Chapter 130. Amount, Duration and Scope of Selected Services
Part I
Outpatient Physical Rehabilitative Services (Repealed)
12VAC30-130-10. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 1.1, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 26, Issue 21, eff. July 21, 2010; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-15. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 2.1; Virginia Register Volume 11, Issue 17, eff. July 1, 1995; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-20. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 2, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 18, Issue 10, eff. February 27, 2002; Volume 26, Issue 21, eff. July 21, 2010; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-30. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 3.2, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 26, Issue 21, eff. July 21, 2010; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-40. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 3.3, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 26, Issue 21, eff. July 21, 2010; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-42. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 4.1; Virginia Register Volume 11, Issue 17, eff. July 1, 1995; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-50. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 5, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 19, Issue 18, eff. July 1, 2003; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-60. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 6, eff. June 29, 1994; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; repealed, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.
12VAC30-130-70. (Repealed.)
Historical Notes
Derived from VR460-04-3.1300 § 7, eff. June 29, 1994; repealed, Virginia Register Volume 11, Issue 17, eff. July 1, 1995.
Part II
Long-Stay Acute Care Hospitals
12VAC30-130-80. Scope.
Medicaid shall cover long-stay acute care hospital services as defined in 12VAC30-130-90 provided by hospitals certified as long-stay acute care hospitals and which have provider agreements with the Department of Medical Assistance Services.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 1, eff. June 29, 1994.
12VAC30-130-90. Authorization for services.
Long-stay acute care hospital stays shall be preauthorized by the submission of a completed comprehensive assessment instrument, a physician certification of the need for long-stay acute care hospital placement, and any additional information that justifies the need for intensive services. Prior authorization shall be required by submission of the information described above. Physician certification must accompany the request. Periods of care not authorized by the Department of Medical Assistance Services shall not be approved for payment.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 2, eff. June 29, 1994.
12VAC30-130-100. Criteria for long-stay acute care hospital stays.
A. Adult long-stay acute care hospital criteria.
1. The resident must have long-term health conditions requiring close medical supervision, 24-hour licensed nursing care, and specialized services or equipment needs. The population to be served includes individuals requiring mechanical ventilation, individuals with communicable diseases requiring universal or respiratory precautions, individuals requiring ongoing intravenous medication or nutrition administration, and individuals requiring comprehensive rehabilitative therapy services.
2. At a minimum, the individual must require physician visits at least once weekly, licensed nursing services 24 hours a day (a registered nurse whose sole responsibility is the designated unit must be on the nursing unit on which the resident resides, 24 hours a day), and coordinated multidisciplinary team approach to meet needs.
3. In addition, the individual must meet at least one of the following requirements:
a. Must require two out of three of the following rehabilitative services: physical therapy, occupational therapy, speech-pathology services; each required therapy must be provided daily, five days per week, for a minimum of one hour each day; individual must demonstrate progress in overall rehabilitative plan of care on a monthly basis; or
b. Must require special equipment such as mechanical ventilators, respiratory therapy equipment (that has to be supervised by a licensed nurse or respiratory therapist), monitoring device (respiratory or cardiac), kinetic therapy; or
c. The individual must require at least one of the following special services:
(1) Ongoing administration of intravenous medications or nutrition (i.e. total parenteral nutrition (TPN), antibiotic therapy, narcotic administration, etc.);
(2) Special infection control precautions such as universal or respiratory precaution (this does not include handwashing precautions only);
(3) Dialysis treatment that is provided on-unit (i.e. peritoneal dialysis);
(4) Daily respiratory therapy treatments that must be provided by a licensed nurse or a respiratory therapist;
(5) Extensive wound care requiring debridement, irrigation, packing, etc., more than two times a day (i.e. grade IV decubiti; large surgical wounds that cannot be closed; second- or third-degree burns covering more than 10% of the body); or
(6) Multiple unstable ostomies (a single ostomy does not constitute a requirement for special care) requiring frequent care (i.e. suctioning every hour, stabilization of feeding, stabilization of elimination, etc.)
B. Pediatric/adolescent patients in long-stay acute care hospitals criteria.
1. To be eligible for long-stay acute care hospital services, the child must have ongoing health conditions requiring close medical supervision, 24-hour licensed nursing supervision, and specialized services or equipment needs. The recipient must be age 21 or under. The population to be served includes children requiring mechanical ventilation, those with communicable diseases requiring universal or respiratory precautions (excluding normal childhood diseases such as chicken pox, measles, strep throat, etc.), those requiring ongoing intravenous medication or nutrition administration, those requiring daily dependence on device-based respiratory or nutritional support (tracheostomy, gastrostomy, etc.), those requiring comprehensive rehabilitative therapy services, and those with a terminal illness.
2. The child must minimally require physician visits at least once weekly, licensed nursing services 24 hours a day (a registered nurse whose sole responsibility is that nursing unit must be on the unit on which the child is residing 24 hours a day), and a coordinated multidisciplinary team approach to meet needs.
3. In addition, the child must meet one of the following requirements:
a. Must require two out of three of the following physical rehabilitative services: physical therapy, occupational therapy, speech-pathology services; each required therapy must be provided daily, five days per week, for a minimum of 45 minutes per day; child must demonstrate progress in overall rehabilitative plan of care on a monthly basis; or
b. Must require special equipment such as mechanical ventilators, respiratory therapy equipment (that has to be supervised by licensed nurse or respiratory therapist), monitoring device (respiratory or cardiac), kinetic therapy, etc; or
c. Must require at least one of the following special services:
(1) Ongoing administration of intravenous medications or nutrition (i.e. total parenteral nutrition (TPN), antibiotic therapy, narcotic administration, etc.);
(2) Special infection control precautions such as universal or respiratory precaution (this does not include handwashing precautions only or isolation for normal childhood diseases such as measles, chicken pox, strep throat, etc.);
(3) Dialysis treatment that is provided within the facility (i.e. peritoneal dialysis);
(4) Daily respiratory therapy treatments that must be provided by a licensed nurse or a respiratory therapist;
(5) Extensive wound care requiring debridement, irrigation, packing, etc., more than two times a day (i.e., grade IV decubiti; large surgical wounds that cannot be closed; second- or third-degree burns covering more than 10% of the body);
(6) Ostomy care requiring services by a licensed nurse;
(7) Services required for terminal care.
4. In addition, the long-stay acute care hospital must provide for the educational and habilitative needs of the child. These services must be age appropriate, must meet state educational requirements, and must be appropriate to the child's cognitive level. Services must also be individualized to meet the specific needs of the child and must be provided in an organized manner that encourages the child to participate. Services may include, but are not limited to, school, active treatment for mental retardation, habilitative therapies, social skills, and leisure activities. Therapeutic leisure activities must be provided daily.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 3, eff. June 29, 1994.
12VAC30-130-110. Documentation requirements.
