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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
8/9/2022

12VAC30-130-5180. Peer support services and family support partners: medical necessity criteria.

A. In order to receive ARTS peer support services, individuals 21 years of age or older shall meet the following requirements:

1. The individual shall have a substance use disorder or co-occurring mental health and substance use disorders diagnosis.

2. The individual shall require recovery-oriented assistance and support services for:

a. The acquisition of skills needed to engage in and maintain recovery;

b. The development of self-advocacy skills to achieve a decreasing dependency on formalized treatment systems; and

c. Increasing responsibilities, wellness potential, and shared accountability for the individual's own recovery.

3. The individual shall demonstrate moderate to severe functional impairment as a result of the diagnosis, and the functional impairment shall be of a degree that it interferes with or limits performance in at least one of the following domains: educational (e.g., obtaining a high school or college degree); social (e.g., developing a social support system); vocational (e.g., obtaining part-time or full-time employment); or self-maintenance (e.g., managing symptoms, understanding his illness, living more independently).

B. Caregivers of individuals younger than 21 years of age who qualify for ARTS family support partners (i) have an individual with a substance use disorder or co-occurring mental health and substance use disorders who requires recovery assistance and (ii) meet two or more of the following:

1. Individual and his caregiver need peer-based recovery oriented services for the maintenance of wellness and acquisition of skills needed to support the individual.

2. Individual and his caregiver need assistance to develop self-advocacy skills to assist the individual in achieving self-management of the individual's health status.

3. Individual and his caregiver need assistance and support to prepare the individual for a successful work or school experience.

4. Individual and his caregiver need assistance to help the individual and caregiver assume responsibility for recovery.

C. Individuals 18 through 20 years of age who meet the medical necessity criteria in subsection A of this section, who would benefit from receiving peer supports directly, and who choose to receive peer support services directly instead of through their family shall be permitted to receive peer support services by an appropriate PRS.

D. To qualify for continued ARTS peer support services and ARTS family support partners, medical necessity criteria shall continue to be met and progress notes shall document the status of progress relative to the goals identified in the recovery resiliency and wellness plan.

E. Discharge shall occur when one or more of the following is met:

1. Goals of the recovery resiliency and wellness plan have been met;

2. The individual, or as applicable for individuals younger than 21 years of age, the caregiver, requests discharge; or

3. The individual, or as applicable for individuals younger than 21 years of age, the caregiver, fail to make minimum contact requirements set forth in 12VAC30-130-5210 L and M or the individual or caregiver, as applicable, discontinues participation in services.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 34, Issue 3, eff. November 16, 2017.

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