Proposed Text
12VAC30-60-181. Utilization review of addiction, and
recovery, and treatment services.
A. Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in the provider's care. Such documentation shall fully disclose the extent of services provided in order to support provider's claims for reimbursement for services rendered. This documentation shall be written and dated at the time the services are rendered. Claims that are not adequately supported by appropriate up-to-date documentation may be subject to recovery of expenditures.
B. Utilization reviews shall be conducted by the Department of Medical Assistance Services or its designated contractor.
C. Service authorizations shall be required for American Society of Addiction Medicine (ASAM) Levels 2.1, 2.5, 3.1, 3.3, 3.5, 3.7, and 4.0.
D. A multidimensional assessment by a credentialed addiction
treatment professional, (CATP), as defined in 12VAC30-130-5020, shall be
required for ASAM Levels 1.0 through 4.0. Certified Substance Abuse
Counselors (CSACs) are able to complete a multidimensional assessment to make
recommendations for an ASAM level of care, which shall be signed and dated by a
CATP within one business day. The multidimensional assessment shall be
maintained in the individual's record by the provider. Medical necessity for
all ASAM levels of care shall be based on the outcome of the
individual's multidimensional assessment.
E. Individual service plans (ISPs) and treatment plans shall be developed upon admission to medically managed intensive inpatient services (ASAM Level 4.0), substance use residential and inpatient services (ASAM Levels 3.1, 3.3, 3.5, and 3,7), and substance use intensive outpatient and partial hospitalization programs (ASAM Levels 2.1 and 2.5). ISPs or treatment plans shall be developed upon initiation of opioid treatment services (OTP) and office-based opioid treatment (OBOT); and substance use outpatient services (ASAM Level 1.0).
1. The provider shall include the individual and the family or caregiver, as may be appropriate, in the development of the ISP or treatment plan. To the extent that the individual's condition requires assistance for participation, assistance shall be provided. The ISP shall be updated at least annually and as the individual's needs and progress change. An ISP that is not updated either annually or as the individual's needs and progress change shall be considered outdated.
2. All ISPs shall be completed and contemporaneously signed and
dated by the credentialed addiction treatment professional CATP
preparing the ISP. For Levels 3.1, 3.3, and 3.5, the ISP may be
completed by a CSAC if the CATP signs and dates within one business day.
3. The child's or adolescent's ISP shall also be signed by the parent or legal guardian, and the adult individual shall sign his own ISP. If the individual, whether a child, adolescent, or adult, is unwilling or unable to sign the ISP, then the service provider shall document the reasons why the individual was not able or willing to sign the ISP.
F. A comprehensive ISP, as defined in 12VAC30-50-226 12VAC30-130-5020,
shall be fully developed within 30 calendar days of the initiation of services.
The comprehensive ISP shall be developed with the individual, in consultation
with the individual's family, as appropriate, and shall address (i) a summary
or reference to the individual's identified needs; (ii) short-term and
long-term goals and measurable objectives for addressing each identified
individually specific need; (iii) services and supports and frequency of
services to accomplish the goals and objectives; (iv) target dates for
accomplishment of goals and objectives; (v) estimated duration of service; (vi)
medication assisted treatment assessment provided on-site or through referral; and
(vi) (vii) the role or roles of other agencies if the plan is a
shared responsibility and the staff designated as responsible for the
coordination and integration of services. The ISP shall be reviewed at least
every 90 calendar days and shall be modified as the needs and progress of the
individual changes. Documentation of the ISP review shall include the dated
signatures of the credentialed addiction treatment professional CATP
and the individual. CSACs may perform the ISP reviews in Levels 3.1,
3.3, and 3.5 if a CATP signs and dates within one business day.
G. Progress notes, as defined in 12VAC30-50-130
12VAC30-60-185, shall disclose the extent of services provided and
corroborate the units billed. Claims not supported by corroborating progress
notes may be subject to recovery of expenditures. Each progress note
shall be individualized to the member to demonstrate the individual's
particular circumstances, treatment, and progress. Claim payments shall be
retracted for services that are not supported by documentation that is
individualized to the member.
H. Documentation shall include assessment and referral for medication assisted treatment as medically indicated.
12VAC30-60-185. Utilization review of substance use case management.
A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:
"Face-to-face" means the same as defined in 12VAC30-130-5020.
"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226 12VAC30-130-5020.
"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes and are part of the minimum documentation requirements that convey the individual's status, staff intervention, and as appropriate, the individual's progress or lack of progress toward goals and objectives in the ISP. The progress notes shall also include, at a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units/hours required to deliver the service. The content of each progress note shall corroborate the time/units billed for each rendered service. Progress notes shall be documented for each service that is billed.
"Register" or "registration" means notifying the Department of Medical Assistance Services or its contractor that an individual will be receiving services that do not require service authorization such as outpatient services for substance use disorders or substance use case management.
B. Utilization review: substance use case management services.
1. The Medicaid enrolled individual shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for a substance use disorder. Tobacco-related disorders or caffeine-related disorders and nonsubstance-related disorders shall not be covered.
2. Reimbursement shall be provided only for "active" case management. An active client for substance use case management shall mean an individual for whom there is a current substance use individual service plan (ISP) in effect that requires a minimum of two distinct substance use case management activities being performed each calendar month and at a minimum one face-to-face client contact at least every 90-calendar-day period.
3. Billing can be submitted for an active recipient only for months in which a minimum of two distinct substance use case management activities are performed.
4. An ISP shall be completed within 30 calendar days of initiation of this service with the individual in a person-centered manner and shall document the need for active substance use case management before such case management services can be billed. The ISP shall require a minimum of two distinct substance use case management activities being performed each calendar month and a minimum of one face-to-face client contact at least every 90 calendar days. The substance use case manager shall review the ISP with the individual at least every 90 calendar days for the purpose of evaluating and updating the individual's progress toward meeting the individualized service plan objectives.
5. The ISP shall be reviewed with the individual present, and the outcome of the review documented in the individual's medical record.
C. Utilization review: substance use case management services.
1. Utilization review general requirements. Utilization reviews shall be conducted by DMAS or its designated contractor. Reimbursement shall be provided only when there is an active ISP and a minimum of two distinct substance use case management activities are performed each calendar month and there is a minimum of one face-to-face client contact at least every 90-calendar-day period. Billing can be submitted only for months in which a minimum of two distinct substance use case management activities are performed within the calendar month.
2. In order to receive reimbursement, providers shall register this service with the managed care organization or the behavioral health services administration, as required, within one business day of service initiation to avoid duplication of services and to ensure informed and seamless care coordination between substance use treatment and substance use case management providers.
3. The Medicaid eligible individual shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for a substance use disorder with the exception of tobacco-related disorders or caffeine-related disorders and nonsubstance-related disorders.
4. Substance use case management shall not be billed for individuals in institutions for mental disease, except during the month prior to discharge to allow for discharge planning, limited to two months within a 12-month period. Substance use case management shall not be billed concurrently with any other type of Medicaid reimbursed case management and care coordination.
5. The ISP, as defined in 12VAC30-50-226 12VAC30-130-5020,
shall document the need for substance use case management and be fully completed
within 30 calendar days of initiation of the service and the substance use case
manager shall review the ISP at least every 90 calendar days. Such reviews
shall be documented in the individual's medical record. If needed a grace
period will be granted following the date of the last review. When the review
is completed in a grace period, the next subsequent review shall be scheduled
90 calendar days from the date the review was initially due and not the date of
actual review.
6. The ISP shall be updated and documented in the individual's medical record at least annually and as an individual's needs change.
7. The provider of substance use case management services shall be licensed by Department of Behavioral Health and Developmental Services as a provider of substance use case management and credentialed by the behavioral health services administration or managed care organization as a provider of substance use case management services.
8. Progress notes, as defined in subsection A of this section, shall be required to disclose the extent of services provided and corroborate the units billed.
12VAC30-70-418. Reimbursement for residential and inpatient substance use treatment services.
1. The following substance use disorder treatment services for adults and adolescents are provided in a residential or inpatient setting: (i) clinically managed population-specific high intensity residential service (ASAM Level 3.3); (ii) clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5); (iii) medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7); and (iv) medically managed intensive inpatient services (ASAM Level 4.0).
2. If one of the services in subdivision 1 is furnished to individuals in a freestanding psychiatric hospital or inpatient psychiatric unit of an acute care hospital, reimbursement shall be based on the hospital reimbursement described in 12VAC30-70-241 and the reimbursement of services provided under arrangement described in 12VAC30-80.
3. If one of the services in subdivision 1 is furnished to individuals in an appropriately licensed residential setting, reimbursement shall be based on the psychiatric residential treatment facility (Level C) reimbursement described in 12VAC30-70-417.
12VAC30-80-32. Reimbursement for substance use disorder services.
A. Physician services described in 12VAC30-50-140, other licensed practitioner services described in 12VAC30-50-150, and clinic services described in 12VAC30-50-180 for assessment and evaluation or treatment of substance use disorders shall be reimbursed using the methodology in 12VAC30-80-30 and 12VAC30-80-190 subject to the following reductions for psychotherapy services for other licensed practitioners.
1. Psychotherapy and substance use disorder counseling services of licensed clinical psychologists shall be reimbursed at 90% of the reimbursement rate for psychiatrists.
2. Psychotherapy and substance use disorder counseling
services provided by independently enrolled licensed clinical social workers,
licensed professional counselors, licensed marriage and family therapists,
licensed psychiatric nurse practitioners, licensed substance abuse treatment
practitioners, or licensed registered clinical nurse
specialists-psychiatric shall be reimbursed at 75% of the reimbursement rate
for licensed clinical psychologists.
3. The same rates shall be paid to governmental and private providers. These services are reimbursed based on the Common Procedural Terminology codes and Healthcare Common Procedure Coding System codes. The agency's rates were set as of July 1, 2007, and are updated as described in 12VAC30-80-190. All rates are published on the Department of Medical Assistance Services (DMAS) website at www.dmas.virginia.gov.
B. Rates for the following addiction and recovery treatment
services (ARTS) physician and clinic services Preferred Office-Based
Treatment Services (OBOT) and Opioid Treatment Programs shall be based on
the agency fee schedule: (i) initiation of medication assisted
treatment induction with a visit unit of service; (ii) individual
and group substance use disorder counseling and psychotherapy with a
15-minute unit of service; and (iii) substance use care coordination with a
monthly unit of service. The agency's rates shall be set as of April 1, 2017.