A. Services not specifically documented in the resident's medical record as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.
B. The long-stay acute care hospital shall maintain and retain the business and professional records sufficient to document fully and accurately the nature, scope, and details of the health care provided. Such records shall be retained for a period of not less than five years from the date of service or as provided by applicable state laws, whichever period is longer, except that, if an audit is initiated within the required retention period, the records must be retained until the audit is completed and every exception resolved.
C. The following documentation must be maintained in the resident's medical record:
1. Each record must identify the resident on each page.
2. Entries must be signed and dated (month, day, and year) by the author, followed by professional title. Care rendered by personnel under the supervision of the provider, which is in accordance with Medicaid policy, must be countersigned by the responsible licensed participating provider.
3. The attending physician must certify at the time of admission that the resident requires long-stay acute hospital care and meets the criteria as defined by DMAS.
4. The record must contain a preliminary working diagnosis and the elements of a history and physical examination upon which the diagnosis is based.
5. All services provided, as well as any treatment plan, must be entered in the record. Any drugs prescribed and administered as part of a physician's treatment plan, including the quantities, route of administration, and the dosage must be recorded.
6. The record must indicate the resident's progress, any change in diagnosis or treatment, and the response to the treatment. The documentation must include in detail all treatment rendered to the resident in accordance with the plan with specific attention to frequency, duration, modality, response to treatment, and identify who provided such treatment.
7. Physician progress notes must be written at least weekly and must reflect that the resident has been examined by the physician.
8. A comprehensive nursing assessment must be made by a registered nurse at the time of admission to the facility. Nursing care plans based on an admission assessment must be resident-specific and must indicate realistic nursing needs, measurable goals, and specifically state the method by which the goals are to be accomplished. They must be updated as needed, but at least monthly. Nursing summaries, in addition to the p.r.n. (as needed) notes, are required weekly. Nursing summaries must give a current, written picture of the resident, the resident's nursing needs, the care being provided, and the resident's response to treatment. The nursing summary at a minimum must address the following: medical status; functional status in activities of daily living, elimination, mobility, and emotional/mental status; special nursing procedures; and identification and resolution of acute illnesses or episodes.
9. Social services documentation must include a social evaluation and history and a social services plan of care including a discharge plan. The social work plans of care must be resident-specific and include measurable goals with realistic time frames. Social work plans of care must be updated as needed and at least monthly every 30 days. Social services progress notes must be written at least every 30 days.
10. Activities documentation must be based on a comprehensive assessment completed by the designated activity coordinator. An activity plan of care must be developed for each resident and must include consideration of the individual's interests and skills, the physician's recommendations, social and rehabilitation goals, and personal care requirements. Individual and group activities must be included in the plan. The activity plan of care must be updated as needed but at least every 30 days. Activity progress notes must be written at least every 30 days. Therapeutic leisure activities must be provided daily.
11. Rehabilitative therapy (physical and occupational therapy or speech-language services) or other health care professional (psychologist, respiratory therapist, etc.) documentation must include an assessment completed by the qualified rehabilitation professional. A plan of care developed specific to the resident must be developed and must include measurable goals with realistic time frames. The plan of care must be updated as needed but at least every 30 days. Rehabilitative therapy or other health care professional progress notes must be written at least every 30 days.
12. Each resident's record must contain a dietary evaluation and plan of care completed by a registered dietician. The plan of care must be resident-specific and must have measurable goals within realistic time frames. The plan of care must be updated as needed, but at least every 30 days. The dietary assessment and monthly plans of care must be completed by a registered dietician. Dietary progress notes must be written at least every 30 days.
13. A coordinated interdisciplinary plan of care must be developed for each resident. The plan of care must be resident-specific and must contain measurable goals within realistic time frames. Based on the physician's plan of care, the interdisciplinary team should include, but is not necessarily limited to, nurses, social workers, activities coordinators, dieticians, rehabilitative therapists, direct care staff, and the resident or responsible party. At a minimum, the interdisciplinary team must review and update the interdisciplinary plan of care as needed but at least every 30 days. The interdisciplinary plan of care review must identify those attending the meeting, changes in goals and approaches, and progress made toward meeting established goals and discharge.
14. For residents age 21 and younger, the record must contain documentation that educational or habilitative services are provided as required. The documentation shall include an evaluation of the resident's educational or habilitative needs, a description of the educational or habilitative services provided, a schedule of planned programs, and records of resident attendance. Educational or habilitative progress notes shall be written at least every 30 days.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 4, eff. June 29, 1994.
12VAC30-130-120. Long-stay acute care hospital services.
All services must be provided by appropriately qualified personnel. The following services are covered long-stay acute care hospital services:
A. Physician services.
1. Physician services shall be performed by a professional who is licensed to practice in the Commonwealth, who is acting within the scope of his license, and who is a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor.
2. An attending physician means a physician who is a doctor of medicine or osteopathy and is identified by the individual as having the most significant role in the determination and delivery of the individual's medical care.
B. Licensed nursing services.
1. Must be provided 24 hours a day (a registered nurse, whose sole responsibility is the designated unit on which the resident resides, must be on the unit 24 hours a day).
2. Nursing services shall be of a level of complexity and sophistication, or the condition of the resident shall be of a nature, that the services can only be performed by a registered nurse or licensed professional nurse, or nursing assistant under the direct supervision of a registered nurse who is experienced in providing the specialized care required by the resident.
C. Rehabilitative services.
1. Rehabilitative services shall be directly and specifically related to written plan of care designed by a physician after any needed consultation with the rehabilitation professional.
2. Physical therapy services shall be of a level of complexity and sophistication, or the condition of the resident shall be of a nature, that the services can only be performed by a physical therapist licensed by the Board of Medicine, or a physical therapy assistant who is licensed by the Board of Medicine and under the direct supervision of a physical therapist licensed by the Board of Medicine.
3. Occupational therapy services shall be of a level of complexity and sophistication, or the condition of the resident shall be of a nature, that the services can only be performed by an occupational therapist registered and certified by the American Occupational Therapy Certification Board or an occupational therapy assistant certified by the American Occupational Therapy Certification Board under the direct supervision of an occupational therapist as defined.
4. Speech-language services shall be of a level of complexity and sophistication, or the condition of the resident shall be of a nature that the services can only be performed by a speech-language pathologist licensed by the Board of Audiology and Speech-Language Pathology.
D. Ancillary services shall be provided directly and specifically related to a plan of care designed by the physician. The ancillary services may include but are not limited to dietary, respiratory therapy services, and psychological services.
1. Dietary services must be of a level of complexity or sophistication, or the nature of the resident shall be of a nature that the services can only be performed or supervised by a dietician, registered with the American Dietetic Association.
