offer integrated services and access Medicaid reimbursement for peer support services. There also is no inherent loss of quality, oversight or capacity to allowing billing under individuals’ licenses compared with licensed organizations.	Specify that providers operating and billing under their individual NPIs and licenses through the Virginia Certification Board can bill for peer support services provided by Peer Recovery Specialists who are employed or contracted by the same entity.
Limitations: ARTS and MH Peer Recovery Support Services	NO CHANGE: “Non-covered activities include:…”	A key aspect of peer support services is that they meet people where they are. This includes conducting outreach to potential clients and providing transportation. These services should be billable because they significantly help individuals overcome barriers to behavioral health services.	To adhere to medical necessity requirements, outreach activities could be billed retroactively for individuals who are diagnosed and recommended for peer support. Transportation provided by Peer Recovery Specialists could be billed at its own rate or in a manner similar to Medicaid transportation benefits.
Service Delivery: limitation for billing of telephone time	NO CHANGES	This section addresses billing of telephone time as a supplement to face-to-face contact. Increasingly, all manner of behavioral health services are being offered via telehealth (video conference). Peer support provided entirely via telehealth should be included as a billable service in addition to face-to-face contact. This would allow for integrated clinical and peer support programs that are provided via telehealth, particularly to increase access in rural and underserved communities. It also would facilitate these types of services in the event of future public health emergencies that affect people’s ability to access in-person care.	Peer support services provided via telehealth (video conference) should be billable in addition to face-to-face contact. There should not be restrictions on the percentage of total peer support time provided via telehealth.

CC: Leaders who care about strengthening Virginians’ health and the vitality of our workforce.

Cheryl Roberts, Acting Director of Department of Medical Assistance Services

Tammy Driscoll, Senior Advisor, Department of Medical Assistance Services

John Littel, Acting Secretary of Health and Human Resources

Nelson Smith, Commissioner of Department of Behavioral Health and Developmental Services

Nathalie Molliet-Ribet, Executive Director, General Assembly Behavioral Health Commission

Virginia General Assembly Substance Abuse Council

CommentID: 122116

5/27/22 6:07 pm

Commenter: Cristy Corbin, Family Support Partners of Virginia, Inc.

Peer Recovery Support Services Supplement

May 27, 2022

Thank you for the opportunity to provide this public comment.

Please note: In this document, I will use the term “peer supporter” as a general reference to the Peer Recovery Specialist, Family Support Partner, and Youth Support Partner.

As the peer support workforce in Virginia has grown and continues to grow, we now have the role of Youth Support Partner (YSP). This form of peer support is a young adult, typically 18 – 30 years of age, who have direct system(s) experience as a youth. The YSP is in recovery from their behavioral health challenges and is assigned to work with children, adolescents, and/or young adults to support them on their recovery journey. A portion of the YSPs currently working in Virginia have completed the PRS Training and are working on obtaining their certification as a PRS. I would offer to add this role as a recognized form of peer support by DMAS. I would suggest adding this title in all areas that reference “Peer Support Services and Family Support Partners” to state: Peer Support Services, Family Support Partners, and Youth Support Partners.

As peer support is a universal form of support for youth, their family members and individuals on their recovery journey, regardless if it’s mental health or substance use-related, is it possible to not segregate ARTS-specific information from mental health-specific information? I would offer to remove these references to reflect peer support as a form of support for anyone on a recovery journey.

Throughout this document, there are references to “mental health conditions and substance use disorders” and “mental health and substance use disorders”. With the needs of youth, they may not necessarily have actual diagnoses of mental health and/or substance use disorders, however, they do display challenging behaviors. There may be youth with school-related needs that stem from their behaviors, resulting in a 504 Plan or an Individualized Education Plan (IEP). Only using the reference to “mental health and substance use disorders”, may exclude these youth and their caregivers from receiving peer support services that could be instrumental in supporting positive outcomes for these individuals and the overall education system. I would offer to expand the description of caregivers being eligible for a Family Support Partner to include “youth with mental health, emotional and/or behavioral challenges, and/or substance use challenges”. I would offer the same reference for youth who may benefit from the direct support of a Youth Support Partner.