The Medicaid and commercial rates for similar services as well as the cost for
providing services shall be considered when establishing the fee schedules so
that payments shall be consistent with economy, efficiency, and quality of
care. The same rates shall be paid to public and private providers. All rates
are published on the DMAS website at www.dmas.virginia.gov.
C. Community ARTS rehabilitation services. Per diem rates for clinically
managed low intensity residential services (ASAM Level 3.1), partial
hospitalization (ASAM Level 2.5), and intensive outpatient (ASAM Level 2.1) for
ARTS shall be based on the agency fee schedule. The Medicaid and commercial
rates for similar services as well as the cost for providing services shall be
considered when establishing the fee schedules so that payments shall be
consistent with economy, efficiency, and quality of care. The same rates shall
be paid to governmental and private providers. The agency's rates shall be set
as of April 1, 2017, and are effective for services on or after that date. All
rates are published on the DMAS website at: www.dmas.virginia.gov.
D. Reimbursement for all clinically managed low intensity residential (ASAM Level 3.1) services shall be based on the therapeutic group home (Level B) reimbursement described in 12VAC30-80-30.
D. E. ARTS federally qualified health center or
rural health clinic services (ASAM Level 1.0) for assessment and evaluation or
treatment of substance use disorder, as described in 12VAC30-130-5000 et seq.,
shall be reimbursed using the methodology described in 12VAC30-80-25.
E. F. Substance use case management services.
Substance use case management services, as described in 12VAC30-50-491, shall
be reimbursed a monthly rate based on the agency fee schedule. The Medicaid and
commercial rates for similar services as well as the cost for providing
services shall be considered when establishing the fee schedules so that
payment shall be consistent with economy, efficiency, and quality of care. The
same rates shall be paid to governmental and private providers. The agency's
rates shall be set as of April 1, 2017, and are effective for services on or
after that date. All rates are published on the DMAS website at
www.dmas.virginia.gov.
F. G. Peer support services. Peer support
services as described in 12VAC30-130-5160 through 12VAC30-130-5210 furnished by
enrolled providers or provider agencies as described in 12VAC30-130-5190 shall
be reimbursed based on the agency fee schedule for 15-minute units of service.
The agency's rates set as of July 1, 2017, are effective for services on or
after that date. All rates are published on the DMAS website at:
www.dmas.virginia.gov.
12VAC30-130-5010. Addiction and recovery treatment services; purpose.
The purpose of this part shall be to establish coverage of treatment for substance use disorders as defined in the American Society of Addiction Medicine (ASAM) Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, Third Edition, as published by the American Society of Addiction Medicine including outpatient physician, nurse practitioner, and clinic services, including evidence-based medication assisted treatment, intensive outpatient services, partial hospitalization services, residential treatment services, and inpatient withdrawal management services as defined in 12VAC30-130-5040 through 12VAC30-130-5150.
12VAC30-130-5020. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Abstinence" means the intentional and consistent restraint from the pathological pursuit of reward or relief, or both, that involves the use of substances.
"Addiction" means a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction is defined as the inability to consistently abstain, impairment in behavioral control, persistence of cravings, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
"Addiction-credentialed physician" means a physician who holds a board certification in addiction medicine from the American Board of Addiction Medicine, a subspecialty board certification in addition to certification in psychiatry from the American Board of Psychiatry and Neurology, or subspecialty board certification in addition medicine from the American Osteopathic Association. DMAS also recognizes physicians with the DATA 2000 buprenorphine waiver and physicians treating addiction who have specialty training or experience in addiction medicine or addiction psychiatry. If treating adolescents, physicians shall have experience and specialty training with adolescent medicine.
"Adherence" means the individual receiving treatment has demonstrated his ability to cooperate with, follow, and take personal responsibility for the implementation of his treatment plans.
"Adolescent" means an individual from 12 years of age to 20 years of age.
"Allied health professional" means counselor aides or group living workers who meet the DBHDS licensing requirements for unlicensed staff in residential settings.
"ARTS" means addiction and recovery treatment services.
"ARTS care coordinator" means an employee of DMAS, its contractor, or MCO who is a licensed practitioner of the healing arts, including a physician or medical director, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed substance abuse treatment practitioner, licensed marriage and family therapist, nurse practitioner, or registered nurse with two years of clinical experience in the treatment of substance use disorders. The ARTS care coordinator performs independent assessments of requests for all ARTS intensive outpatient programs (ASAM Level 2.1); partial hospitalization programs (ASAM Level 2.5); residential treatment services (ASAM Levels 3.1, 3.3, 3,5, and 3.7); and inpatient services (ASAM Level 3.7 and 4.0).
"ASAM criteria" means the six different life areas used by the ASAM Patient Placement Criteria to develop a holistic biopsychosocial assessment of an individual that is used for service planning, level of care, and length of stay treatment decisions.
"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS. The DMAS designated BHSA shall be
authorized to constitute, oversee, enroll, and train a provider network;
perform service authorization; adjudicate claims; process claims; gather and
maintain data; reimburse providers; perform quality assessment and improvement;
conduct member outreach and education; resolve member and provider issues; and
perform utilization management including care coordination for the provision of
Medicaid-covered behavioral health services. DMAS shall retain authority for
and oversight of the BHSA entity or entities.
"BHA" means behavioral health authority.
"Biomedical" means biological or physical aspects of a member's condition that require assessment and services that are delivered by appropriately credentialed medical staff, who are available to assess and treat co-occurring biomedical disorders that may be the result of, or independent of, a substance use disorder.
"Buprenorphine-waivered practitioners" means
health care providers licensed under Virginia law and registered with the Drug
Enforcement Administration (DEA) to prescribe Schedule III, IV, or V
medications for treatment of pain. Physicians shall have completed the
buprenorphine waiver training course and obtained the waiver to prescribe or
dispense buprenorphine for opioid use disorder required under the Drug
Addiction Treatment Act of 2000 (DATA 2000). have obtained the
buprenorphine waiver through the Drug Addiction Treatment Act of 2000 (DATA
2000). They shall have been issued a DEA-X number by the DEA to
prescribe buprenorphine for the treatment of opioid use disorder. Practitioners
Nurse practitioners and physician assistants shall have obtained the
buprenorphine waiver through DATA 2000. who are not physicians must Practitioners
shall meet all federal and state requirements and be supervised by or work
in collaboration with a qualifying physician who is buprenorphine waivered. as
required by the applicable regulatory board. Nurse practitioners may
practice without a written or electronic practice agreement with a qualifying
physician as set forth in §54.1-2957 of the Code of Virginia. All
buprenorphine-waivered practitioners shall have a DEA-X number to prescribe
buprenorphine for the treatment of opioid use disorder.
"Care coordination" means collaboration and sharing
of information among health care providers who are involved with an
individual's health care to improve assist in improving the care of
the individual. This includes e-consultations from primary care to
specialists.
"Certified substance abuse counselor" or "CSAC" means the same as defined in § 54.1-3507.1 of the Code of Virginia.
"Certified substance abuse counseling-assistant" or "CSAC-A" means the same as defined in § 54.1-3507.2 of the Code of Virginia.
"Certified substance abuse counselor-supervisee" means an individual who has completed the educational requirements described in § 54.1-3507.1 C (i) of the Code of Virginia, but who has not completed the practice hours described in § 54.1-3507.1 C (ii) of the Code of Virginia.
"Child" means an individual from birth up to 12 years of age.
"Clinical experience" means, for the purpose of these ARTS requirements, practical experience in providing direct services to individuals with diagnoses of substance use disorder. Clinical experience shall include supervised internships, supervised practicums, or supervised field experience. Clinical experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience.
"Co-occurring disorders" means the presence of
concurrent substance use disorder and mental illness without implication as to
which disorder is primary and which secondary, which disorder occurred first,
or whether one disorder caused the other. Other terms used to describe
co-occurring disorders include "dual diagnosis,'' "dual disorders,''
"mentally ill chemically addicted (MICA)," "chemically addicted
mentally ill (CAMI),'' "mentally ill substance abusers (MISA),''
"mentally ill chemically dependent (MICD),'' "concurrent disorders,''
"coexisting disorders,'' "comorbid disorders,'' and "individuals
with co-occurring psychiatric and substance symptomatology (ICOPSS)."
"Counseling" means the same as defined in § 54.1-3500 of the Code of Virginia.
"Credentialed addiction treatment professionals" or
"CATP" means an individual licensed or registered with the appropriate
Board in the following roles: (i) an addiction-credentialed physician or
physician with experience or training in addiction medicine; (ii) physician
extenders with experience or training in addiction medicine; (iii) a
licensed psychiatrist; (iv) a licensed clinical psychologist; (v)
a licensed clinical social worker; (vi) a licensed professional
counselor; (vii) a certified psychiatric clinical nurse
specialist; (viii) a licensed psychiatric nurse practitioner; (ix)
a licensed marriage and family therapist; (x) a licensed substance abuse
treatment practitioner; (xi) residents under supervision of a licensed
professional counselor (18VAC115-20-10), licensed marriage and family therapist
(18VAC115-50-10), or licensed substance abuse treatment practitioner
(18VAC115-60-10) and in a residency approved by registered with
the Virginia Board of Counseling; (xii) residents in psychology under
supervision of a licensed clinical psychologist and in a residency approved
by registered with the Virginia Board of Psychology
(18VAC125-20-10); or (xiii) supervisees in social work under the
supervision of a licensed clinical social worker approved by and
registered with the Virginia Board of Social Work (18VAC140-20-10); or
an individual with certification as a substance abuse counselor (CSAC)
(18VAC115-30-10) accordance with 54.1-3507.1 of the Code of Virginia; or
certification as a substance abuse counseling-assistant (CSAC-A)
(18VAC115-30-10) of the Code of Virginia.
"CSB" means community services board.
"DBHDS" means the Department of Behavioral Health and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.) of Title 37.2 of the Code of Virginia.
"DHP" means the Department of Health Professions.
"DMAS" or "the department" means
the Department of Medical Assistance Services and its contractor or contractors
consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of
Virginia.
"DSM-5" means the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric Association.
"Evidence-based" means an empirically-supported clinical practice or intervention with a proven ability to produce positive outcomes.
"Face-to-face" means encounters that occur in person or through telemedicine.
"FAMIS" means the Family Access to Medical
Insurance Security Plan as set out in 12VAC30-141.
"FQHC" means federally qualified health center.
"Individual" means the patient, client, beneficiary, or member who receives services set out in 12VAC30-130-5000 et seq. These terms are used interchangeably.