2. Respiratory therapy services must be of a level of complexity and sophistication, or the nature of the resident shall be of a nature that the services can only be performed by a respiratory therapist. Respiratory therapy services must be provided by a respiratory therapist certified by the Board of Medicine or registered with the National Board for Respiratory Care. If the facility agrees to provide care to a resident who is dependent on mechanical assistance for respiration (positive or negative pressure mechanical ventilators), respiratory therapy services must be available 24 hours daily. If the facility contracts for respiratory therapy services, a respiratory therapist must be on call 24 hours daily and available to the facility in a timely manner.
3. Psychology services shall be of a level of complexity or sophistication, or the condition shall be of a nature that the services can only be performed by a psychologist licensed by the Board of Medicine or by a licensed clinical social worker under the direct supervision of a licensed clinical psychologist or a licensed psychologist clinical.
4. Activity programs under the supervision of designated activities coordinators. The program of activities must include both individual and group activities which are based on consideration of interest, skills, physical and mental status, and personal care requirements.
5. Provide social services to each resident in an effort to assist the resident, his family and the facility staff in understanding the significant social and emotional factors related to the health problems, to assist with appropriate utilization of community resources and to coordinate discharge plans. Social services must be provided by a social worker with at least a bachelor's degree in social work or similar qualifications.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 5, eff. June 29, 1994.
12VAC30-130-130. Long-stay acute care hospital requirements.
A. A coordinated multidisciplinary team approach shall be implemented to meet the needs of the resident. Based on the physician's plan of care, the interdisciplinary team should include, but is not necessarily limited to, nurses, social workers, activity coordinators, dieticians, rehabilitative therapists, and any direct care staff.
B. The long-stay acute care hospital shall provide for the educational and habilitative needs of residents age 21 or younger. These services must be age appropriate, must meet state educational requirements, and must be appropriate to the child's cognitive level. Services must be individualized to meet the specific needs of the child and must be provided in an organized manner which encourages the child to participate. Services may include but are not limited to school, active treatment for mental retardation, habilitative therapies, social skills and leisure activities. Therapeutic leisure activities must be provided daily.
C. The long-stay acute care hospital shall provide an acceptable plan for assuring that residents requiring long-stay acute hospital care are afforded the same opportunity for participating in integrated facility activities as the other facility residents.
D. Nonemergency transportation shall be provided so that residents may participate in community activities sponsored by the facility or community activities in which the facility is providing transportation for other facility residents.
E. The long-stay acute care hospital shall coordinate discharge planning for the resident utilizing all available resources in an effort to assist the resident to maximize his potential for independence and self-sufficiency and to assure that services are being provided by the most effective level of care.
F. The long-stay acute care hospital shall provide family or caregiver training in the skills necessary for the care of the resident in the community, should the resident or the resident's caregiver so desire.
G. The long-stay acute care hospital shall provide all necessary durable medical equipment to sustain life or monitor vital signs and to carry out a plan of care designed by the physician. This equipment may include but is not limited to mechanical ventilator, apnea monitor, etc.
H. The long-stay acute care hospital shall provide utilization review activities as follows:
1. Purpose. The objective of the utilization review mechanism is the maintenance of high-quality patient care and the most efficient utilization of resources through an educational approach involving the study of patient care as well as to ensure that inpatient care is provided only when medically necessary and that the care meets quality standards.
a. In addition to the certification by the resident's physician, the hospital shall have a utilization review plan which provides for review of all Medicaid patient stays and medical care evaluation studies of admissions, durations of stay, and professional services rendered.
b. Effective utilization review shall be maintained on a continuing basis to ensure the medical necessity of the services for which the program pays and to promote the most efficient use of available health facilities and services.
2. The Department of Medical Assistance Services delegates to the local facilities' utilization review departments the utilization review of inpatient hospital services for all Medicaid admissions. The hospital must have a utilization review plan reflecting 100% review of Medicaid residents, approved by the Division of Licensure and Certification of the Department of Health, and DMAS or the appropriate licensing agency in the state in which the institution is licensed.
3. The hospital utilization review coordinator shall approve the medical necessity, based on admission criteria approved by the utilization review committee, within one working day of admission. In the event of an intervening Saturday, Sunday, or holiday, a review must be performed the next working day. This review shall be reflected in the hospital utilization review plan and the resident's record.
4. If the admission is determined medically necessary, an initial stay review date must be assigned and reflected on the utilization review sheets. Continued or extended stay review must be assigned prior to or on the date assigned for the initial stay. If the facility's utilization review committee has reason to believe that an inpatient admission was not medically necessary, it may review the admission at any time. However, the decision of a utilization review committee in one facility shall not be binding upon the utilization review committee in another facility.
5. If the admission or continued stay is found to be medically unnecessary, the attending physician shall be notified and be allowed to present additional information. If the hospital physician advisor still finds the admission or continued stay unnecessary, a notice of adverse decision must be made within one working day after the admission or continued stay is denied. Copies of this decision must be sent by the utilization review committee's designated agent to the hospital administrator, attending physician, recipient or recipient's authorized representative, and Medicaid.
6. As part of the utilization review plan, long-stay acute care hospitals shall have one medical or patient care evaluation study in process and one completed each calendar year. Medical care evaluation studies must contain the elements mandated by 42 CFR 456.141 through 456.145. The elements are objectives of study, results of the study, evaluation of the results, and action plan or recommendations as indicated by study results.
7. The Department of Medical Assistance Services shall monitor the length of stay for inpatient hospital stays. The guidelines used shall be based on the criteria described in 12VAC30-130-100. If the stay or any portion of the stay is found to be medically unnecessary, contrary to program requirements, or if the required documentation has not been received, reimbursement will not be made by Medicaid.
8. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.
I. The long-stay acute care hospital shall provide all medical supplies necessary to provide care as directed by the physician's plan of care for the resident. These supplies may include but are not limited to suction catheters, tracheostomy care supplies, oxygen, etc.
J. The long-stay acute care hospital shall provide all nutritional elements including those that must be administered intravenously. This includes providing all necessary equipment or supplies necessary to administer the nutrients.
K. The long-stay acute care hospital shall submit all necessary health care and medical social service information on the resident to DMAS for preadmission authorization. The provider cannot bill DMAS for services that have not been preauthorized.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.10 § 6, eff. June 29, 1994.
Part III
Preadmission Screening and Annual Resident Review
12VAC30-130-140. Definitions.
"Community Services Board (CSB)" means the local governmental agency responsible for local mental health, mental retardation, and substance abuse services. Boards function as service providers, client advocates, and community educators.
"Dementia" means, for the purposes described herein, having a primary diagnosis of dementia, as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987, or a nonprimary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined herein.
"Diagnostic and Statistical Manual of Mental Disorders, 3rd edition" means the 1987 publication of the American Psychiatric Association classifying diagnoses of abnormal behavior.