In addition, this document has multiple references to “his or her”; I would offer to use the term “their” to be more gender-inclusive.

PEER RECOVERY SUPPORT SERVICES

1^ST Paragraph:

Peer Recovery Support Services are delivered by trained and certified peer recovery specialists… peer supporters don’t currently have to be certified (in most instances) to work as a peer supporter. We do have to be certified by the Virginia Certification Board and registered with the Board of Counseling in order to bill Medicaid for peer support services. I would offer to remove “and certified” from this sentence.
Further in this same sentence, it is referenced that “…extend the reach of treatment beyond the clinical setting into a member’s community and natural environment…” yet, there is a heavy lean on clinical requirements for the role of a peer supporter. I would offer for DMAS to consider re-evaluating the restrictions around peer support being lumped in with clinical requirements as peer support is a non-clinical form of support that is a highly effective evidence-based model of care, as noted in the next sentence.
The final sentence – “…consumers of mental health and substance use services…” I would offer to change the term “consumers” to “recipients” or “participants” as the word “consumer” may have a negative connotation. This term isn’t typically used in the work as a peer supporter.

2^ND Paragraph:

“…expanded the Medicaid benefit to allow for credentialing and reimbursement…” The term “credentialing” in this sentence implies that as peer supporters are working through the credentialing requirements, i.e., 500 practice hours with supervision, we can bill Medicaid for this time. Is this the intention?

DEFINITIONS:

Behavioral Health Service: I would offer to instead of using the term “mental health and/or substance use disorders” repeatedly throughout this manual to reference “behavioral health challenges” except where specific information is referencing youth. I would offer to use the phrasing as listed at the top of this document.
Caregiver: I would offer “any responsible adult in the primary role of parenting a youth”. The current description may exclude the role of a foster and/or kinship family member. The term “employed” may need to be expounded upon to reflect whether or not foster and/or kinship parents/caregivers are considered “employed” if they receive funding to support their respective youth.
Family Support Partners: I would offer: …provided to the Caregiver of Medicaid-eligible members under age 21 that is the focus of support. Family Support Partners are Caregivers who are successful in the navigation of the child behavioral health system (to include courts, schools, social services, etc.), with their own youth, who is trained to offer support and assistance in helping the Caregivers determine their needs around how to best support their youth and how to access and utilize the resources to address those needs. The services provided to the Caregiver… Services are expected to improve outcomes for youth with challenging behaviors and/or complex needs who are involved in one or more systems and increase the youth and Caregiver’s confidence… These services are rendered by an FSP who is (i) a direct Caregiver of a minor or adult child with a history of challenging behaviors, or (ii) an adult with personal experience with a family member with mental health and/or substance use challenges with direct experience navigating behavioral health resources, services and/or supports.
- PRS (should be FSP) shall perform the service…” or add this same verbiage to the definition of the ”Peer Support Services”.
Peer Recovery Specialist: second sentence – “…from the effects of mental health, substance use disorders…” last sentence – add Youth Support Partners
Peer Recovery Support Services: In acknowledging that the definition in the cited code uses the phrase “mental illness, addiction or both”, this is inconsistent with the terminology in this document. I would offer to use either “behavioral health challenges” or “mental health and/or substance use disorders” to maintain consistency.
Peer Support Services: last sentence – I would offer to remove “illness or disorder” and use the suggested terminology referenced in the previous definition as stated above.
Progress Notes: as peer supporters don’t offer “treatment” per se, I would offer to replace this term with “experiences”. In the behavioral health field, the term “professional” is typically used to identify clinical personnel. I would offer to either add a definition to describe “professional” to show that it encompasses the role of a peer supporter, or remove it from this definition. Because this document is specific to peer support work, I would offer to replace “…staff interventions…” with “PRS/FSP/YSP interventions” or “peer staff interventions”.