"Individual service plan" or "ISP" means the
same as the term is defined in 12VAC30-50-226. an initial and
comprehensive treatment plan that is regularly updated and specific to the
individual's unique treatment needs as identified in the assessment. The
ISP contains, but is not limited to, the individual's treatment or training
needs, the individual's goals and measureable objectives to meet the identified
needs, services to be provided with the recommended frequency to accomplish the
measurable goals and objectives, and an individualized discharge plan that
describes transition to other appropriate services. The individual shall
be included in the development of the ISP and the ISP shall be signed by the
individual. If the individual is a minor, the ISP shall also be signed by
the individual's parent or legal guardian. Documentation shall be
provided if the individual, who is a minor child or an adult who lacks legal capacity,
is unable or unwilling to sign the ISP.
"Induction phase" means the medically monitored initiation of buprenorphine, buprenorphine/naloxone, naltrexone, or methadone treatment performed in a qualified practitioner's office or licensed OTP. The goal of the induction phase is to find the individual's ideal dose of buprenorphine, buprenorphine/naloxone, naltrexone, or methadone. The ideal dose minimizes both side effects and drug craving.
"Licensed practical nurse" means a professional who is licensed by the Commonwealth as a practical nurse or holds a multi-state licensure privilege to practice practical nursing according to 18VAC90-19-80.
"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the Code of Virginia, which means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis that (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with, or employed by the health carrier.
"Medication assisted treatment" or "MAT" means the same as 42 CFR 8.2.
"Multidimensional assessment" or "assessment" means
the individualized, person-centered biopsychosocial assessment performed
face-to-face, in which the provider obtains comprehensive information from the
individual (including family members and significant others as needed)
including history of the present illness; family history; developmental
history; alcohol, tobacco, and other drug use or addictive behavior history;
personal/social history; legal history; psychiatric history; medical history;
spiritual history as appropriate; review of systems; mental status exam;
physical examination; formulation and diagnoses; survey of assets,
vulnerabilities and supports; and treatment recommendations. The ASAM
multidimensional assessment is a theoretical framework for this individualized,
person-centered assessment that includes the following six dimensions:
(i) acute intoxication or likelihood of withdrawal potential, or
both; (ii) biomedical medical conditions and complications,
both historical and current ; (iii) emotional, behavioral, or cognitive conditions
status and complications any identified issues; (iv) individual's
readiness to change; (v) risks for relapse, or continued
use, or continued problem potential; and (vi) recovery or living home
environment. The level of care determination, ISP, and recovery strategies
development may be based upon this multidimensional assessment.
"Office-based opioid treatment" or "Preferred
OBOT" means addiction treatment services for individuals with moderate
to severe a primary opioid use disorder provided by
buprenorphine-waivered practitioners working in collaboration with credentialed
addiction treatment practitioners CATPs providing psychosocial
psychotherapy and substance use disorder counseling in public and
private practice settings.
"Opiate" means one of a group of alkaloids
derived from the opium poppy (papaver somniferum) that has the ability to
induce analgesia, euphoria, and, in higher doses, stupor, coma, and respiratory
depression but excludes synthetic opioids.
"Opioid" means any psychoactive chemical that resembles morphine in pharmacological effects, including opiates and synthetic/semisynthetic agents that exert their effects by binding to highly selective receptors in the brain where morphine and endogenous opioids affect their actions.
"Opioid treatment program" or "OTP" means a
program certified by the U.S. Substance Abuse and Mental Health Services
Administration (SAMHSA) that engages in supervised assessment and treatment,
using methadone, buprenorphine, L-alpha acetyl methadol, or naltrexone, of
individuals who are addicted to opioids. the same as 42 CFR 8.2.
"Opioid treatment services" or "OTS" means
preferred office-based opioid treatment (OBOT) OBOT and opioid
treatment programs OTPs that encompass a variety of pharmacological
and nonpharmacological treatment modalities including substance use disorder
counseling and psychotherapy.
"Overdose" means the inadvertent or deliberate consumption of a dose of a chemical substance much larger than either habitually used by the individual or ordinarily used for treatment of an illness that is likely to result in a serious toxic reaction or death.
"Physician extenders" means licensed nurse practitioners
as defined in 18VAC90-30-10 § 54.1-3000 of the Code of Virginia and
licensed physician assistants as defined in § 54.1-2900 of the Code of
Virginia.
"Practitioner" means a provider who is permitted
to prescribe buprenorphine by the scope of his licenses under federal and state
law.
"Program of assertive community treatment" or "PACT" means the same as defined in 12VAC35-105-20.
"Psychoeducation" means (i) a specific form of education aimed at helping individuals who have a substance use disorder or mental illness and their family members or caregivers to access clear and concise information about substance use disorders or mental illness; and (ii) a way of accessing and learning strategies to deal with substance use disorders or mental illness and its effects in order to design effective treatment plans and strategies.
"Psychotherapy" or "therapy" means the use of psychological methods in a professional relationship to assist a person or persons to acquire great human effectiveness or to modify feelings, conditions, attitudes, and behaviors that are emotionally, intellectually, or socially ineffectual or maladaptive.
"Recovery" means a process of sustained effort that addresses the biological, psychological, social, and spiritual disturbances inherent in addiction and consistently pursues abstinence, behavior control, dealing with cravings, recognizing problems in one's behaviors and interpersonal relationships, and more effective coping with emotional responses leading to reversal of negative, self-defeating internal processes and behaviors and allowing healing of relationships with self and others. The concepts of humility, acceptance, and surrender are useful in this process.
"Registered nurse" or "RN" means a
professional who is either licensed by the Commonwealth or who holds a multi-state
licensure privilege to practice nursing the same as "professional nurse"
as defined in § 54.1-3000 of the Code of Virginia.
"Relapse" means a process in which an individual who has established abstinence or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pursuit of reward or relief through the use of substances and other behaviors often leading to disengagement from recovery activities. Relapse can be triggered by exposure to (i) rewarding substances and behaviors, (ii) environmental cues to use, and (iii) emotional stressors that trigger heightened activity in brain stress circuits. The event of using or acting out is the latter part of the process, which can be prevented by early intervention.
"RHC" means rural health clinic.
"SBIRT" means screening, brief intervention, and referral to treatment. SBIRT services are an evidence-based and community-based practice designed to identify, reduce, and prevent problematic substance use disorders.
"Service authorization" means the process to approve
specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by
a DMAS service authorization or its contractor, BHSA, or MCO
prior to service delivery and reimbursement in order to validate that the
service requested is medically necessary and meets DMAS and DMAS contractor
criteria for reimbursement. Service authorization does not guarantee payment
for the service.
"Substance use care coordinator" means staff in an OTP or
Preferred-OBOT setting who has either: 1) at least a bachelor's degree in
one of the following fields (social work, psychology, psychiatric
rehabilitation, sociology, counseling, vocational rehabilitation, or human
services counseling and at least either: a) one year of substance use related
direct experience or training or a combination of experience or training in
providing services to individuals with a diagnosis of substance use disorder,
or b) a minimum of one year of clinical experience or training in working with
individuals with co-occurring diagnoses of substance use disorder and mental
illness; or 2) licensure by the Commonwealth as a registered nurse with at
least either: a) one year of direct experience or training, or combination of
experience and training in providing services to individuals with a diagnosis
of substance use disorder, or b) a minimum of one year of clinical experience
or training, or a combination of experience and training in working with
individuals with co-occurring diagnoses of substance use disorder and mental
illness; or 3) certification by the Board of Counseling as a Certified
Substance Abuse Counselor (CSAC) or CSAC-Assistant under supervision as defined
in 18VAC115-30-10 et seq CSAC or CSAC-A.
"Substance use case management" means the same as set out in 12VAC30-50-491.
"Substance use disorder" or "SUD" means a substance-related
addictive disorder, as defined in the DSM-5 with the exception of
tobacco-related disorders and non-substance-related disorders, marked by a
cluster of cognitive, behavioral, and physiological symptoms indicating that
the individual continues to use, is seeking treatment for the use of, or is
in active recovery from the use of alcohol, tobacco, or other
drugs despite significant related problems.
"Substance use disorder counseling" means the same as substance abuse counseling as defined in 18VAC115-30-10.
"Telemedicine" means the practice of the medical
arts via electronic means rather than face-to-face. the real-time
two-way transfer of medical data and information using an interactive
audio-video connection for the purposes of medical diagnosis and
treatment. The member is located at the originating site, while the
provider renders services from a remote location via the audio-video
connection. Equipment utilized for telemedicine shall be of sufficient
audio quality and visual clarity as to be functionally equivalent to a
face-to-face encounter for professional medical services.
"Tolerance" or "tolerate" means a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time.
"Withdrawal management" means services to assist an individual's withdrawal from the use of substances.
12VAC30-130-5030. Eligible individuals.
Children and adults who participate in Medicaid managed care
plans and Medicaid fee for service and meet ASAM medical necessity criteria
shall be eligible for ARTS. Notwithstanding the coverage limitations set
forth in the Governor's Access Plan for the Seriously Mental Ill (GAP SMI),
GAP-SMI enrollees who meet ASAM medical necessity criteria shall be eligible
for ARTS with the exception of inpatient detoxification services (ASAM Level
4.0) and substance use case management.
12VAC30-130-5040. Covered services: requirements; limits; standards.
A. Addiction and recovery and treatment
services.
1. In order to be covered, ARTS shall (i) meet medical
necessity criteria based upon the multidimensional assessment completed by a credentialed
addiction treatment professional CATP within the scope of their
practice or CSAC under the supervision of a CATP, and (ii) be
accurately reflected in provider medical record documentation and on providers'
claims for services by recognized diagnosis codes that support and are consistent
with the requested professional services. ARTS services require a primary
substance use diagnosis and the purpose for treatment shall be related to the
substance use disorder. Individuals may have a secondary, co-occurring
diagnosis. CATPs or CSACS under the supervision of a CATP shall complete
the multidimensional assessments. CATPs must sign and date assessments
performed by a CSAC within one business day.
2. These ARTS services, with their service definitions, shall
be covered: (i) medically managed intensive inpatient services (ASAM Level 4);
(ii) substance use residential/inpatient services (ASAM Levels 3.1, 3.3, 3.5,
and 3.7); (iii) substance use intensive outpatient and partial hospitalization
programs (ASAM Levels 2.1 and 2.5); (iv) opioid treatment services,
(opioid treatment programs and office-based preferred office-based
opioid treatment); (v) substance use outpatient services (ASAM Level 1.0); (vi)
early intervention services (ASAM Level 0.5); (vii) substance use care
coordination, (viii) substance use case management services; and (ix)
withdrawal management services, which shall be provided when medically
necessary, in all levels of care. as a component of the
medically managed inpatient services (ASAM Level 4.0), substance use
residential/inpatient services (ASAM Levels 3.3, 3.5, and 3.7), substance use
intensive outpatient and partial hospitalization programs (ASAM Levels 2.1 and
2.5), opioid treatment services, opioid treatment programs and office-based
opioid treatment, and substance use outpatient services (ASAM Level 1.0).