"Interfacility transfer" means when an individual is transferred from one nursing facility (NF) to another nursing facility, with or without an intervening hospital stay. Interfacility transfers are subject to annual resident review rather than preadmission screening. In cases of transfer of a resident with MI or MR or a related condition (MR/RC) from a NF to a hospital or to another NF, the transferring NF is responsible for ensuring that copies of the resident's most recent preadmission screening and annual resident review (PASARR) and resident assessment reports shall accompany the transferring resident.
"Level I identification" means the process performed to identify nursing facility applicants with a condition of mental illness or mental retardation.
"Level II evaluation" means the evaluation process for nursing facility applicants who are identified as having a condition of mental illness or mental retardation as defined herein. The purpose of the Level II evaluation is to recommend placement of and services to nursing facility applicants with statutorily defined mental illness or mental retardation.
"Mental Illness (MI)" means a serious mental illness meeting all of the following requirements:
1. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987 that is a schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder that may lead to a chronic disability. The disorder is not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined here;
2. The disorder results in functional limitations in major life activities within the past three to six months that would be appropriate for the individual's developmental stage. An individual typically has at least one of the following characteristics on a continuing or intermittent basis:
a. Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships, and social isolation;
b. Concentration, persistence, and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structures, activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks; and
c. Adaptation to change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system.
3. The treatment history indicates that the individual has experienced at least one of the following:
a. Psychiatric treatment more intensive than outpatient care more than once in the past two years (e.g., partial hospitalization or inpatient hospitalization); or
b. Within the last two years, due to the mental disorder, experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.
"Mental Retardation (MR)" means the presence of a level of retardation (mild, moderate, severe, or profound) described in the American Association on Mental Retardation's Manual on Classification in Mental Retardation (1983) or has a related condition. A person with related conditions (RC) means the individual has a severe chronic disability that meets all of the following conditions:
1. It is attributable to cerebral palsy or epilepsy or any other condition, other than mental illness, found to be closely related to mental retardation because this condition may result in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons;
2. It is manifested before the person reaches age 22;
3. It is likely to continue indefinitely; and
4. It results in substantial functional limitations in three or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.
"MI/MR Supplement" means the assessment form developed to meet the requirements of OBRA '87. Its purpose is to identify individuals with mental illness and mental retardation before their admission to a nursing facility.
"New admission" means an individual who is admitted to any nursing facility for the first time or does not qualify as a readmission. New admissions are subject to preadmission screening.
"Non-Medicaid-eligible Individuals" means persons who are not Medicaid eligible or are not expected to be Medicaid eligible within 180 days of admission to a nursing facility.
"Nursing Home Preadmission Screening Committee (NHPASC)" means a committee established for the purpose of determining whether a Medicaid-eligible individual meets nursing facility criteria.
"Qualified Mental Health Professional (QMHP)" means a clinician in the health profession who is trained and experienced in providing psychiatric or mental health services to individuals who have a psychiatric diagnosis. In the Commonwealth, authorized professionals and minimal qualifications for a QMHP are as follows:
1. Physician: a doctor of medicine or osteopathy licensed in Virginia;
2. Psychiatrist: a doctor of medicine or osteopathy, specializing in psychiatry and licensed in Virginia;
3. Psychologist: an individual with a master's degree in psychology from an accredited college or university with at least one year of clinical experience;
4. Social worker: an individual with a master's or bachelor's degree from a school of social work accredited or approved by the Council on Social Work Education with at least one year of clinical experience;
5. Registered nurse: a registered nurse licensed in the State of Virginia with at least one year of clinical experience; and
6. Mental health worker: an individual with professional education, training, and/or a degree in human services or related field from an accredited college deemed equivalent to those described above and at least one year of clinical experience providing direct services to persons with a diagnosis of mental illness.
"Readmission" means an individual who was readmitted to a facility from a hospital to which he or she was transferred for the purpose of receiving care. Readmissions are subject to annual resident review rather than preadmission screening.
"State Mental Health or Mental Retardation Authority (MH/MRA)" means the designated representative of the Department of Mental Health, Mental Retardation and Substance Abuse Services who shall make determinations regarding placement of and services to nursing facility applicants who have conditions of mental illness or mental retardation.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 1, eff. June 1, 1994.
12VAC30-130-150. Persons subject to nursing home preadmission screening and identification of conditions of mental illness and mental retardation (Level I).
A. As a condition of a nursing facility's Medicaid participation, all persons applying for admission shall be screened to determine whether they have a condition of mental illness (MI) or mental retardation (MR) or a related condition (RC), and if so, whether they require the level of services provided by a nursing facility (NF). Nursing facilities shall ensure that applicants for admission have been screened and those who are identified as being MI or MR/RC are not admitted until determinations have been made by the State Mental Health or Mental Retardation Authority (MH/MHA) with respect to their placement. NHPASCs complete the Level I process for individuals who are Medicaid eligible or expect to become Medicaid eligible within 180 days. Nursing facilities must ensure that the appropriate screenings are conducted for non-Medicaid eligible applicants.
B. No individual, regardless of pay status, may be admitted to a nursing facility unless the Level I screening has been completed, and, if it is determined that the individual has a condition of MI or MR/RC as defined herein, then he or she shall not be admitted until the Level II determination has been made.
C. The Level I identification function shall provide at least, in the case of first time identifications, for the issuance of written notice to the individual or resident and his or her legal representative if the individual is suspected of having MI or MR/RC and is being referred to the MH/MRA for Level II screening. The NHPASC shall send this notice to Medicaid-eligible individuals who are referred for a Level II screening. The admitting NF shall send the notice to non-Medicaid individuals.
D. All Level I and Level II determinations shall be recorded in the individual's medical record.
E. When a preadmission screening has not been performed timely, but is performed at a later date, federal financial participation (FFP) is available only for services furnished after the screening has been performed.
F. The state in which the individual is a resident (or will be at the time he or she becomes eligible for Medicaid) must pay for the PASARR and make the required determinations. In the case of non-Medicaid eligible applicants, the receiving NF is responsible to ensure that the appropriate screenings have been completed prior to the individual's admission.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 2, eff. June 1, 1994.
12VAC30-130-160. Level II determination.
A. For each resident of a NF who has a condition of MI or MR/RC, the MH/MRA, as appropriate, must determine whether the individual requires the level of services provided by a NF, an inpatient psychiatric hospital for individuals under age 21, an institution for mental disease (IMD) providing medical assistance to individuals age 65 and older, an intermediate care facility for the mentally retarded (ICF/MR), or specialized services for either MI or MR/RC.
B. When a Level II evaluation is required, a determination shall be made within an annual average of seven to nine working days of the referral for screening. The MH/MRA shall convey determinations verbally to NFs and the individual and confirm them in writing.