Provider Enrollment

While it is appreciated that this list has been expanded to incorporate more environments that a peer supporter could be utilized to impact a youth, their Caregiver and/or an individual’s recovery journey, this list is exclusive to the variety of peer-run agencies, Recovery Community Organizations, and the like, that are located throughout Virginia. Maintaining this exclusionary list will negatively impact the accessibility to the evidence-based model of peer support for those either in recovery or wanting to start their recovery journey. I would offer to add to both the ARTS and MH sections – “Recovery Community Organizations approved by DBHDS’s Office of Recovery Services”; and “Peer-Run agencies approved by DBHDS’s Office of Recovery Services”.

The ARTS list of providers has the General Acute Care Hospital and Hospital Emergency Department listed separately. The MH list has them combined in the first listing. I would offer to replicate the MH entry (#1.) in the ARTS list to maintain consistency.

Peer Recovery Specialists

Peer Support Services and Family Support Partners shall be rendered by a PRS who: Being that there two different definitions for Peer Support Services and Family Support Partners, using “PRS” here seems to actually be excluding the FSP role, based on the definition listed in this manual for the Peer Support Services.

Is sufficiently trained and certified… does this need to be here if it’s included in the definitions of the roles? Or, if it’s here, does it need to be in the definition?
12VAC35-250 – sections 10 & 20 do not incorporate the definition of the Family Support Partner.
Is registered with the Board of Counseling… - this is the first reference in this manual for a PRS needing to be registered in order for peer support services to be considered for reimbursement from Medicaid. I would offer to add “Registered – Certified Peer Recovery Specialist” as a definition in the beginning of this manual.

In considering the effects of language and the fact that peer support services are nonclinical, I would offer the following: remove the term “caseload” and replace it with “assignment load”; remove the term “client” and replace it with “youth”, “Caregiver” and “individual”; or remove it all together to reflect “…time allowing for new assignments as those…”

In addition, I believe assignment loads (FT – 15/ PT – 9) should be determined by the Supervisor and their peer support staff based on the peer supporter’s availability and ability to effectively provide the service, as well as the program’s needs. Does DMAS offer these types of limitations on other professions?

Supervision of Peer Recovery Specialists

I would offer to expand this reference to include the Family Support Partner.

Direct Supervision of the PRS shall be provided as needed…

1. …less than 12 months…
2. …over 12 months and fewer than 24 months…

As referenced in the section above, supervision needs should be determined by the Supervisor based on their program’s needs. I would offer to remove numbers one and two in this section. Also, are these recommendations stipulated in other professions?

Service Delivery

…services may be rendered in the provider’s office or in the community, or both. Does the term “community” incorporate the youth and Caregiver’s or individual’s home? Does it incorporate a school, court or other provider’s office? In the role of the FSP (and YSP), this form of peer support is routinely provided in the home, at IEP meetings, during court hearings, and occasionally during medication management appointments. The FSP functions as an additional set of eyes and ears on behalf of the Caregiver to ensure they are understanding what is being asked or expected of them, as well as encouraging and empowering them to speak up for their family’s needs.

Billing shall occur only for services provided with the member present. I would offer - Module 18 of the PRS Training curriculum discusses the aspects of advocacy to include self-advocacy, advocacy for others and system advocacy. There are times when the peer supporter needs to communicate with system partners on behalf of the youth, their Caregiver or the individual to ensure their voice and choice is heard and understood by that system partner. This also may occur when the system partner isn’t being heard and understood by the youth, their Caregiver or the individual, and the peer supporter can help bridge this gap/repair these relationships. This is a form of advocacy within the role of a peer supporter and should be included as a billable service with clear documentation on the purpose and intent of these interactions.
Telephone time… Frequently, youth and individuals prefer to communicate by text messaging or virtual/video conferencing due to their diagnoses of anxiety and being comfortable with speaking on the phone. This restriction “…to 25% or less of total time per recipient per calendar year.” may impede the effectiveness of the peer support service. While peer supporters typically make every effort to meet face-to-face, this may not always be accomplished based on the member’s needs and challenges. I would offer to expand the acceptance of text messaging as a recognized form of communication in providing peer support as well as the use of virtual/video conferencing.
Contact shall be made with the member… I would offer to remove” receiving Peer Support Services or Family Support Partners” as this seems redundant.
Peer Support Services or Family Support Partners may operate… Services shall not be delivered at the same time and within the same space of another service. I would offer to remove this last sentence. In the work as an FSP, it is routinely practiced that FSPs work alongside the Intensive Care Coordination service, Intensive In-home Services, Functional Family Therapy, Mental Health Skill-Building, and even outpatient therapy or medication management appointments. The FSP supports the youth and their Caregiver in understanding what is being asked or expected of them and ensuring their voice and choice is being heard and understood by the other provider. The FSP has been instrumental in ensuring the other provider’s expectations of the youth and their Caregiver are followed through on and there is consistent communication with that provider both from the family as well as the FSP. This is usually referred to in reporting as “Team Collaboration”.
Peer Support Services shall be an ancillary service…I would offer to remove this statement as there are aspects of peer support, i.e., emergency departments, crisis stabilization units, mobile crisis teams, etc., where the peer supporter is the first contact for recovery supports. This indicates that the Peer Support Service is the primary service and could lead to the youth, their Caregiver or individual pursuing further forms of supports and/or services to enter into or maintain their recovery.