B. ARTS services shall be fully integrated with all physical health and behavioral health services for a complete continuum of care for all Medicaid individuals meeting the medical necessity criteria. In order to receive reimbursement for ARTS services, the individual shall be enrolled in Virginia Medicaid and shall meet the following medical necessity criteria:
1. The individual shall demonstrate at least one diagnosis from
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for Substance-Related
substance-related and Addictive Disorders addictive disorders
with the exception of tobacco-related disorders or caffeine-related
disorders or dependence and nonsubstance-related and non-substance
related addictive disorders or be marked by a cluster of
cognitive, behavioral, and physiological symptoms indicating that the individual
continues to use, is seeking treatment for the use of, or is in active recovery
from the use of alcohol or other drugs despite significant related
problems. Youth younger than 21 years of age may also qualify if they are
assessed to be at risk for developing a substance use disorder, for
youth younger than 21 years of age using the ASAM multidimensional assessment.
2. The individual shall be assessed by a certified addiction
treatment professional CATP or CSAC under the supervision of a CATP
who will determine if he meets the severity and intensity of treatment
requirements for each service level defined by the most current version of the
American Society of Addiction Medicine (ASAM) Treatment Criteria for Addictive,
Substance-Related and Co-Occurring Conditions (Third Edition, 2013). Medical
necessity for ASAM levels of care shall be based on the outcome of the
individual's documented multidimensional assessment. The following
outpatient ASAM levels of care do not require a complete multidimensional
assessment using the ASAM theoretical framework to determine medical necessity
but do require an assessment by a certified addiction treatment professional:
opioid treatment programs, office-based opioid treatment, and substance use
outpatient services (ASAM Level 1.0).
3. For individuals younger than 21 years of age who do not meet the ASAM medical necessity criteria upon initial review, a second individualized review shall be conducted to determine if the individual needs medically necessary treatment under the early periodic screening diagnosis and treatment (EPSDT) benefit described in § 1905(a) of the Social Security Act to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening.
C. Determination of medical necessity based on ASAM criteria for addiction and recovery treatment services.
1. DMAS or its contractor contracted managed care
organizations and the BHSA shall employ or contract with licensed treatment
professionals to apply the ASAM criteria to review and coordinate service needs
when administering ARTS benefits.
2. The ARTS care coordinator or a licensed physician or medical
director employed by DMAS or its contractor, or the MCO or BHSA
shall perform an independent assessment of requests for all ARTS intensive
outpatient services (ASAM Level 2.1), partial hospitalization services (Level
2.5), residential treatment services (ASAM Levels 3.1, 3.3, 3.5, and 3.7)
and ARTS inpatient treatment services (ASAM Level Levels 3.7 and
4.0).
3. Length of treatment and service limits shall be determined
by the ARTS care coordinator or a licensed physician or medical director
employed by the BHSA DMAS or its contractor, or MCO who is
applying the ASAM criteria.
4. "ARTS care coordinator" means a licensed
practitioner of the healing arts, including a physician or medical director,
licensed clinical psychologist, licensed clinical social worker, licensed
professional counselor, or nurse practitioner or registered nurse with clinical
experience in substance use disorders, who is employed by the BHSA or MCO to
perform an independent assessment of requests for all ARTS residential
treatment services and inpatient services (ASAM Levels 3.1, 3.3, 3.5, 3.7, and
4.0).
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services.
A. Settings for opioid treatment program (OTP)
services. The agency-based OTP provider shall be licensed by DBHDS and
contracted by the BHSA DMAS or its contractor or MCO. The
staffing requirements for OTP providers shall follow the DBHDS licensing
requirements set forth in 12VAC35-105-925 and in the DBHDS guidance document
entitled "Opioid/Medication Assisted Treatment License & Oversight" (March,
2017). The interdisciplinary team shall include CATPs acting within the scope
of practice in accordance to their professional regulatory board and stated and
federal requirements, including an addiction credentialed physician as defined
in 12VAC30-130-5020. Opioid treatment services OTP services
are allowable in allowed simultaneously for members in other ASAM
Levels including 1.0 through 3.7 (excluding inpatient services). OTP's
shall meet the service components, staff requirements, and risk management
requirements.
B. OTP service components.
1. Linking the individual to psychological, medical, and psychiatric consultation as necessary to meet the individual's needs.
2. Access to emergency medical and psychiatric care through connections with more intensive levels of care.
3. Access to evaluation and ongoing primary care.
4. Ability to conduct or arrange for appropriate laboratory and
toxicology tests including urine drug screenings (either urine or
blood serums).
5. Licensed physicians Physicians are available
to evaluate and monitor (i) use of methadone, buprenorphine products, or
naltrexone products and (ii) pharmacists and nurses to dispense and administer
these medications and follow the Board of Medicine guidance for treatment of
individuals with buprenorphine for addiction.
6. Individualized, patient-centered assessment and treatment.
7. Ability to assess, order, administer, reassess, and regulate medication and dose levels appropriate to the individual; supervise withdrawal management from opioid analgesics, including methadone, buprenorphine products, or naltrexone products; and oversee and facilitate access to appropriate treatment for opioid use disorder.
8. Medication for other physical and mental health illness is provided as needed either on site or through collaboration with other providers.
9. Cognitive, behavioral, and other substance use
disorder-focused therapies psychotherapies and substance use disorder
counseling by a CATP, reflecting a variety of treatment approaches,
provided to the individual on an individual, group, or family basis. CSACs
and CSAC-supervisees are recognized to provide substance use disorder
counseling in these settings as allowed within scope of practice as defined in
Virginia Code §54.1-3507.1.
10. Optional substance use care coordination that includes integrating behavioral health into primary care and specialty medical settings through interdisciplinary care planning and monitoring individual progress and tracking individual outcomes; supporting conversations between buprenorphine-waivered practitioners and behavioral health professionals to develop and monitor individualized treatment plans; linking individuals with community resources to facilitate referrals and respond to social service needs; and tracking and supporting individuals when they obtain medical, behavioral health, or social services outside the practice.
11. Provide on-site screening or Ability ability
to refer for screening for infectious diseases such as human immunodeficiency
virus, hepatitis B and C, and tuberculosis at treatment initiation and then at
least annually or more often based on risk factors. and the ability
to provide or refer for treatment of infectious diseases as necessary.
12. Medication administration on site during the induction phase must be provided by a physician, nurse practitioner, physician assistant, or registered nurse. Medication administration during the maintenance phase may be provided either by a registered nurse or licensed practical nurse.
13. Prescribing naloxone for each member receiving methadone, buprenorphine products, or naltrexone products.
14. Ability to provide pregnancy testing for women of childbearing age.
15. Ability to provide or refer individuals of childbearing age to family planning services.
C. OTP staff requirements.
1. Staff requirements shall meet the licensing requirements of
12VAC35-105-925. The interdisciplinary team shall include credentialed
addiction professionals CATPs trained in the treatment of opioid use
disorder including an addiction credentialed physician or physician extender
and credentialed addiction treatment professionals CATPs as
defined in 12VAC30-130-5020. "Addiction-credentialed physician"
means a physician who holds a board certification in addiction medicine from
the American Board of Addiction Medicine, a subspecialty board certification in
addiction psychiatry from the American Board of Psychiatry and Neurology, or
subspecialty board certification in addiction medicine from the American
Osteopathic Association. In situations where a certified addiction physician is
not available, physicians treating addiction should have some specialty
training or experience in addiction medicine or addiction psychiatry. If
treating adolescents, they should have experience with adolescent medicine.
OTPs may utilize CSACs and CSAC-supervisees to provide substance use disorder
counseling and psychoeducational services within their scope of practice as
defined in Virginia Code §54.1-3507.1. OTPs may also utilize CSAC-A's
(§54.1-3507.2) as well as registered peer recovery specialists within their
scope of practice. A registered peer recovery specialist shall meet the
definition in § 54.1-3500 of the Code of Virginia.
2. Staff shall be knowledgeable in the assessment, interpretation, and treatment of the biopsychosocial dimensions of alcohol or other substance use disorders.
3. A physician or physician extender as defined in 12VAC30-130-5020, shall be available during medication dispensing and clinical operating hours, in person or by telephone.
D. OTP risk management shall be clearly and adequately documented in each individual's record and shall include:
1. Random urine drug screening (either urine or blood
serums) for all individuals, conducted at least eight times during a
12-month period as described in 12VAC35-105-980. Definitive screenings shall
only be utilized when clinically indicated. Outcomes of the drug screening
shall be used to support positive patient outcomes and recovery.
2. A check of the Virginia Prescription Monitoring Program prior to initiation of buprenorphine products or naltrexone products and at least quarterly for all individuals.
3. Prescribing naloxone.
3. 4. Opioid overdose prevention education including
the prescribing of naloxone. including the purpose of and the
administration of naloxone and the impact of polysubstance use. Education
shall include discussion of the role of medication assisted treatment and the
opportunity to reduce harm associated with polysubstance use. The goal is to
help individuals remain in treatment to reduce the risk for harm.
5. Clinically indicated infectious disease testing such as HIV, Hepatitis A/B/C, syphilis, and tuberculosis testing at treatment initiation and then annually or more frequently depending on the clinical scenario and the patient's risk. Those who test positive shall be treated either on-site or through referral.
6. Individuals without immunity to the hepatitis B virus shall be offered vaccination either on-site or through referral.
7. Individuals without HIV infection shall be offered pre-exposure prophylaxis to prevent HIV infection either on-site or through referral.
8. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either on-site or through referral.
12VAC30-130-5060. Covered services: clinic services preferred office-based opioid treatment.