C. The MH/MRA shall notify in writing the following entities of a Level II determination:
1. The evaluated individual and his or her legal representative;
2. The admitting or retaining NF;
3. The individual or resident's attending physician; and
4. The discharging hospital.
D. Each notice described above shall include the following:
1. Whether a NF level of services is needed;
2. Whether specialized services are needed;
3. The placement options available to the individual; and
4. The rights of the individual to appeal the determination.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 3, eff. June 1, 1994.
12VAC30-130-170. Categorical determinations.
A. For each individual for whom the Level I screening has resulted in the determination that the individual meets nursing facility level of care and has a condition of MI or MR/RC as defined herein, a Level II evaluation does not have to be completed if one of the following categorical determinations are met:
1. The individual has a terminal illness in which a physician has documented that life expectancy is less than six months; or
2. The individual has a severe illness such as coma, functioning at brain stem level, or other conditions which result in a level of impairment so severe that the individual could not be expected to benefit from specialized services. When this category is used, documentation shall be available which fully describes the severity of the condition.
B. These categorical determinations shall only be applied following the Level I review and only if existing data on the individual appear to be current and accurate and are sufficient to allow the evaluator readily to determine that the individual fits the category.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 4, eff. June 1, 1994.
12VAC30-130-180. Annual resident review.
A. A review and determination must be conducted for each resident of a NF who has MI or MR/RC not less often than annually. "Annually" is defined as occurring within every fourth quarter after the previous preadmission screening or annual resident review.
B. When an annual resident review has not been performed timely, but is performed at a later date, federal financial participation (FFP) is available only for services furnished after the review has been performed.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 5, eff. June 1, 1994.
12VAC30-130-190. Determinations and placement of individuals with MI or MR/RC.
A. If the MH/MRA determines that a resident or applicant for admission to a NF requires a NF level of services, the NF may admit or retain the individual. If the MH/MRA determines that a resident or applicant for admission requires both a NF level of services and specialized services for MI or MR/RC, the NF may admit or retain the individual and the state must provide or arrange for the provision of the specialized services needed by the individual while he resides in the NF.
B. If the MH/MRA determines that an applicant for admission to a NF does not require NF services, the applicant cannot be admitted. NF services are not a covered Medicaid service for that individual, and further screening is not required.
C. If the MH/MRA determines that a resident requires neither the level of services by a NF nor specialized services for MI or MR/RC, regardless of the length of stay in the facility, the state must (i) arrange for the safe and orderly discharge of the resident from the facility; and (ii) prepare and orient the resident for discharge.
D. For any resident who has continuously resided in a NF for at least 30 months before the date of the determination, and who requires only specialized services, the state must, in consultation with the resident's family or legal representative and caregivers (i) offer the resident the choice of remaining in the facility or of receiving services in an alternative appropriate setting; (ii) inform the resident of the institutional and noninstitutional alternatives available; (iii) clarify the effect on eligibility for Medicaid services if the resident chooses to leave the facility, including its effect on readmission to the facility or eligibility for community-based services; and (iv) regardless of the resident's choice to remain in the NF or to be discharged to a community setting, provide for, or arrange for the provision of specialized services for the MI or MR.
E. For any resident who has not continuously resided in a NF for at least 30 months before the date of the determination, the state must, in consultation with the resident's family or legal representative and caregivers (i) arrange for the safe and orderly discharge of the resident from the facility; (ii) prepare and orient the resident for discharge; and (iii) provide for, or arrange for the provision of, specialized services for the MI or MR.
F. For the purposes of establishing length of stay in a NF, the 30 months of continuous residence in a NF or longer is calculated back from the date of the first annual resident review determination which finds that the individual is not in need of NF level of services. The 30 months of continuous residence in a NF may include temporary absences for hospitalization and therapeutic leave and may consist of consecutive residences in more than one NF.
G. Placement of an individual with MI or MR/RC in a NF may be considered appropriate only when the individual's needs are such that he or she meets the minimum standards for admission and his or her needs for treatment do not exceed the level of services which can be delivered in the NF to which the individual is admitted either through NF services alone or, where necessary, through NF services supplemented by specialized services provided by or arranged for by the state.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 6, eff. June 1, 1994.
12VAC30-130-200. PASARR evaluation criteria.
A. The state's PASARR program must identify all individuals who are suspected of having MI or MR/RC as defined herein. The identification function and determination that NF criteria is met is termed Level I. Level II is the function of evaluating and determining whether NF placement is appropriate to meet the individual's MH/MR/RC needs and whether specialized services are needed.
B. Evaluations performed under PASARR and PASARR notices must be adapted to the cultural background, language, ethnic origin, and means of communication used by the individual being evaluated. PASARR evaluations must involve the individual being evaluated, the individual's legal representative, if one has been designated under state law, and the individual's family if available and the individual or the legal representative agrees to family participation. When parts of a PASARR evaluation are performed by more than one evaluator, there must be interdisciplinary coordination among the evaluators.
C. All information that is necessary for determining whether it is appropriate for the individual with MI or MR/RC to be placed in a NF or in another appropriate setting should be gathered throughout all applicable portions of the PASARR evaluation. The determinations relating to the need for NF level of care and specialized services are interrelated and must be based upon a comprehensive analysis of all data concerning the individual.
D. Evaluators may use relevant evaluative data, obtained prior to initiation of preadmission screening or annual resident review, if the data are considered valid and accurate and reflect the current functional status of the individual. However, in the case of individualized evaluations, the PASARR program may need to gather additional information to supplement and verify the currency and accuracy of existing data and to assess proper placement and treatment.
E. For individualized PASARR determinations, findings must be issued in the form of a written evaluative report which (i) identifies the name and professional title of person(s) who performed the evaluation(s) and the date on which each portion of the evaluation was administered; (ii) provides a summary of the medical and social history, including the positive traits or developmental strengths and weaknesses or developmental needs of the evaluated individual; (iii) if NF services are recommended, identifies the specific services which are required to meet the evaluated individual's needs; (iv) if specialized services are not recommended, identifies any specific MR/RC or MH services which are of a lesser intensity than specialized services that are required to meet the evaluated individual's needs; (v) if specialized services are recommended, identifies the specific MR/RC or MH services required to meet the evaluated individual's needs; and (vi) includes the basis for the report's conclusions.
F. For categorical PASARR determinations, findings must be issued in the form of an abbreviated written evaluative report which (i) identifies the name and professional title of the person applying the categorical determination and the data on which the application was made; (ii) explains the categorical determination(s) that has (have) been made; (iii) identifies, to the extent possible, based on the available data, NF services, including any mental health or specialized psychiatric rehabilitative services, that may be needed; and (iv) includes the bases for the report's conclusions.
