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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 130. Amount, Duration and Scope of Selected Services
11/21/2024

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 CATP contracted by DMAS or its contractor or an MCO to perform the services in the following community based settings: primary care clinics, outpatient health system clinics, psychiatry clinics, FQHCs, RHCs, 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 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, 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 shall be provided by a CATP. Services shall be provided in person or by telemedicine.

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.

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.

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.

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.

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. 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 is secondary, which disorder occurred first, or whether one disorder caused the other.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 33, Issue 12, eff. April 1, 2017; amended, Virginia Register Volume 36, Issue 11, eff. March 5, 2020.

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