A. Preferred Office-based office-based
opioid treatment (OBOT) shall be provided by a buprenorphine-waivered practitioner
and may be provided in a variety of practice settings including primary care
clinics, outpatient health system clinics, psychiatry clinics, federally
qualified health centers FQHCs, CSBs/BHAs CSBs, BHAs,
local health department clinics, and physician offices. The practitioner shall
be contracted by the BHSA DMAS or its contractor or MCO to
perform OBOT services. OBOT services shall meet the following criteria:
1. OBOT service components.
a. Access to emergency medical and psychiatric care.
b. Affiliations with more intensive levels of care such as
intensive outpatient programs and partial hospitalization programs that
unstable to which individuals can be referred to when
clinically indicated.
c. Individualized, patient-centered multidimensional assessment and treatment.
d. Assessing, ordering, administering, reassessing, and regulating medication and dose levels appropriate to the individual; supervising withdrawal management from opioid analgesics; and overseeing and facilitating access to appropriate treatment for opioid use disorder and alcohol use disorder.
e. Medication for other physical and mental illnesses health
disorders shall be provided as needed either on site or through
collaboration with other providers.
f. Ensure buprenorphine products are only dispensed on-site during the induction phase. After the induction phase, buprenorphine products shall be prescribed to the member.
g. Ensure buprenorphine monoproduct is only prescribed in accordance with Board of Medicine rules related to the prescribing of buprenorphine for addiction.
f. h. Cognitive, behavioral, and other substance
use disorder-focused therapies counseling and psychotherapies,
reflecting a variety of treatment approaches, shall be provided to the
individual on an individual, group, or family basis and shall be provided by credentialed
addiction treatment professionals CATPs working in collaboration
with the buprenorphine-waivered practitioner who is prescribing buprenorphine
products or naltrexone products to individuals with moderate to severe a
primary opioid use disorder. These therapies can be provided via
telemedicine as long as they meet the department's DMAS
requirements for an OBOT and for the use of telemedicine. (See the Medicaid
Memo entitled "Updates to Telemedicine Coverage" dated May 13, 2014.)
Preferred OBOTs may utilize CSACs and CSAC-supervisees to provide substance
use disorder counseling and psychoeducational services within their scope of
practice as defined in Virginia Code §54.1-3507.1.
g. i. Substance use care coordination provided
including interdisciplinary care planning between buprenorphine-waivered physician
practitioner and the licensed behavioral health provider treatment
team to develop and monitor individualized and personalized treatment plans
focused on the best outcomes for the individual. This care coordination
includes monitoring individual progress, tracking individual outcomes, linking
individual with community resources to facilitate referrals and respond to
social service needs, and tracking and supporting the individual's medical,
behavioral health, or social services received outside the practice.
h. j. Provide onsite screening or Referral
referral for screening for clinically indicated infectious diseases
such as human immunodeficiency virus, hepatitis B and C, and tuberculosis disease
testing such as HIV, hepatitis A/B/C, syphilis, and tuberculosis at
treatment initiation and then at least annually or more often based on risk
factors. and the ability to provide or refer for treatment of
infectious diseases as necessary.
k. Medication administration on-site during the induction phase shall be provided by a physician, nurse practitioner, physician assistant, or registered nurse.
l. Ability to provide pregnancy testing for women of childbearing age.
m. Ability to provide or refer individuals of childbearing age for family planning services.
B. OBOT staff requirements.
1. Buprenorphine-waivered practitioner licensed under
Virginia law who has completed one of the continuing medical education courses
approved by the federal Center for Substance Abuse Treatment and obtained the
waiver to prescribe or dispense buprenorphine for opioid use disorder required
under the Drug Addiction Treatment Act of 2000 (21 USC § 800 et seq.). The
practitioner must have a DEA-X number issued by the U.S. Drug Enforcement
Agency that is included on all buprenorphine prescriptions for treatment of
opioid use disorder practitioners are required.
2. Credentialed addiction treatment professionals CATPs
are required and shall work in collaboration with the
buprenorphine-waivered practitioner who is prescribing buprenorphine products
or naltrexone products to individuals with moderate to severe a
primary opioid use disorder. This collaboration can be in person or via
telemedicine as long as it meets the department's requirements for the OBOT
setting and for telemedicine. CSACs, CSAC-supervisees, and CSAC-A's are also
recognized in the Preferred OBOT setting as well as registered peer recovery
specialists. A registered peer recovery specialist shall meet the
definition in § 54.1-3500 of the Code of Virginia.
C. OBOT risk management shall be documented in each individual's record and shall include:
1. Random urine drug screening (either urine or blood
serums) for all individuals, conducted at a minimum of eight times per
year. Drug screenings include presumptive and definitive screenings and
shall be accurately interpreted. Definitive screenings shall only be
utilized when clinically indicated. Outcomes of the drug screening shall be
used to support positive patient outcomes and recovery.
2. A check of the Virginia Prescription Monitoring Program prior to initiation of buprenorphine products or naltrexone products and at least quarterly for all individuals thereafter.
3. Prescribing naloxone.
3. 4. Opioid overdose prevention education including
the prescribing of naloxone. including the purpose of and the
administration of naloxone and the impact of polysubstance use. Education
shall include discussion of the role of medication assisted treatment and the
opportunity to reduce harm associated with polysubstance use. The goal is to
help individuals remain in treatment to reduce the risk for harm.
5. Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.
6. Clinically indicated infectious disease testing such as HIV, hepatitis A/B/C, syphilis, and tuberculosis testing at treatment initiation and then annually or more frequently, depending on the clinical scenario and the patient's risk. Those who test positive shall be treated either on-site or through referral.
7. Individuals without immunity to the hepatitis B virus shall be offered vaccination either on-site or through referral.
8. Patients without HIV infection shall be offered pre-exposure prophylaxis to prevent HIV infection either on-site or through referral.
9. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either on-site or through referral.
12VAC30-130-5070. Covered services: practitioner services - early intervention/screening brief intervention and referral to treatment (ASAM Level 0.5).
A. Early intervention (ASAM Level 0.5) settings for screening,
brief intervention, and referral to treatment (SBIRT) services shall include
health care settings including local health departments, federally qualified
health centers FQHCs, rural health clinics RHCs, CSBs/BHAs
CSBs, BHAs, health systems, emergency departments, pharmacies, physician
offices, and outpatient clinics. These providers Providers shall
be licensed by DHP the Department of Health Professions and
either directly contracted by the BHSA DMAS or its contractor or
MCO to perform the interpretation and intervention for this level of
care, or employed by organizations that are contracted by the BHSA DMAS
or its contractor or MCO.
B. Early intervention/SBIRT (ASAM Level 0.5) service components shall include:
1. Identifying individuals who may have alcohol or other substance use problems using an evidence-based screening tool.
2. Following administration of the evidence-based screening
tool, a brief intervention by a licensed clinician CATP acting within
the scope of their practice shall be provided to educate individuals about
substance use, alert these individuals to possible consequences and, if needed,
begin to motivate individuals to take steps to change their behaviors. Billing
shall occur through the licensed provider or agency.
C. Early intervention/SBIRT (ASAM Level 0.5) staff
requirements. Physicians, pharmacists, and other credentialed
addiction treatment professionals CATPs shall administer the
evidence-based screening tool with the individual and provide the counseling
and intervention. Licensed providers may delegate administration of the
evidence-based screening tool to other clinical staff as allowed by their scope
of practice, such as physicians delegating administration of the tool to
CSACs, CSAC-supervisees, a licensed registered nurse or licensed
practical nurse, but the licensed provider shall review the tool with the
individual and provide the counseling and intervention. The
physician may delegate the counseling and intervention but shall be available
for review as needed. Billing for SBIRT shall occur through the licensed
provider or agency.
12VAC30-130-5080. Covered services: outpatient services - physician services (ASAM Level 1.0).
A. Outpatient services (ASAM Level 1.0) shall be provided by a
credentialed addiction treatment professional CATP, psychiatrist,
or physician contracted by the BHSA DMAS or its contractor or
MCO to perform the services in the following community based settings: primary
care clinics, outpatient health system clinics, psychiatry clinics, federally
qualified health centers (FQHCs) FQHCs, RHCs, community
service boards/BHAs CSBs, BHAs, local health departments, and
physician and provider offices. Reimbursement for substance use outpatient
services shall be made for medically necessary services provided in accordance
with an ISP or the treatment plan and include withdrawal management as
necessary. Services can be provided face-to-face in person or by
telemedicine. Outpatient services shall meet the ASAM Level 1.0 service
components and staff requirements as follows:
1. Outpatient services (ASAM Level 1.0) service components.
a. Substance use outpatient services shall be provided fewer
than nine hours per week and may be delivered in the following health care
settings: local health departments, FQHCs, rural health clinics, CSBs/BHAs
CSBs, BHAs, health systems, emergency departments, physician and
provider offices, and outpatient clinics. Provision of services in a setting
other than the office or a clinic, as defined in this subsection shall be
documented. Services shall include professionally directed screening, evaluation,
treatment, and ongoing recovery and disease management services.
b. A multidimensional assessment shall (i) be used, (ii) be documented to determine that an individual meets the medical necessity criteria, and (iii) include the evaluation or analysis of substance use disorders, the diagnosis of substance use disorder, and the assessment of treatment needs to provide medically necessary services. The multidimensional assessment shall include a physical examination and laboratory testing necessary for substance use disorder treatment as necessary.
c. Individual psychotherapy or substance use disorder
counseling between the individual and shall be provided by a credentialed
addiction treatment professional CATP shall be provided.
Services shall be provided face to face in person or by
telemedicine shall qualify as reimbursable.
d. Group psychotherapy or substance use disorder
counseling shall be provided by a credentialed addiction treatment
professional, CATP with a maximum of 10 individuals in the group shall
be provided. Such counseling and shall focus on the needs of the
individuals served.
e. Family therapy psychotherapy or substance use
disorder counseling shall be provided by a CATP to facilitate the
individual's recovery and support for the family's recovery.
f. Evidenced-based patient education on addiction, treatment, recovery, and associated health risks shall be provided.
g. Medication services shall be provided including the prescription of or administration of medication related to substance use treatment, or the assessment of the side effects or results of that medication. Medication services shall be provided by staff lawfully authorized to provide such services who shall order laboratory testing within their scope of practice or licensure.
h. Collateral services shall be provided. "Collateral
services" means services provided by therapists or counselors for the
purpose of engaging persons who are significant to the individual receiving SUD
services. The services are focused on the individual's treatment needs and
support achievement of his recovery goals.
2. Outpatient services (ASAM Level 1.0) staff requirements shall include:
a. Credentialed addiction treatment professional CATP;
or
b. A registered nurse or a practical nurse who is licensed by the Commonwealth with at least one year of clinical experience involving medication management.
B. Outpatient services (ASAM Level 1.0) co-occurring enhanced programs shall include:
1. Ongoing substance use case management for highly crisis prone individuals with co-occurring disorders.
2. Credentialed addiction treatment professionals CATPs
who are trained in severe and chronic mental health and psychiatric disorders
and are able to assess, monitor, and manage individuals who have a co-occurring
mental health disorder. "Co-occurring disorders" means the presence of
concurrent substance use disorder and mental illness without implication as to
which disorder is primary and which secondary, which disorder occurred first,
or whether one disorder caused the other.