G. For both categorical and individualized determinations, findings of the evaluation must correspond to the person's current functional status, mental health, and mental retardation status as documented in medical and social history records. Findings of the evaluation must be interpreted and explained to the individual and, where applicable, to a legal representative designed under state law by the assessment team or the MH/MRA. The evaluation report must be sent to the individual and his legal representative, appropriate state authority in sufficient time to meet the required time frames, admitting or retaining NF, individual's attending physician, and the discharging hospital if the individual is seeking NF admission from a hospital. The evaluation may be terminated at any time during the evaluation that the individual being evaluated does not have MI or MR/RC or has a primary diagnosis of dementia or a nonprimary diagnosis of dementia without a primary diagnosis that is a serious mental illness, and does not have a diagnosis of MR or a related condition.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 7, eff. June 1, 1994.
12VAC30-130-210. Specialized services.
A. For mental illness, specialized services means the services specified by the state which, combined with services provided by the NF, results in the continuous and aggressive implementation of an individualized plan of care that:
1. Is developed and supervised by an interdisciplinary team which includes a physician, qualified mental health professionals, and as appropriate, other professionals;
2. Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness which necessitates supervision by trained mental health personnel;
3. Is directed toward diagnosing and reducing the resident's behavioral symptoms that may necessitate institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time; and
4. Prescribes inpatient psychiatric services for any individual determined to be a danger to self or others. For nursing facility residents who are determined to be a danger to self or others due to mental illness, the nursing facility must coordinate admission to an inpatient psychiatric hospital.
B. For mental retardation or related conditions, specialized services means the services specified by the state which, combined with services provided by the NF or other service providers, results in treatment which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward the following;
1. The acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible; and
2. The prevention or deceleration of regression or loss of current optimal functional status.
C. The state must provide or arrange for the provision of specialized services to all NF residents with MI or MR/RC whose needs are such that continuous supervision, treatment, and training by qualified MH/MR personnel is necessary as identified by their Level I and II assessments. The NF must provide MH or MR/RC services which are of a lesser intensity than specialized services to all residents who need such services.
1. Services that shall be the responsibility of the nursing facility to provide to residents shall include, but are not limited to:
a. Physical therapy
b. Speech-language pathology services
c. Occupational therapy
d. Restorative nursing
e. Behavior management interventions that do not require ongoing consultation and monitoring by a licensed psychiatrist or psychologist
f. Basic grooming and hygiene needs
g. Nutritional needs, including supplements and assistance with eating
h. Adjustment needs resulting from admission to a nursing facility and ongoing psychosocial emotional support
i. Noncustomized durable medical equipment and supplies
2. Specialized services for the purposes of PASARR shall include the following. The State Mental Health or Mental Retardation Authority shall ensure the provision of specialized services when they are provided by a non-Medicaid-enrolled provider or when the services are not covered by Medicaid.
a. Partial hospitalization
b. Transportation to Medicaid-covered services or specialized services necessary to treat conditions of mental illness or mental retardation
c. Day health and rehabilitation
d. Psychosocial rehabilitation
e. Crisis intervention
f. Customized durable medical equipment, for residents without a patient pay, that would allow the resident to participate in specialized services
g. Behavior management interventions requiring ongoing consultation and monitoring by a licensed psychiatrist or psychologist
h. One-to-one supervision necessary for behavior management
i. Vision and hearing needs related to mental illness or mental retardation for persons over age 21
j. Dental needs resulting from mental illness or mental retardation sequela for persons over age 21
k. Habilitation
l. Supported employment for persons with mental illness or mental retardation
m. Case management services
n. Individual psychotherapy
o. Day treatment
p. Individual and group counseling
q. Inpatient psychiatric care
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 8, eff. June 1, 1994.
12VAC30-130-220. Placement options.
A. The placement options and required state actions resulting from PASARR are as follows:
1. Can be admitted to a NF. Any applicant for admission to a NF who has MI or MR/RC and who requires the level of services provided by a NF, regardless of whether specialized services are also needed, may be admitted to a NF, if the placement is appropriate. If specialized services are also needed, the state is responsible for providing or arranging for the provision of the specialized services.
2. Cannot be admitted to a NF. Any applicant for admission to a NF who has MI or MR/RC and who does not require the level of services provided by a NF, regardless of whether specialized services are also needed, is inappropriate for NF placement and must be not be admitted.
3. Can be considered appropriate for continued placement in a NF. Any NF resident with MI or MR/RC who requires the level of services provided by a NF, regardless of the length of his or her stay or the need for specialized services, can continue to reside in the NF, if the placement is appropriate.
4. May choose to remain in the NF even though the placement would otherwise be inappropriate. Any NF resident with MI or MR/RC who does not require the level of services provided by the NF but does require specialized services and who has continuously resided in a NF for at least 30 consecutive months before the date of determination may choose to continue to reside in the facility or to receive covered services in an alternative appropriate institutional or noninstitutional setting. Wherever the resident chooses to reside, the state must meet his or her specialized services needs. The determination notice must provide information concerning how, when, and by whom the various placement options available to the resident will be fully explained to the resident.
5. Cannot be considered appropriate for continued placement in a NF and must be discharged (short-term residents). Any NF resident with MI or MR/RC who does not require the level of services provided by a NF but does require specialized services and who has resided in a NF for less than 30 consecutive months be discharged to an appropriate setting where the state must provide specialized services. The determination notice must provide information on how, when, and by whom the resident will be advised of discharge arrangements and of his/her appeal rights under both PASARR and discharge provisions.
6. Cannot be considered appropriate for continued placement in a NF and must be discharged (short or long-term residents). Any NF resident with MI or MR/RC who does not require the level of services provided by a NF and does not require specialized services regardless of his or her length of stay, must be discharged. The determination notice must provide information on how, when and by whom the resident will be advised of discharge arrangements and of his or her appeal rights under both PASARR and discharge provisions.
7. Specialized services needed in a NF. If a determination is made to admit or allow to remain in a NF any individual who requires specialized services, the determination must be supported by assurances that the specialized services that are needed can and will be provided or arranged for in a timely manner by the state which the individual resides in the NF.
B. The state PASARR system shall maintain records of evaluations and determinations, regardless of whether they are performed categorically or individually, in order to support its determinations and actions and to protect the appeal rights of individuals subjected to PASARR. The state PASARR system shall establish and maintain a tracking system for all individuals with MI or MR/RC in NFs to ensure that appeals and future reviews are performed.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 9, eff. June 1, 1994.
12VAC30-130-230. Evaluating the need for NF services and NF level of care (PASARR/NF).
A. For each applicant for admission to a NF and each NF resident who has MI or MR/RC, the evaluator must assess whether (i) the applicant's or resident's total needs are such that his needs can be met in an appropriate community setting; (ii) the individual's total needs are such that they can be met only on an inpatient basis, which may include the option of placement in a home and community-based services waiver program, but for which the inpatient care would be required; (iii) if inpatient care is appropriate and desired, the NF is an appropriate institutional setting for meeting those needs; or (iv) if the inpatient care is appropriate and desired but the NF is not the appropriate setting for meeting the individual's needs, another setting such as an ICF/MR (including small, community-based facilities), an IMD providing services to individuals ages 65 or older, or a psychiatric hospital is an appropriate institutional setting for meeting those needs.