ARTS – Peer Support Services

3. Demonstrate moderate to severe functional impairment… because peer support is nonclinical and it is expected to use a strength-based approach to include language – I would offer to rephrase “functional impairment” to “needs and/or challenges”.

ARTS Family Support Partners

With the definition of the Family Support Partner including “…or (ii) an adult with personal experience with a family member with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services.” there is a consistent reference to FSPs being in the role of supporting the Caregivers of the identified youth Medicaid member. There is no reference to the adult family member FSP being able to support another adult family member who is navigating the challenges of their loved one dealing with behavioral health challenges. Is it DMAS’s intention that only Caregivers with youth can be supported by an FSP or is it intended that adult family members FSPs can support other adult family members of an adult individual-Medicaid member? There seems to be confusion around the part 2 definition of the FSP and how this is intended to be implemented in Virginia.
With the addition of the reference to “Individuals aged 18-20 who meet medical necessity criteria…” I would offer to add additional language to reflect that the Caregiver of this young adult may still have access to an FSP as well as add that the individual may opt to continue working with their Youth Support Partner, should they have one prior to their 18^th birthday or acquire a YSP after turning 18.

DOCUMENTATION OF REQUIRED ACTIVITIES

Last sentence – “This documentation shall be written, signed, and dated…” Is the term “written” literal?

Recovery, Resiliency, and Wellness Plan

Second paragraph, second sentence – typo “qualitied” should be “qualified”

Review of Recovery, Resiliency, and Wellness Plan

First sentence - …every 90 calendar days with the member and family or caregiver as applicable. I would offer for consistency in language, remove “and family”.
…(ii) be conducted in a manner that enables the member… I would offer to add “or Caregiver as applicable”.

Progress Notes

In this section, add “or Caregiver as applicable” where “member” is referenced.

Care Coordination Documentation

First paragraph – last sentence – please see the above comments regarding advocacy in the role of the peer supporter and Team Collaboration.

SERVICE AUTHORIZATION AND BILLING:…

Second paragraph – are there service delivery limits placed on other professions? I would offer to allow the Supervisor to determine the needs of their peer support program to determine how the peer supporter is utilized.
Rates for ARTS and Mental Health services are available on the DMAS website… the memo references the 12.5% temporary rate increase being valid through June 30, 2022. Through a variety of stakeholder meetings and conversations with CSBs and private providers, billing Medicaid for peer support services has been a limited option for most due to the reimbursement rates that Virginia has in place. I would offer to make it a priority to raise the peer support reimbursement rate permanently to ensure broader access to this evidence-based model. And, has there been any research conducted to determine whether or not there was an increase in the billing for peer support services from July 1, 2021 through June 30, 2022 when the temporary increase was in place?

LIMITATIONS:…

Last paragraph on page 22 – Family Support Partners is allowable only when the service is directed… with the definition of an FSP including an adult family member, are youth and their Caregivers the only target population for this role?

Respectfully submitted,

Cristy A. Corbin, CPRS

President-Family Support Partners of Virginia, Inc.

804.723.1215

CommentID: 122117