12VAC30-130-5090. Covered services: community based services - intensive outpatient services (ASAM Level 2.1).
A. Intensive outpatient services (ASAM Level 2.1) shall be a
structured program of skilled treatment services for adults, children, and
adolescents delivering a minimum of three service hours per service day for
adults to achieve an average of nine to 19 hours of services per
week on average for adults and a minimum of two service hours per
service day for children and adolescents to achieve an average of six to 19
hours of services per week for children and adolescents on average.
Withdrawal management services may be provided as necessary. The following
service components shall be provided weekly as directed by the ISP for
reimbursement:
1. Medical, psychological, psychiatric, laboratory, and toxicology services, which are available through consultation or referral.
2. Psychiatric and other individualized treatment planning.
3. Individual, family, and group psychotherapy,
substance use disorder counseling, medication management, family
therapy, and psychoeducation. "Psychoeducation" means (i) a
specific form of education aimed at helping individuals who have a substance
use disorder or mental illness and their family members or caregivers to access
clear and concise information about substance use disorders or mental illness
and (ii) a way of accessing and learning strategies to deal with substance use
disorders or mental illness and its effects in order to design effective
treatment plans and strategies.
4. Medication assisted treatment provided on-site or through referral.
4. 5. Occupational and recreational therapies,
motivational interviewing, enhancement, and engagement strategies to inspire an
individual's motivation to change behaviors.
5. 6. Psychiatric and medical consultation, which
shall be available within 24 hours of the requested consult by telephone and
preferably within 72 hours of the requested consult in person or via
telemedicine.
6. 7. Psychopharmacological consultation.
7. 8. Addiction medication management and 24-hour
crisis services.
8. 9. Medical, psychological, psychiatric,
laboratory, and toxicology services.
B. Intensive outpatient services (ASAM Level 2.1) shall be
provided by agency-based providers that shall be licensed by DBHDS as a
substance abuse intensive outpatient service for adults, children, and
adolescents and contracted with the BHSA DMAS or its contractor
or MCO to provide this service. Intensive outpatient service providers shall
meet the ASAM Level 2.1 service components and staff requirements as follows:
1. Interdisciplinary team of credentialed addiction
treatment professionals CATPs shall be required. ASAM Level 2.1
may utilize CSACs or CSAC-supervisees to provide substance use disorder
counseling and psychoeducational services within their scope of practice as
defined in Virginia Code §54.1-3507.1.
2. Generalist physicians or physicians with experience in addiction medicine are permitted to provide general medical evaluations and concurrent/integrated general medical care.
3. Physicians and physician extenders either employed, contracted or through referral arrangements with the agency, shall have a DEA-X number to prescribe buprenorphine.
3. 4. Staff shall be cross-trained to understand
signs and symptoms of psychiatric disorders and be able to understand and
explain the uses of psychotropic medications and understand interactions with
substance use and other addictive disorders.
4. 5. Emergency services, which shall be
available, when necessary, by telephone 24 hours per day and seven days per
week when the treatment program is not in session.
5. 6. Direct affiliation with, or close
coordination through referrals to, higher and lower levels of care and
supportive housing services.
C. Intensive outpatient services (ASAM Level 2.1) co-occurring enhanced programs.
1. Co-occurring capable programs offer these therapies and support systems in intensive outpatient services described in this section to individuals with co-occurring addictive and psychiatric disorders who are able to tolerate and benefit from a planned program of therapies.
2. Individuals who are not able to benefit from a full program
of therapies will be offered enhanced program services to match the intensity
of hours in ASAM Level 2.1, including substance use case management, program of
assertive community treatment (PACT), medication management, and psychotherapy.
"Program of assertive community treatment" or "PACT"
means the same as defined in 12VAC30-105-20.
12VAC30-130-5100. Covered services: community based care - partial hospitalization services (ASAM Level 2.5).
A. Partial hospitalization services (ASAM Level 2.5) components. Partial hospitalization services components shall include the following, as defined in the ISP and provided on a weekly basis:
1. Individualized treatment planning.
2. A minimum of 20 hours per week and at least five service
hours per service day of skilled treatment services with a planned format
including individual and group psychotherapy, substance use disorder
counseling, medication management, family therapy, education groups,
occupational and recreational therapy, and other therapies. Withdrawal
management services may be provided as necessary. Time not spent in skilled, clinically
intensive treatment is not billable.
3. Family therapies psychotherapy and substance use
disorder counseling involving family members, guardians, or significant
other in the assessment, treatment, and continuing care of the individual.
4. A planned format of therapies, delivered in individual or
group settings.
5. 4. Motivational interviewing, enhancement, and
engagement strategies.
5. Medication assisted treatment provided on-site or through referral.
B. Partial hospitalization services (ASAM Level 2.5). The
substance use partial hospitalization service provider shall be licensed by
DBHDS as a substance abuse partial hospitalization program or substance
abuse/mental health partial hospitalization program and contracted with the
BHSA DMAS or its contractor or MCO. Partial hospitalization service
providers shall meet the ASAM Level 2.5 support systems and staff requirements
as follows:
1. Interdisciplinary team comprised of credentialed
addiction treatment professionals CATPs and shall include an
addiction-credentialed physician, or physician with experience in addiction
medicine, or physician extenders as defined in 12VAC30-130-5020, shall be
required. ASAM Level 2.5 may utilize CSACs or CSAC-supervisees to
provide substance use disorder counseling and psychoeducational services within
their scope of practice as defined in Virginia Code §54.1-3507.1.
2. Physicians shall have specialty training or experience, or both, in addiction medicine or addiction psychiatry. Physicians who treat adolescents shall have experience with adolescent medicine.
3. Physicians and physician extenders, either employed or contracted with the agency, shall have a DEA-X number to prescribe buprenorphine.
3. 4. Program staff shall be cross-trained to
understand signs and symptoms of mental illness and be able to understand and
explain the uses of psychotropic medications and understand interactions with
substance use and other addictive disorders.
4. 5. Medical, psychological, psychiatric,
laboratory, and toxicology services that are available by consult or referral.
5. 6. Psychiatric and medical formal agreements
to provide medical consult within eight hours of the requested consult by
telephone or within 48 hours in person or via telemedicine.
6. 7. Emergency services are available 24-hours a
day and seven days a week.
7. 8. Direct affiliation with or close
coordination through referrals to higher and lower levels of care and
supportive housing services.
C. Partial hospitalization services (ASAM Level 2.5) co-occurring enhanced programs shall offer:
1. Therapies and support systems as described in this section
to individuals with co-occurring addictive and psychiatric disorders who are
able to tolerate and benefit from a full program of therapies. Other
individuals who are not able to benefit from a full program of therapies (who
are severely or chronically mentally ill) will be offered enhanced program
services to constitute intensity of hours in Level 2.5, including substance use
case management, assertive community treatment PACT, medication
management, and psychotherapy.
2. Psychiatric services as appropriate to meet the individual's mental health condition. Services may be available by telephone and on site, or closely coordinated off site, or via telemedicine within a shorter time than in a co-occurring capable program.
3. Clinical leadership and oversight and, at a minimum, capacity to consult with an addiction psychiatrist via telephone, telemedicine, or in person.
4. Credentialed addiction treatment professionals
CATPs with experience assessing and treating co-occurring mental illness.
12VAC30-130-5110. Covered services: clinically managed low intensity residential services (ASAM Level 3.1).
A. Clinically managed low intensity residential services (ASAM
Level 3.1). The agency-based residential group home services (ASAM Level 3.1)
shall be licensed by DBHDS as a mental health and substance abuse group home
service for adults or children or licensed by DBHDS as a substance abuse
halfway house supervised living residence for adults and contracted
by the BHSA DMAS or its contractor or MCO. Clinically directed
program activities constituting at least five hours per week of professionally
directed treatment shall be designed to stabilize and maintain substance use
disorder symptoms and to develop and apply recovery skills. Activities shall include
relapse prevention, interpersonal choice exploration, and development of social
networks in support of recovery. This service shall not include settings where
clinical treatment services are not provided. ASAM Level 3.1 clinically managed
low intensity residential service providers shall meet the service components
and staff requirements of this section.
B. Clinically managed low intensity residential services (ASAM Level 3.1) service components.
1. Physician consultation and emergency services, which shall be available 24 hours a day and seven days per week.
2. Arrangements for medically necessary procedures including laboratory and toxicology tests that are appropriate to the severity and urgency of an individual's condition.
3. Arrangements for pharmacotherapy for psychiatric or
anti-addiction medications needs.
4. Medication assisted treatment provided on-site or through referral.
4. 5. Arrangements for higher and lower levels of
care and other services.
C. The following services shall be provided as directed by the ISP:
1. Clinically-directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life;
2. Addiction pharmacotherapy and drug screening;
3. Motivational enhancement and engagement strategies;
4. Substance use disorder Counseling counseling
and clinical monitoring;
5. Regular monitoring of the individual's medication adherence;
6. Recovery support services;
7. Services for the individual's family and significant others, as appropriate to advance the individual's treatment goals and objectives identified in the ISP; and
8. Education on benefits of medication assisted treatment and referral to treatment as necessary.
D. Clinically managed low intensity residential services (ASAM Level 3.1) staff requirements.
1. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
2. Clinical staff who are experienced and knowledgeable about the biopsychosocial and psychosocial dimensions and treatment of substance use disorders. Clinical staff shall be able to identify the signs and symptoms of acute psychiatric conditions and decompensation.
3. An addiction-credentialed physician or physician with
experience in addiction medicine or physician extenders acting within their
scope of practice shall review the residential group home admission if
the multidimensional assessment indicates medical concerns or systems in
Dimensions 1 or 2, to confirm medical necessity for services, and a team of
credentialed addiction treatment professionals CATPs shall
develop and shall ensure delivery of the ISP. For ASAM Level 3.1, the ISP
may be completed by a CSAC or CSAC-supervisee if the CATP signs and dates
within one business day.
4. Coordination with community physicians to review treatment as needed.
5. Appropriately credentialed medical staff shall be available to assess and treat co-occurring biomedical disorders and to monitor the individual's administration of prescribed medications.
E. Clinically managed low intensity residential services (ASAM Level 3.1) co-occurring enhanced programs as required by ASAM.
