12VAC30-130-5020 Definitions:
"Credentialed addiction treatment 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) (vi) (vii) a licensed certified psychiatric clinical nurse specialist; (vii) (viii) a licensed psychiatric nurse practitioner; (viii) (ix) …… 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.
Recommendation: It is confusing to have the multiple references differentiating CSACS from CATPs. We have been operating all of the time with the understanding that a CSAC is a CATP based on the definition given in the current DMAS ARTS Manual.
CSAC should be returned to the list of credentialed individuals who meet criteria to be a CATP. These individuals have completed significant didactic training and supervision as well as have passed a competency exam indicating knowledge of the population being served in order to become certified. By scope of practice and credentialing, CSAC are unable to provide services without a licensed supervisor thereby inherently including supervision/oversight within the role they fill within their agency. Therefore, CSAC should be able to write and implement ISPs and complete the Multidimensional Assessment without the need for a co-signature of a licensed person. Additionally, there are sufficient safeguards in regulations to ensure that individuals’ needs are being noted and/or addressed by other licensed professions required as members of the treatment team with the levels of care, especially at ASAM 3.1-3.7. Finally, Service Request Authorizations require the signature of a team member that is licensed or license-type (Resident/Supervisee) in order to be submitted for review so there is already someone reviewing appropriateness for the level of care based on medical necessity so requiring co-signatures on CSAC documentation is duplicative and excessive.
CSAC should be returned to the definition of credentialed staff who meet CATP requirements and all references within the proposed changes should be removed.
Recommendation: CSAC-Supervisee should be added to the list of credentialed individuals who meet criteria to be a CATP, just as Residents in Counseling and Supervisees in Social Work are. In order to be a Supervisee, there needs to be an identified certified/licensed supervisor and the required hours of didactic training must already be completed. If necessary, require a co-signature for Supervisees as they are still in their training process and have not yet become completed supervised experience or passed the credentialing exam.
Recommendation: “Psychiatric” type NP program is not needed or required to treat SUD or become a buprenorphine waivered practitioner. All references to Nurse Practitioners should have additional specifiers deleted, both in CATP definitions and throughout the document- examples “psychiatric” or “family” nurse practitioner. Could simply note “licensed Nurse Practitioners” instead. Using the more specific language decreases available qualified workforce.
12VAC30-60-181 UR
D. Multidimensional Assessment – if completed by CSAC, must be co-signed by CATP (new definition) Recommendation: See recommendation to return CSAC to CATP definition above.
E.1 “… 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.”
Recommendation: This language should be clarified to include the need for review every 90 days, should be changed to REWRITTEN (rather than updated) or should be combined with F below where it outlines the need for “review every 90 days calendar days and shall be modified as the needs and progress of the individual change.”
E.2 “All ISPs shall be completed and contemporaneously signed and dated by the 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.”
Recommendation: See recommendation to return CSAC to CATP definition above.
F. (vi) The comprehensive ISP … shall include: …, Medication Assisted Treatment Assessment, which shall be provided onsite or through referral
Recommendation: A MAT assessment contains data determining eligibility for the service. Assessment data drives development of the ISP. It is more appropriate to require different documentation that a MAT assessment was offered. If the client receives MAT, the ISP would reflect the on-going MAT service at that time.
F… CSACs may perform the ISP reviews in ASAM Levels 3.1, 3.3, and 3.5 if a CATP signs and dates the ISP review
Recommendation: See return of CSAC to CATP definition above. CSACs should be considered CATP and be qualified to write and implement ISPs for all levels of care without the need for co-signature of licensed or license-type staff.
12VAC30-70-418. Reimbursement for residential and inpatient substance use treatment services.
Recommendation: Due to the significant staffing requirements in the above indicated levels of care for residential settings, it is recommended to consider re-evaluation of reimbursement rates for these services. These are residential levels of care which require 24 hour supervision and services provided by medical and clinical staff that reimburse at a lower rate than that of ASAM 2.5 on a daily basis.
12VAC30-130-5020 Definitions
"Face-to-face" means encounters that occur in person or through telemedicine
Recommendation: Clarification may be needed as this would seem to imply that any service indicated as being provided as “face-to-face” would be allowable as “telemedicine.” (See telemedicine recommendation.)
"Individual service plan" or "ISP" means an initial and comprehensive treatment plan … An ISP includes documentation if the individual is a minor child or an adult who lacks legal capacity and is unable or unwilling to sign the ISP.
Recommendation: Update language to include “if the individual is a minor or incapacitated adult, the ISP is also signed by the individual’s parent or legal guardian.”
"Psychotherapy" or "therapy" means the use of psychological methods in a professional relationship to assist a person to acquire great human effectiveness or to modify feelings, …
Recommendation: Provide clarification (quantify or qualify) what “acquire great human effectiveness” means as this is not clear.
"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.
Recommendations: Resolve inconsistencies in definitions of “Telemedicine,” “face-to-face” and within ASAM 1.0 level of services (“Services shall be provided face to face in person or by telemedicine.”)
12VAC30-130-5040. A. Addiction and recovery treatment services.
1. In order to be covered, ARTS shall (i) meet medical necessity criteria based upon the multidimensional assessment completed by a CATP or a CSAC under the supervision of a CATP and … 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. 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.
Recommendation: See return of CSAC to CATP definition above. CSACs should be considered CATP and be qualified to write and implement ISPs for all levels of care without the need for co-signature of licensed or license-type staff.
Recommendation: Where the regulations indicate, “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” delete the word “primary” from all references of this language within the proposed changes. Requiring “primary substance use diagnosis” discriminates against those with mental health disorders. Most people with SUD also have co-occurring disorders. This language would rule out people with primary MH disorders who also validly need SUD treatment. It would also rule out people with true co-occurring disorders. It is often difficult to separate out which diagnoses are primary, especially without a period of prolonged sobriety. All people with SUD should have access to covered treatment.
