May 19, 2020
To Whom It May Concern,
On behalf of the VACSB MH and SUD Councils, thank you for the opportunity to comment on the potential impact of the proposed ARTS updates within the Virginia State Plan for Medical Assistance. The Council's comments reflect those of its members.
Sincerely,
Leslie Stephen, LCSW
Chair – VACSB Mental Health Council
12VAC30-60-181. Utilization review of addiction, and recovery, and treatment services
E2. All ISPs shall be completed and contemporaneously signed and dated by the credentialed addiction treatment professional CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.
--Allow CSACs to complete ISP for tx in ASAM Levels 1, 2, and 2.5.
--Add in CSAC for 3.7- In 3.7, clients must see physician or extender for physical within 24 hours of admission. There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) . This will increase availability as licensed staff are difficult to recruit and not available to work weekends.
F. This section is for an ISP. A Medication assisted Treatment assessment does not belong here. It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language. Adding in an assessment in appropriate.
---The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
12VAC30-130-5020. Definitions.
"Credentialed addiction treatment professionals" professional" 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; (iii) (iv) a licensed clinical psychologist; (iv) (v) a licensed clinical social worker; (v) (vi) a licensed professional counselor; (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) a licensed marriage and family therapist; (ix) (x) a licensed substance abuse treatment practitioner; (x) residents (xi) a resident who is under the 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 is registered with the Virginia Board of Counseling; (xi) residents (xii) a resident in psychology who is under supervision of a licensed clinical psychologist and in a residency approved by is registered with the Virginia Board of Psychology (18VAC125-20-10); (xii) supervisees or (xiii) a supervisee in social work who is under the supervision of a licensed clinical social worker approved by and is registered with the Virginia Board of Social Work (18VAC140-20-10); or (xiii) an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certification as a substance abuse counseling-assistant (CSAC-A) (18VAC115-30-10) under supervision of licensed provider and within his scope of practice, as described in §§ 54.1-3507.1 and 54.1-3507.2 of the Code of Virginia.
---Clarify that in case where the provider is both the CSAC and a LMHP, the provider is categorized as a CATP and does not require additional sign-off on multi-dimensional assessments or ISPs.
"Credentialed addiction treatment professionals" professional" 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; (iii) (iv) a licensed clinical psychologist; (iv) (v) a licensed clinical social worker; (v) (vi) a licensed professional counselor; (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) a licensed marriage and family therapist; (ix) (x) a licensed substance abuse treatment practitioner; (x) residents (xi) a resident who is under the 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 is registered with the Virginia Board of Counseling; (xi) residents (xii) a resident in psychology who is under supervision of a licensed clinical psychologist and in a residency approved by is registered with the Virginia Board of Psychology (18VAC125-20-10); (xii) supervisees or (xiii) a supervisee in social work who is under the supervision of a licensed clinical social worker approved by and is registered with the Virginia Board of Social Work (18VAC140-20-10); or (xiii) an individual with certification as a substance abuse counselor (CSAC) (18VAC115-30-10) or certification as a substance abuse counseling-assistant (CSAC-A) (18VAC115-30-10) under supervision of licensed provider and within his scope of practice, as described in §§ 54.1-3507.1 and 54.1-3507.2 of the Code of Virginia
-----Segment above needs to be added back in. CSACs provide essential services and should be allowed to create a substance related ISP with oversight from licensed staff. If this is left in, must address that CSACs can perform ISP’s with oversight.
---If CSACs cannot complete an ISP (with sign off by licensed) all “Primary Counselor” staff must be licensed. This would be cost prohibitive. All BH2s would need to be converted to senior clinicians. In addition, recruitment would be impossible. Statewide, there is already a shortage of licensed staff. By adding this requirement, it will make it impossible to recruit and hire essential staff, thus reducing services available during an opioid crisis. At the very least, allow CSACs with sign off by licensed to complete ISP and MDA assessment in 3.1, 3.3, 3.5, 3.7. In these setting, there are other credentialed staff on site an available ensure the client has his/her needs met.
---Add in Licensed Nurse practitioner with experience or training in addiction medicine- Across the State, many nurse practitioners (adult or family) have extensive training and experience in addiction medicine. They should be included.
---Adding Nurse Practitioners into the eligible providers is important. Not counting FNP's as LMHP's is limiting. While they do not have as much training as a MHNP or PNP, they clearly are on the front lines of providing treatment for BH conditions and shouldn't be excluded.
"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.
---Allow for telehealth to be provided to a member located in the member’s home. This removes the barrier of transportation in rural and suburban communities. This change will increase client engagement (as demonstrated by increased engagement during COVID19). Engagement is the first ingredient for recovery.
12VAC30-130-5040. Covered services: requirements; limits; standards.
A.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 within the scope of their practice CATP or a CSAC under the supervision of a CATP and (ii) be accurately reflected in provider medical record documentation and on providers' provider 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. A CATP or a CSAC under the supervision of a CATP shall complete the multidimensional assessments. A CATP must sign and date assessments performed by a CSAC within one business day.
---Evidence based approaches (to include David Mee-Lee/chief editor of the ASAM criteria) acknowledge that individuals with co-occurring disorders can have multiple primary disorders. One is not primary over the other. Clarify wording to reflect this. The individual must have a primary substance use disorder, but that does not mean he cannot also have another primary disorder.
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services
D.1. Random urine drug screening, using 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.
---Leave it at 12 months versus one year. 12 months is more definitive
D. 8. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either onsite or through referral.
---This says to test. The individual has the right to choose. This is too prescriptive. A test can be offered
12VAC30-130-5060. Covered services: clinic services - preferred office-based opioid treatment.
D.5. Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.
---Good
12VAC30-130-5080. Covered services: outpatient services - physician services (ASAM Level 1.0).
A.1. 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.
---Allow for groups to be provided via telehealth with the member who is at home.
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 provider 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 (psychiatric residential treatment facility) provider; (v) a "mental health residential-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.
---3.7 has extensive additional requirements to include expensive medical personnel. Rates for this service need to be reviewed.
B1. Daily clinical services provided by an interdisciplinary team to involve appropriate medical and nursing services, as well as individual, group, and family activity services, as appropriate to the needs and current functioning level of the individual. Activities may include pharmacological, including medication assisted treatment that is provided onsite 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.
---It is not clinically appropriate and may often be contraindicated to begin therapy during acute withdrawal.
Other areas that should be addressed
1. Take out treatment history from ISP
It does not belong here. It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language. Add treatment history as part of MDA assessment. Adding in an assessment in appropriate.
The assessment should be in the Assessment/ MDA. The ISP should reflect needs/goals and preferences as indicated in the assessment.
2. Discharge Planning sections for 3.3, 3.5, 3.7 are confusing and unrealistic. The timeframes, especially for 3.7 is unrealistic and will result in lack on continuity of care. Programs cannot wait for the MCO to approve a discharge plan before talking to potential future providers in a short term 7-day program. This needs to be revamped where the provider.
3. Need to change timeframe for the MDA Assessment in 3.7 programs to reflect that it is inappropriate to attempt to conduct a full psycho social history while the individual is in the acute phases of withdrawal. While the current regulations allow the PDE to be delayed due to individual illness/withdrawal, the service authorization is still expected in 24 hours but includes information that is gathered in the MDA. Specify that providers may complete service authorization form dimension 1 and 2 with 24 hours and complete the rest in 72 hours. Otherwise, the provider has to take the chance of not being paid or else must require a sick client to participate.