1. In addition to the ASAM Level 3.1 service components listed in this section, programs for individuals with both unstable substance use and psychiatric disorders shall offer appropriate psychiatric services, including medication evaluation and laboratory services. Such services are provided either on site, via telemedicine, or closely coordinated with an off-site provider, as appropriate to the severity and urgency of the individual's mental health condition.
2. Certified addiction treatment professionals shall be cross-trained in addiction and mental health to (i) understand the signs and symptoms of mental illness and (ii) understand and be able to explain to the individual the purpose of psychotropic medications and interactions with substance use.
3. The therapies described in this section shall be offered as well as planned clinical activities (either on site or with an off-site provider) that are designed to stabilize and maintain the individual's mental health program and psychiatric symptoms.
4. Goals of therapy shall apply to both the substance use disorder and any co-occurring mental illness.
5. Medication education and management shall be provided.
12VAC30-130-5120. Covered services: clinically managed population - specific high intensity residential service (ASAM Level 3.3).
A. Clinically managed population-specific high intensity
residential service (ASAM Level 3.3). The facility-based provider shall
be licensed by DBHDS to provide as: (i) a
supervised residential treatment services service for adults or
licensed by DBHDS to provide (ii) a substance abuse
residential treatment service for adults, (iii) a substance
abuse residential treatment service for women with children, supervised
residential treatment services for adults, or (iv) a
substance abuse and mental health residential treatment services service
for adults, that has substance abuse listed on its license or within
the "licensed as" statements; a Level C service; or (v) a "Mental Health
Residential-Children" provider that has substance abuse listed on its license
or within the "licensed as" statements. and All providers shall
be contracted by the BHSA DMAS or its contractor or MCO. ASAM
Level 3.3 settings do not include sober houses, boarding houses, or group homes
where treatment services are not provided. Residential treatment service
providers for clinically managed population-specific high intensity residential
service (ASAM Level 3.3) shall meet the service components and staff
requirements in this section.
B. Clinically managed population-specific high intensity residential service (ASAM Level 3.3) service components.
1. Clinically managed population-specific high intensity residential service components shall include:
a. Access to a consulting physician or physician extender either employed, contracted or through referral arrangements with the agency, with a DEA-X number to prescribe buprenorphine and emergency services 24 hours a day and seven days a week;
b. Arrangements for higher and lower levels of care;
c. Arrangements for laboratory and toxicology services appropriate to the severity of need; and
d. Arrangements for addiction pharmacotherapy including medication assisted treatment provided on-site or through referral.
2. The following therapies shall be provided as directed by the ISP for reimbursement:
a. Clinically-directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life;
b. Addiction pharmacotherapy and drug screening including
medication assisted treatment provided on-site or through referral;
c. Drug screening (either urine or blood serums);
c. d. Range of cognitive and behavioral therapies
psychotherapies, administered individually and in family and group
settings, as appropriate to the individual's needs, to assist the individual
in initial involvement or re-engagement in regular productive daily activity;
e. Substance use disorder counseling and psychoeducation activities provided individually or in family and group settings, to promote recovery;
d. f. Recreational therapy, art, music, physical
therapy, and vocational rehabilitation;
e. g. Motivational enhancement and engagement
strategies;
f. h. Regular monitoring of the individual's
medication adherence;
g. i. Recovery support services;
h. j. Services for the individual's family and
significant others, as appropriate to advance the individual's treatment goals
and objectives identified in the ISP;
i. k. Education on benefits of medication
assisted treatment and referral to treatment as necessary; and
j. l. Withdrawal management services may be
provided as necessary.
C. Clinically managed population-specific high intensity residential service (ASAM Level 3.3) staff requirements.
1. The interdisciplinary team shall include credentialed addiction
treatment professionals, physicians, or physician extenders CATPs
and allied health professionals in an interdisciplinary team. ASAM Level 3.3
may utilize CSACs or CSAC-supervisees to provide substance use disorder
counseling and psychoeducational services within their scope of practice as
defined in Virginia Code §54.1-3507.1.
2. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
3. Clinical or credentialed staff who are experienced
and knowledgeable about the biopsychosocial dimensions and treatment of
substance use disorders and who are available on site or by telephone 24 hours
per day. Licensed Clinical clinical staff shall be able to
identify acute psychiatric conditions and decompensation.
4. Substance use case management is included in this level of care.
5. Appropriately credentialed medical staff shall be available to assess and treat co-occurring biomedical disorders and to monitor the individual's administration of prescribed medications.
D. Clinically managed population-specific high intensity residential service co-occurring enhanced programs, as required by ASAM.
1. Appropriate psychiatric services, including medication evaluation and laboratory services, shall be provided on site or through a closely coordinated off-site provider, as appropriate to the severity and urgency of the individual's mental condition.
2. Psychiatrists and credentialed addiction treatment
professionals CATPs shall be available to assess and treat
co-occurring substance use and mental illness using specialized training in
behavior management techniques.
12VAC30-130-5130. Covered services: clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5).
A. Clinically managed high intensity residential services (adult)
and clinically managed medium intensity residential services (adolescent) (ASAM
Level 3.5) settings for services. The facility based residential treatment
service provider (ASAM Level 3.5) shall be licensed by DBHDS as: (i)
a substance abuse residential treatment services service for
adults or children, (ii) a psychiatric unit that has substance abuse
listed on its license or within the "licensed as" statements, (iii) a substance
abuse residential treatment service for women with children, or (iv)
a substance abuse and mental health residential treatment services service
for adults and children that has substance abuse listed on its license or
within the "licensed as" statements, (v) a Level C provider, or (vi) a "Mental
Health Residential-Children" provider that has substance abuse on its license
or within the "licensed as" statements and shall be contracted by the
BHSA DMAS or its contractor or MCO. Residential treatment providers
(ASAM Level 3.5) shall meet the service components and staff requirements in
this section.
B. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) service components.
1. These residential treatment services, as required by ASAM, include:
a. Telephone or in-person consultation with a physician or physician extender who shall be available to perform required physician services. Emergency services shall be available 24 hours per day and seven days per week;
b. Arrangements for more and less intensive levels of care and other services such as sheltered workshops, literacy training, and adult education;
c. Arrangements for needed procedures including medical, psychiatric, psychological, laboratory, and toxicology services appropriate to the severity of need; and
d. Arrangements for addiction pharmacotherapy including medication assisted treatment provided on-site or through referral.
2. The following therapies shall be provided as directed by the ISP for reimbursement:
a. Clinically directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life. Activities shall be designed to stabilize and maintain substance use disorder symptoms and apply recovery skills and may include relapse prevention, interpersonal choice exploration, and development of social networks in support of recovery.
b. Range of cognitive, and behavioral therapies
psychotherapies and substance use disorder counseling administered
individually and in family and group settings to assist the individual in
initial involvement or re-engagement in regular productive daily activities
including education on medication management, addiction pharmacotherapy, and
education skill building groups to enhance the individual's understanding of
substance use and mental illness.
c. Psychoeducational activities.
c. d. Addiction pharmacotherapy and drug screening.
d. e. Recreational therapy, art, music, physical
therapy, and vocational rehabilitation.
e. f. Motivational enhancements and engagement
strategies.
f. g. Monitoring the adherence to prescribed
medications and over-the-counter medications and supplements.
g. h. Daily scheduled professional services and
interdisciplinary assessments and treatment designed to develop and apply
recovery skills.
h. i. Services for family and significant
others, as appropriate, to advance the individual's treatment goals and
objectives identified in the ISP.
i. Education on benefits of medication assisted treatment
and referral to treatment as necessary.
j. Withdrawal management services may be provided as necessary.
C. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) staff requirements.
1. The interdisciplinary team shall include credentialed
addiction treatment professionals CATPs, physicians, or physician
extenders and allied health professionals. Physicians and physician
extenders either employed, contracted or through referral arrangements with the
agency, shall have a DEA-X number to prescribe buprenorphine. ASAM Level
3.5 may utilize CSACs or CSAC-supervisees to provide substance use disorder
counseling and psychoeducational services within their scope of practice as
defined in Virginia Code §54.1-3507.1.
2. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
3. Clinical staff who are experienced in and knowledgeable about the biopsychosocial dimensions and treatment of substance use disorders. Clinical staff shall be able to identify acute psychiatric conditions and decompensations.
4. Substance use case management shall be provided in this level of care.
5. Appropriately credentialed medical staff shall be available on site or by telephone 24 hours per day, seven days per week to assess and treat co-occurring biological and physiological disorders and to monitor the individual's administration of medications in accordance with a physician's prescription.
D. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) co-occurring enhanced programs as required by ASAM.
1. Psychiatric services, medication evaluation, and laboratory services shall be provided. Such services shall be available by telephone within eight hours of requested service and on site or via telemedicine, or closely coordinated with an off-site provider within 24 hours of requested service, as appropriate to the severity and urgency of the individual's mental and physical condition.
2. Staff shall be credentialed addiction treatment
professionals CATPs who are able to assess and treat co-occurring
substance use and psychiatric disorders.
3. Planned clinical activities shall be required and shall be designed to stabilize and maintain the individual's mental health problems and psychiatric symptoms.
4. Medication education and management shall be provided.
12VAC30-130-5140. Covered services: medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7).
A. Medically monitored intensive inpatient services (adult)
and medically monitored high intensity inpatient services (adolescent) (ASAM
Level 3.7) settings for services. The facility-based providers of ASAM Level
3.7 services shall be licensed by DBHDS as: an inpatient
psychiatric unit with a DBHDS medical detoxification license, (i) a
freestanding psychiatric hospital or inpatient psychiatric unit with a DBHDS
medical detoxification license or managed withdrawal license; (ii) a
residential crisis stabilization unit with a DBHDS medical detoxification
license or managed withdrawal license; (iii) a substance abuse
residential treatment services (RTS) for adults/children service for
women with children with a DBHDS medical detoxification managed
withdrawal license; or a residential crisis stabilization unit
with DBHDS medical detoxification license (iv) a Level C provider; (v) a
"Mental Health-Children" provider with a substance abuse residential license
and a DBHDS managed withdrawal license; (vi) a "Managed Withdrawal-Medical
Detox Adult Residential Treatment" provider; or (vii) a "Medical Detox-Chemical
Dependency Unit" for adults and shall be contracted by the BHSA DMAS
or its contractor or the MCO. ASAM Level 3.7 providers shall meet the
service components and staff requirements in this section.
B. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) service components. The following therapies shall be provided as directed by the ISP for reimbursement:
1. Daily clinical services provided by an interdisciplinary
team to involve appropriate medical and nursing services, as well as
individual, group, and family activity services. Activities may include
pharmacological, including medication assisted treatment provided on-site or
through referral, withdrawal management, cognitive-behavioral, and other therapies
psychotherapies and substance use disorder counseling administered on an
individual or group basis and modified to meet the individual's level of
understanding and assist in the individual's recovery.
2. Counseling and clinical monitoring to facilitate re-involvement in regular productive daily activities and successful re-integration into family living if applicable.
3. Psychoeducational activities.
3. 3. Random drug screens to monitor use and
strengthen recovery and treatment gains.
4. 4. Regular medication monitoring.
5. 5. Planned clinical activities to enhance
understanding of substance use disorders.
6. 6. Health education associated with the course
of addiction and other potential health related risk factors including
tuberculosis, human immunodeficiency virus, hepatitis B and C, and other
sexually transmitted infections.
7. 7. Evidence based practices, such as
motivational interviewing to address the individuals readiness to change,
designed to facilitate understanding of the relationship of the substance use
disorder and life impacts.
8. 8. Daily treatments to manage acute symptoms
of biomedical substance use or mental illness.
9. 9. Services to family and significant others
as appropriate to advance the individual's treatment goals and objectives
identified in the ISP.
10. 10. Physician monitoring, nursing care, and
observation shall be available. A physician shall be available to assess the
individual in person or via telemedicine within 24 hours of admission
and thereafter as medically necessary.
11. 12. A licensed and registered nurse
shall conduct an alcohol or other drug-focused nursing assessment upon
admission. A licensed registered nurse or licensed practical nurse shall be
responsible for monitoring the individual's progress and for medication
administration duties.
12. 13. Additional medical specialty
consultation, psychological, laboratory, and toxicology services shall be
available on site, either through consultation or referral.
13. 14. Coordination of necessary services shall
be available on site or through referral to a closely coordinated off-site
provider to transition the individual to lower levels of care.
14. 15. Psychiatric services shall be available
on site or through consultation or referral to a closely coordinated
off-site provider when a presenting problem could be attended to at a later
time. Such services shall be available within eight hours of requested service
by telephone or within 24 hours of requested service in person or via
telemedicine.
C. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) staff requirements.
1. The interdisciplinary team shall include credentialed
addiction treatment professionals CATPs and addiction-credentialed
physicians or physicians with experience in addiction medicine to assess,
treat, and obtain and interpret information regarding the individual's
psychiatric and substance use disorders. Physicians and physician
extenders either employed, contracted or through referral arrangements with the
agency, shall have a DEA-X for prescribing buprenorphine. ASAM Level 3.7
may utilize CSACs or CSAC-supervisees to provide substance use disorder
counseling and psychoeducational services within their scope of practice as
defined in Virginia Code §54.1-3507.1.
2. Clinical staff shall be knowledgeable about the biological and psychosocial dimensions of substance use disorders and mental illnesses and their treatment. Clinical staff shall be able to identify acute psychiatric conditions, symptom increase or escalation, and decompensation.
3. Clinical staff shall be able to provide a planned regimen of 24-hour professionally directed evaluation, care, and treatment including the administration of prescribed medications.
4. Addiction-credentialed physician or physician with experience in addiction medicine shall oversee the treatment process and assure quality of care. Licensed physicians shall perform physical examinations for all individuals who are admitted. Staff shall supervise addiction pharmacotherapy integrated with psychosocial therapies. The professional may be a physician or psychiatrist, or physician extender as defined in 12VAC30-130-5020 if knowledgeable about addiction treatment.
D. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) co-occurring enhanced programs as required by ASAM.
1. Appropriate psychiatric services, medication evaluation, and laboratory services shall be available.
2. A psychiatrist assessment of the individual shall occur within four hours of admission by telephone and within 24 hours following admission in person or via telemedicine, or sooner, as appropriate to the individual's behavioral health condition, and thereafter as medically necessary.
3. A behavioral health-focused assessment at the time of admission shall be performed by a registered nurse or licensed mental health clinician. A licensed registered nurse or licensed practical nurse supervised by a registered nurse shall be responsible for monitoring the individual's progress and administering or monitoring the individual's self-administration of medications.
4. Psychiatrists and credentialed addiction treatment
professionals CATPs who are able to assess and treat co-occurring
psychiatric disorders and who have specialized training in the behavior
management techniques and evidenced-based practices shall be available.
5. Access to an addiction-credentialed physician shall be available along with access to either a psychiatrist, a certified addiction psychiatrist, or a psychiatrist with experience in addiction medicine.
6. Credentialed addiction treatment professionals CATPs
shall have experience and training in addiction and mental health to understand
the signs and symptoms of mental illness and be able to provide education to
the individual on the interaction of substance use and psychotropic
medications.
7. Planned clinical activities shall be offered and designed to promote stabilization and maintenance of the individual's behavioral health needs, recovery, and psychiatric symptoms.
8. Medication education and management shall be offered.
12VAC30-130-5150. Covered services: medically managed intensive inpatient services (ASAM Level 4.0).
A. Medically managed intensive inpatient services (ASAM Level 4.0) settings for services. Acute care hospitals licensed by the Virginia Department of Health shall be the designated setting for medically managed intensive inpatient treatment and shall offer medically directed acute withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress resulting from, or occurring with, an individual's use of alcohol and other drugs. Such service settings shall offer medically directed acute withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress, or all of these, resulting from, or co-occurring with, an individual's use of alcohol or other drugs with the exception of tobacco-related disorders, caffeine-related disorders or dependence or nonsubstance-related disorders.
B. Medically managed intensive inpatient services (ASAM Level 4.0) service components.
1. The service components of medically managed intensive inpatient services shall be:
a. An evaluation or analysis of substance use disorders shall be provided, including the diagnosis of substance use disorders and the assessment of treatment needs for medically necessary services.
b. Observation and monitoring the individual's course of withdrawal shall be provided. This shall be conducted as frequently as deemed appropriate for the individual and the level of care the individual is receiving. This may include, for example, observation of the individual's health status.
c. Medication services, including the prescription or administration related to substance use disorder treatment services or the assessment of the side effects or results of that medication, conducted by appropriate licensed staff who provide such services within their scope of practice or license.
2. The following therapies shall be provided for reimbursement:
a. Daily clinical services provided by an interdisciplinary
team to stabilize acute addictive or psychiatric symptoms. Activities shall
include pharmacological, cognitive-behavioral, and other therapies psychotherapies
or substance use disorder counseling administered on an individual or group
basis and modified to meet the individual's level of understanding. For
individuals with a severe biomedical disorder, physical health interventions
are available to supplement addiction treatment. For the individual who has
less stable psychiatric symptoms, ASAM Level 4.0 co-occurring capable programs
offer individualized treatment activities designed to monitor the individual's
mental health and to address the interaction of the mental health programs and
substance use disorders.
b. Health education services.
c. Planned clinical interventions that are designed to enhance the individual's understanding and acceptance of illness of addiction and the recovery process.
d. Services for the individual's family, guardian, or significant other, as appropriate, to advance the individual's treatment and recovery goals and objectives identified in the ISP.
e. This level of care offers 24-hour nursing care and daily physician care for severe, unstable problems in any of the following ASAM dimensions: (i) acute intoxication or withdrawal potential; (ii) biomedical conditions and complications; and (iii) emotional, behavioral, or cognitive conditions and complications.
f. Discharge services shall be the process to prepare the individual for referral into another level of care, post treatment return or reentry into the community, or the linkage of the individual to essential community treatment, housing, recovery, and human services.
C. Medically managed intensive inpatient services (ASAM Level 4.0) staff requirements.
1. An interdisciplinary staff of appropriately credentialed clinical staff including, for example, addiction-credentialed physicians or physicians with experience in addiction medicine, licensed nurse practitioners, licensed physician assistants, registered nurses, licensed professional counselors, licensed clinical psychologists, or licensed clinical social workers who assess and treat individuals with severe substance use disorders or addicted individuals with concomitant acute biomedical, emotional, or behavioral disorders. Physicians and physician extenders either employed, contracted or through referral arrangements with the agency, shall have a DEA-X to prescribe buprenorphine.
2. Medical management by physicians and primary nursing care shall be available 24 hours per day and counseling services shall be available 16 hours per day.
D. Medically managed intensive inpatient services (ASAM Level 4.0) co-occurring enhanced programs. These programs shall be provided by appropriately licensed or registered credentialed mental health professionals who assess and treat the individual's co-occurring mental illness and are knowledgeable about the biological and psychosocial dimensions of psychiatric disorders and his treatment.
FORMS (12VAC30-130)
Forms accompanying Part II of this chapter:
Virginia Uniform Assessment Instrument
Forms accompanying Part III of this chapter:
MI/MR Supplement Level I (form and instructions)
MI/MR Supplement Level II.
Forms accompanying Part VII of this chapter:
Request for Hospice Benefits DMAS-420, Revised 5/91
Forms accompanying Part VIII of this chapter:
Inventory for Client and Agency Planning (ICAP) Response Booklet, D9200/D9210, 1986
Forms accompanying Part IX of this chapter:
Patient Information form
Instructions for Completion DMAS-122 form
Forms accompanying Part XII of this chapter:
Health Insurance Premium Payment (HIPP) Program Insurance Information Request Form
Health Insurance Premium Payment (HIPP) Program Medical History Form (HIPP Form-7, Rev. 11/92).
Health Insurance Premium Payment (HIPP) Program Employers Insurance Verification Form (HIPP Form-2, Rev. 11/92)
Health Insurance Premium Payment (HIPP) Program Employer Agreement (HIPP Form-3, Rev. 11/92)
Health Insurance Premium Payment (HIPP) Program Notice of HIPP Determination (HIPP Form-4, Rev. 11/92)
Health Insurance Premium Payment (HIPP) Program Notice of HIPP Approval
Health Insurance Premium Payment (HIPP) Program Notice of HIPP Status (HIPP Form-6, Rev. 11/92)
Inventory for Client and Agency Planning (ICAP) Response Booklet, D9200/D9210, 1986
Forms accompanying Part XIV of this chapter:
Residential Psychiatric Treatment for Children and Adolescents, FH/REV (eff. 10/99)
Forms accompanying Part XV of this chapter:
Treatment Foster Care Case Management Agreement, TFC CM Provider Agreement DMAS-345, FH/REV (eff. 10/99)
Forms accompanying Part XVIII of this chapter:
Virginia Independent Clinical Assessment Program (VICAP) (eff. 6/11)
Forms accompanying Part XX of this chapter:
Opioid/Medication Assisted Treatment License & Oversight (March, 2017)