12VAC30-130-5060. B.OBOT service components
10. Provision of onsite screening or referral for screening for clinically indicated infectious disease testing for diseases such as HIV; hepatitis A, B, and 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.
Recommendation: Clarify what “at initiation” of services means. Is a screening (verbal questions) sufficient or are labs required? Is it that we need to perform or order labs and receive results before MAT induction can occur? What if an individual refuses the testing as they have a right to do – are we to not allow prescribing of medications for MAT? This would also hold true for any places that it references the “ability to provide pregnancy testing for women of childbearing age.”(#12) Again, we cannot force an individual to complete a pregnancy test and/or do we need to ensure we have results before we can initiate MAT services?
C. OBOT staff requirements
2. 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-As 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.
Recommendation: See return of CSAC to CATP definition above. CSAC is recognized as an appropriate provider at this level of service and should be considered a CATP based on training and experience.
D. OBOT risk management shall be documented in each individual’s record and shall include: (Subsections 1, 6, 7, 8, 9 specifically)
Recommendation: What if an individual refuses the testing as they have a right to do – are we to not allow prescribing of medications for MAT? This would also hold true for any places that it references the “ability to provide pregnancy testing for women of childbearing age. Again, we cannot force an individual to complete a pregnancy test and/or do we need to ensure we have results before we can initiate or continue MAT services?
12VAC30-130-5080.
1. Outpatient services (ASAM Level 1.0) service components:
b. … The multidimensional assessment shall include a physical examination and laboratory testing necessary for substance use disorder treatment as necessary.
Recommendation: Remove the language “ shall include a physical examination and laboratory testing” or update to say “may include” as it is less prescriptive and could allow for exam but not require it.
c. Individual psychotherapy or substance use disorder counseling shall be provided CATP. Services shall be provided face to face in person or by telemedicine.
Recommendation: clarification needed in language indicating that services shall be provided in person or by telemedicine. See comment related to telemedicine definition.
d. Group psychotherapy or substance use disorder counseling shall be provided by a CATP with a maximum of 10 individuals in the group and shall focus on the needs of the individuals served.
Recommendation: Expand the group size to allow for a maximum of 12 individuals in the group setting to expand capacity to provide services and allow for scheduling of 12 participants to take into account no-shows or absences.
Recommendation: Allow group services as ASAM Level 1.0 to be provided via telehealth, not just individual services. Telehealth has increased retention and engagement by up to 30% during the COVID-19 period; telehealth allows for a reduction in barriers to treatment such as childcare and transportation.
e. Family 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.
Recommendation: “Shall be provided” is too prescriptive and would be better described as “encouraged” or “allowed.” Often, clients have dysfunctional and unhealthy relationships with their family and it would be inappropriate, and not therapeutic, to require participation in such activity. Furthermore, we cannot force a client to participate in services they object to nor can we force a family member to participate in family therapy against their will.
2. Outpatient services (ASAM Level 1.0) staff requirements shall include:
a. A 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.
Recommendation: It is unclear how an RN or LPN with one year of clinical experience involving medication management would meet the criteria to provide “professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services” as described in regulations for ASAM Level 1.0 when they are not designated at a CATP. CSAC, who has specialized training and experience in SUD related services, should be allowed to provide services at this level and be considered a CATP.
12VAC30-130-5090. (ASAM Level 2.1).
A. The following service components shall be provided weekly as directed by the ISP for reimbursement)
Recommendation: Update language to indicate “may be provided weekly…” All items are not appropriate for every client. For example, family therapy, MAT, psychopharmacological consultation, addiction medication management, psychiatric consultation, etc. are not required for each and every client.
B. 2. Generalist physicians or physicians with experience in addiction medicine are permitted to provide general medical evaluations and concurrent or integrated general medical care.
Recommendation: Clarification of what is included in “general medical evaluations and concurrent or integrated general medical care.” If supports are in place for members to be referred for primary care services and/or evaluation is consultation sufficient to meet this need or does the physician need to be an employee/contractor of the agency? Are these physicians consultants to the team or are they providing actual medical care to individuals? Is it allowable to use Physician Extenders for this purposed as they are allowed in subsection 3 as long as they have a DEA-X number for buprenorphine prescribing?
12VAC30-130-5100. partial hospitalization services (ASAM Level 2.5).
A. Partial hospitalization services (ASAM Level 2.5) components…shall include the following, … provided on a weekly basis:
3. Family psychotherapy and substance use disorder counseling involving family members, guardians, or significant others in the assessment, treatment, and continuing care of the individual.
Recommendation: “Shall be provided” is too prescriptive and would be better described as “encouraged” or “allowed.” Often, clients have dysfunctional and unhealthy relationships with their family and it would be inappropriate, and not therapeutic, to require participation in such activity. Furthermore, we cannot force a client to participate in services they object to nor can we force a family member to participate in family therapy against their will.
General Feedback:
Highly recommend allowing group counseling options via telehealth. COVID-19 experiences have resulted in significant increased engagement (from prior levels of approximately 50% to current levels of approximately 80%) and is ideal for some who have barriers to treatment such as transportation and child care needs.
There is no indication in the proposed regulations for maximum group size for levels of care other than ASAM Level 1.0. Current regulations cap group size for 2.1, 2.5, 3.5, and 3.7 at 10 participants for group. If it is recommended that if there will be a group size maximum for these other levels of care that it be expanded to 12 participants to allow for increased capacity for services as well as to account for no shows/absences.