As Executive Director of the Virginia Association of Community-Based Providers (VACBP), I want to express concerns about the inadequate notificiation of the opportunity to review and comment on these proposed regulatory changes.  If the Department is interested in the advice of highly professional and experienced people who are striving every day to provide life changing services to people in serious need, there should be a direct communication to all providers, notifying them that their advice is needed in order to establish the most effective regulations. 

This evening, I reviewed the comments on the website (it is notable that prior to today, there were only six comments on the site) and there is a remarkable consistency in the concerns expressed about changes to IIH that will make it harder for children and familes to receive the service and harder for providers to successfully provide it.  It appears that the proposed changes are consistent with many other changes to community-based early intervention services over the past several years.  The changes have not improved the efficiency, effectiveness or accountaility in the delivery of services -- that would take cooperation with providers and efforts to innovate -- to do things better.  These proposed changes will likley reduce access to lower cost services and create more demand for higher cost services -- including social services and criminal justice system services.  The roles of public and private providers of services must be leveraged with effective regulation in order for our system to achieve the significant transformation that is necessary. I have included below the comments and questions of a VACBP member who took time with last minute notice today to respond.  I hope these comments and questions are helpful.  I believe more input from more providers would be beneficial and I hope you will create a process where that can happen.

Comments/Concerns Regarding Town Hall Discussion 1/29/15

Under 12VAC30-50-226 Community mental health services

Definitions –

(page 10 0f 41 when printed)Clinical Experience – What clarity can we receive on this section? The manner in which it is written may be interpreted that the only experience that counts as clinical experience is that which is for the provision of mental health day treatment/partial hospitalization, intensive community treatment, psychosocial rehabilitation, mental health supports [skill building], crisis stabilization or crisis intervention. If this is the case, this will significantly limit the number of qualified staff and in particular newly qualified staff, as they can only get “clinical experience” in a field that can only hire them once they have the “clinical experience.”

(page 11 of 41 when printed) LMHP-Resident – This section specifies that an individual “cannot perform the functions of an LMHP-R or be considered a “resident” until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Counseling.” This significantly burdens employers, as they would be required to recruit and hire individuals that may take months to be preapproved by the VA Board of Counseling before they are able to perform their specific job duties. Our specific experience has been with LMHP-R’s, as we have dealt directly with the VA Board of Counseling. As the regulations require provider specific intakes completed by LMHPs, LMHP-Rs, LMHP-RP, or LMHP-S, for MHSS and now Crisis Stabilization, this significantly limits providers’ abilities to provide services. In some areas of Southwest Virginia there are significantly limited numbers of LMHPs, which forces employers to hire Residents or Supervisees, but there are also limited Licensed Supervisors that can act in a supervisory capacity to oversee an individual’s residency.  Additionally, since the regulation states that it must be the specific site that is approved, any new employee would have to go through the registration of a supervisor process regardless if they are already approved to be a resident by the Board of Counseling. We have gone through registering our LMHP-R’s and have been notified by the Board that there is a backlog of sometimes 50 applicants and that approval from the Board of Counseling will take up to and maybe more than three months. Furthermore, the Board of Counseling will not approve Resident status for individual working only as MHSS Assessors/LMHP-Rs as the Board of Counseling reports this does not provide the Resident with the depth of clinical experience needed to prepare them for working independently as a counselor. The Board of Counseling has also questioned and reported concerns about LMHP-R’s providing supervision to other staff as a part of the Residency, as the Board views this as outside the purpose of a Residency, which in the Board’s opinion should be focused on Residents providing direct service. The Board of Counseling does not recognize MHSS as a direct service that qualifies as Residency experience. Nor does PSR qualify for Residency experience. Crisis Stabilization Services may count toward a residency. This creates a situation where these regulations and the Board of Counseling come into direct conflict, effectively limiting providers ability to provide these services. While the regulations suggest that and LMHP-R could supervise QMHP-As, QMHP-Es, and QMHPPs, the Board of Counseling does not approve of this as a main job duty. Additionally, the Board of Counseling does not approve of LMHP-Rs only conducting assessments/intakes.

7.            Crisis Stabilization Services (page 16 of 41 when printed) – The intake must be completed by and LMHP, LMHP-Resident, LMHP-Supervisee, LMHP –RP. This again creates a situation where individuals may not be served due to the limited availability of these types of qualified staff.

               f. 3 – (page 17 of 41 when printed) “Exhibit such inappropriate behavior that immediate interventions documented by the mental health, social services, or judicial system are or have been necessary.” Does “documented” mean separate documentation from the specific mental health, social services, or judicial system provider? If so this creates an even more burdensome intake process that requires providers to get even more outside documentation such as police records, CPS investigations (which may not be released), etc.