B. In determining appropriate placement, the evaluator must prioritize the physical and mental needs of the individual being evaluated, taking into account the severity of each condition.
C. At a minimum the data relied on to make a determination must include: (i) evaluation of physical status (for example, diagnoses, date of onset, medical history, and prognosis); (ii) evaluation of mental status (for example, diagnoses, date of onset, medical history, likelihood that the individual may be a danger to himself/herself or others); and (iii) functional assessment (activities of daily living).
D. Based on the data compiled, the MH/MRA must determine whether an NF level of services is needed.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 10, eff. June 1, 1994.
12VAC30-130-240. Evaluating whether an individual with MI requires specialized services (PASARR/MI).
A. The purpose of this section is to identify the minimum data needs and process requirements for the state MHA, which is responsible for determining whether or not the applicant or resident with MI needs a specialized services program for mental illness.
B. Minimum data collected must include:
1. A comprehensive history and physical examination of the person. If the history and physical examination are not performed by a physician, then a physician must review and concur with the conclusions. The following areas must be included (if not previously addressed): complete medical history; review of all body systems; specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes; and in case of abnormal findings which are the basis for a NF placement, additional evaluations conducted by appropriate specialists.
2. A comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic mental illness.
3. A psychological evaluation of the person, including current living arrangements and medical and support systems.
4. A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of intellectual functioning, memory functioning, and orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, and degree of reality testing (presence and content of delusions) and hallucinations.
5. A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment must determine whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that NF placement is required. The functional assessment must address the following areas: Self-monitoring of health status, self-administering and scheduling of medical treatment, including medication compliance, or both, self-monitoring of nutritional status, handling money, dressing appropriately, and grooming.
C. The state may designate the mental health professionals who are qualified to perform the evaluations required including the comprehensive drug history; psychosocial evaluation; comprehensive psychiatric evaluation; functional assessment; and to make the determination required.
D. Based on the data compiled, a qualified mental health professional, as designated by the state, must validate the diagnosis of mental illness and determine whether a program of psychiatric specialized services is needed.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 11, eff. June 1, 1994.
12VAC30-130-250. Evaluating whether an individual with MR/RC requires specialized services (PASARR/MR).
A. The purpose of this section is to identify the minimum data needs and process requirements for the state MRA to determine whether or not the applicant or resident with mental retardation or a related condition needs a continuous specialized services program. Minimum data collected must include the individual's comprehensive history and physical examination results to identify the following information or, in the absence of data, must include information that permits a reviewer specifically to assess:
1. The individual's medical problems;
2. The level of impact these problems have on the individual's independent functioning;
3. All current medications used by the individual and the current response of the individual to any prescribed medications in the following drug groups: hypnotics, antipsychotics (neuroleptics), mood stabilizers and antidepressants, antianxiety-sedative agents, and anti-Parkinsonian agents.
4. Self-monitoring of health status;
5. Self-administering and scheduling of medical treatments;
6. Self-monitoring of nutritional status;
7. Self-help development such as toileting, dressing, grooming, and eating;
8. Sensorimotor development, such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, eye-hand coordination, and extent to which prosthetic, orthotic, corrective or mechanical supportive devices can improve the individual's functional capacity;
9. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which nonoral communication systems can improve the individual's function capacity, auditory functioning, and extent to which amplification devices (e.g. hearing aid) or a program of amplification can improve the individual's functional capacity;
10. Social development, such as interpersonal skills, recreation-leisure skills, and relationships with others;
11. Academic/educational development, including functional learning skills;
12. Independent living development such as meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bed making, care of clothing, and orientation skills (for individuals with visual impairments);
13. Vocational development, including present vocational skills;
14. Affective development such as interests, and skills involved with expressing emotions, making judgments, and making independent decisions; and
15. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).
B. The state must ensure that a licensed psychologist identifies the intellectual functioning measurement of individuals with MR or a related condition. Based on the data compiled, the MRA, using appropriate personnel as designated by the state, must validate that the individual has MR or is a person with a related condition and must determine whether specialized services for MR/RC are needed. In making this determination, the MHA must make a qualitative judgment on the extent to which the person's status reflects, singly and collectively, the characteristics commonly associated with the need for specialized services, including:
1. Inability to take care of most personal care needs; understand simple commands; communicate basic needs and wants; be employed at a productive wage level without systematic long term supervision or support; learn new skills without aggressive and consistent training; apply skills learned in a training situation to other environments or settings without aggressive and consistent training; demonstrate behavior appropriate to the time, situation or place without direct supervision; and make decisions requiring informed consent without extreme difficulty;
2. Demonstration of severe maladaptive behavior(s) that place the person or others in jeopardy to health and safety; and
3. Presence of other skill deficits or specialized training needs that necessitate the availability of trained MR personnel, 24 hours per day, to teach the person functional skills.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 12, eff. June 1, 1994.
12VAC30-130-260. Appeals.
A. Following notification to the NF of the Level II assessment determination by the state MH/MRA, the NF must inform the individual of the decision indicating the reasons for acceptance or denial and the method of appeal. Any individual, regardless of method of payment, who wishes to appeal the decision of the Level II evaluation may do so by sending written notification to the Department of Medical Assistance Services, Division of Client Appeals.
B. Decisions made by the annual resident review teams shall also be appealable to DMAS. The reviewed individual shall send written notification to DMAS, Division of Client Appeals.
C. All appeal requests must be made within 30 days of the individual's notification of the review decision.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.3910 § 13, eff. June 1, 1994; amended, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.
Part IV
Drug Utilization Review Program
12VAC30-130-270. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Abuse" means (i) use of health services by recipients which is inconsistent with sound fiscal or medical practices and that results in unnecessary costs to the Virginia Medicaid program or in reimbursement for a level of use or a pattern of services that is not medically necessary, or (ii) provider practices which are inconsistent with sound fiscal or medical practices and that result in (a) unnecessary costs to the Virginia Medicaid program, or (b) reimbursement for a level of use or a pattern of services that is not medically necessary or that fails to meet professionally recognized standards for health care.
"Appropriate and medically necessary" means drug prescribing and dispensing practices which conform with the criteria and standards developed pursuant to this regulation and are consistent with the diagnosis or treatment of an identified condition.
"Criteria and standards" means predetermined objective tests established by or approved by the Drug Utilization Review Board for use in both retrospective and prospective screening of the quality and appropriateness of pharmacy services for Medicaid recipients. Objective tests shall include both criteria, which are based upon professional expertise, prior experience, and the professional literature with which the quality, medical necessity, and appropriateness of health care services may be compared, and standards, which are professionally developed expressions of the range of acceptable variation from a criterion.