8.            Mental Health Support Services (MHSS) (page 18 of 41 when printed) – Please note that this should be Mental Health Skills Building Services. If providers are required to implement changes in the title of a service set forth by DMAS, it seems a fair expectation that DMAS and the regulations set forth would also be required to implement this change in title.

               a.3 – same as above regarding the need to document outside interventions.

12VAC30-60-5 Applicability of utilization review requirements (page 19 of 41 when printed)

F. 3 – “Payments shall not be permitted to healthcare entities that either hold provisional license or fail to enter into a Medicaid Provider Enrollment Agreement for a service prior to rendering that service” – This suggests an extremely punitive review of providers by DBHDS and would effectively shut down any provider that is on a provisional license.  Also, when a provider is first licensed to provide a service, they are under a provisional license.  Would they not get paid?  What is the objective of a provisional license at this point, if the provider can no longer receive payment?

12VAC30-60-143 Mental Health Service utilization criteria; definitions

B.4 (page 28 of 41 when printed) – This section identifies that providers violating the marketing requirements and regulations “shall be terminated as a Medicaid provider.” The marketing guidelines have been in place with the previous consequence involving fines. However, these regulations were not enforced. Rather than making a more severe regulation, why not enforce the regulation that was already in place?

B. 6 – Regarding informing an individual’s PCP – What about Clients who do not have a PCP? Additionally, if a client does not want a provider to communicate with a PCP, they may refuse to sign a release of information. To then communicate with the PCP would violate the Client’s Human Rights.

B.7 – “An ISP that is not updated either annually or as the treatment interventions based on the needs and progress of the individual change shall be considered outdated.” Other language in the document reports that providers will not receive reimbursement for services conducted under an outdated ISP. What guidance is offered on determining when the needs and progress of an individual require a change to the ISP?  Individuals are dynamic in nature and theoretically, the ISP may be updated daily under this requirement. Who will be interpreting when the needs and progress of a client require an ISP update?

D.1 – (page 29 of 41 when printed) – PSR intakes must be completed by an LMHP, LMHP-R, LMHP-S, LMHP-RP. This again creates a barrier to individuals receiving services in parts of Southwest Virginia where LMHPs, residents, supervisees, etc. are extremely limited.

H.1- (page 32 of 41 when printed) – Crisis Stabilization intakes must be completed by an LMHP, LMHP-R, LMHP-S, LMHP-RP. This again creates a barrier to individuals receiving services in parts of Southwest Virginia where LMHPs, residents, supervisees, etc. are extremely limited.

12VAc30-130-2000

Part XVII – Marketing of Provider Services

D.1 – (page 35 of 41 when printed) Discusses providers not offering “non-cash incentives” for rewarding behavioral changes and “compliance with goals and objectives staged in beneficiaries’ ISP.” This seems very open to interpretation. Does this include praising a client for achieving an identified objective or offering a small token of recognition when a client achieves specific goals and objectives and is ready to be discharged to a less intense level of care? Recognizing, validating, and honoring a client’s growth is an important part of any treatment process.

D.2.f – (page 36 of 41 when printed) Providers shall not collect or use PHI provided by another entity to identify and market services to prospective beneficiaries.  This suggests that providers may not take referrals from other providers and that only individuals calling directly for services may receive information from providers. Clients with SMI often struggle with accessing appropriate services. If a client is struggling with accessing services, what recourse does a referral source such as a psychiatrist, CM, outpatient counseling, etc. have?

12VAC30-130-3010

Independent Clinical Assessments are required for individuals under the age of 21 for MHSS. There are a host of issues related to this that have already been discussed.

 12VAc30-130-3020  - Independent Clinical Assessment Requirements

D. – “DMAS may apply the independent clinical assessment requirement to any of the other Medicaid-covered community mental health services set out in 12VAC30-50-130 and 12VAC30-50-226 with appropriate and timely notice to providers.” Who determines what is appropriate and timely? The ICA process has been extremely challenging in areas where the CSB was ill prepared. Additionally, there is a conflict of interest for CSB’s to conduct ICA’s when they offer the services. How is it independent in these cases, if the assessors work for an agency that provides the services recommended by the ICA ? Finally, the collaboration required to ensure individuals receive services in a timely and appropriate manner require cooperation from the CSB, which in some areas has been significantly lacking. What recourse do individuals have who are not served appropriately by their local CSB, and what recourse to private providers have when individuals report significant barriers to services due to CSB practices?