"Code" means the Code of Virginia.
"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
"Director" means the Director of DMAS.
"Drug Utilization Review (DUR)" means a formal continuing program for assessing medical and recipients' drug utilization data against explicit standards and criteria and, as necessary, introducing remedial strategies.
"Drug Utilization Review Board (DUR Board)" means the group of health care professionals appointed by the director and established pursuant to § 1927(g)(3) Title XIX of the Social Security Act.
"Drug Utilization Review Committee (DUR Committee)" means a committee composed of health care professionals who make recommendations for developing and modifying drug therapy review standards or criteria, participate in retrospective reviews, recommend remedial strategies, and evaluate the success of the interventions.
"Exceptional drug utilization pattern" means a pattern of drug use that differs from the standards and criteria established pursuant to this part.
"Fraud" means any act including intentional deception or misrepresentation that constitutes fraud under applicable federal or state laws.
"OBRA 90" means the Omnibus Budget Reconciliation Act of 1990.
"Patient's agent" means the person or persons selected by the recipient to act on his behalf with regard to the recipient's receipt of Title XIX pharmacy services.
"Patient counseling" means communication of information by the pharmacist, in person whenever practicable, to patients receiving benefits under Title XIX of the Social Security Act or the patient's agent, to improve therapeutic outcomes by encouraging proper use of prescription medications and devices.
"Prospective drug utilization review" means a review by the pharmacist of the prescription medication order and the patient's drug therapy before each prescription is filled. The review shall include an examination of any patient profile (which has been maintained by the pharmacist) to determine the possibility of potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse or misuse).
"Restriction" means (i) an administrative limitation imposed by DMAS on a recipient which requires the recipient to obtain access to specific types of health care services only through a designated primary provider or (ii) an administrative limitation imposed on a provider to prohibit participation as a designated primary provider, referral provider, or covering provider for restricted recipients.
"Retrospective drug utilization review" means the drug use review process that is conducted by DMAS using historic or archived medical or drug use data which may include but is not restricted to patient profiles and historical trends.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 1, eff. June 16, 1993; amended, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-130-280. Authority.
Section 1927 of Title XIX Social Security Act provides the authority for this program.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 2, eff. June 16, 1993.
12VAC30-130-290. Scope and purpose.
A. DMAS shall implement and conduct a drug utilization review program (DUR program) for covered drugs prescribed for eligible recipients. The program shall help to ensure that prescriptions are appropriate, medically necessary, and are not likely to cause medically adverse events. The program shall provide for ongoing retrospective DUR, prospective DUR and an educational outreach program to educate practitioners on common drug therapy problems with the aim of improving prescribing practices. As needed, the program shall also provide for electronic messages as well as rejected or denied services when such claims are not consistent with DUR criteria and requirements. The primary objectives shall be:
1. Improving in the quality of care;
2. Maintaining program integrity (i.e., controlling problems of fraud and benefit abuse); and
3. Conserving program funds and individual expenditures.
B. Certain organized health care settings shall be exempt from the further requirements of retrospective and prospective DUR process as provided for in § 4401 of OBRA 90.
C. The purpose of retrospective DUR shall be to screen for:
1. Monitoring for therapeutic appropriateness;
2. Overutilization and underutilization;
3. Appropriate use of generic products;
4. Therapeutic duplication;
5. Drug-disease/health contraindications;
6. Drug-drug interactions;
7. Incorrect drug dosage or duration of treatment;
8. Clinical abuse/misuse and fraud, and as necessary
9. Introduce to physicians and pharmacists remedial strategies to improve the quality of care rendered to their patients.
D. The purpose of prospective DUR shall be to screen for:
1. Potential drug therapy problems due to therapeutic duplication;
2. Drug-disease/health contraindications;
3. Drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs);
4. Incorrect drug dosage or duration of drug treatment;
5. Drug-allergy interactions; and
6. Clinical abuse and misuse.
E. In instances where initial claims for reimbursement of covered services are determined to be in conflict with DUR criteria and requirements, such claims shall receive electronic messages or be rejected or denied, as appropriate, back to the dispensing pharmacist with notification as to the substance of the conflict. The dispensing pharmacist will be afforded the opportunity to provide an intervention, based on his professional expertise and knowledge, to modify the service to be claimed for reimbursement. If the modification no longer conflicts with the DUR criteria, the claim for the modified service shall be adjudicated for payment. If the modification requires additional information from the prescriber, the pharmacist shall advise the prescribing physician of the continuing conflict and advise the physician to seek prior authorization approval from either DMAS or the pharmacy benefits contractor for his treatment plans.
F. Designated interventions may include provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 3, eff. June 16, 1993; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005; Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-130-300. Retrospective DUR.
A. The retrospective DUR program shall provide, through drug claims processing and information retrieval systems, for ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and individuals receiving benefits under Title XIX of the Social Security Act.
B. The DUR program shall, on an ongoing basis, assess data on drug use against predetermined criteria and standards which have been approved by the DUR Board.
C. Summary data concerning identified exceptional drug utilization patterns shall be developed and submitted by DMAS to the DUR Board at least quarterly, or as often as monthly if requested by the DUR Board. This data shall include at least a summary of the drug therapy problems most often observed in the course of retrospective reviews, summaries of physician responses to educational interventions, and the results of intensified reviews and monitoring of selected prescribers or dispensers.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 4, eff. June 16, 1993.
12VAC30-130-310. Prospective DUR.
A. Patient medication profile. On and after January 1, 1993, pharmacists shall make a reasonable effort to maintain a patient medication record system for persons covered under Title XIX of the Social Security Act for whom prescriptions are dispensed. For purposes of this regulation, a reasonable effort shall have been made if the information set forth in subdivision 1 of this subsection is requested by the pharmacist or the pharmacist's designee from the patient or the patient's agent.
1. A reasonable effort shall be made by the participating pharmacist to obtain, record, and maintain at least the following information on each patient's profile:
a. Patient's name, address, telephone number;
b. Date of birth (or current age) and gender;
c. Medical history
(1) Significant patient health problems known to the pharmacist,
(2) Prescription drug reactions or known allergies,
(3) A comprehensive list of prescription and nonprescription medications and legend drug administration devices known by the pharmacist to have been used by the patient; and
d. Prescriber information to include, but not necessarily be limited to, name, address, and Medicaid and Drug Enforcement Agency (DEA) provider numbers.
e. Pharmacist's comments relevant to the patient's drug use, including any failure to accept the pharmacist's offer to counsel.
2. Such information may be recorded in any system of records and may be considered by the pharmacist in the exercise of his professional judgment concerning both the offer to counsel and content of counseling. DMAS or its designated agent is authorized to survey pharmacists' patients in order to determine compliance with and report on the mandates of federal and state law and regulations.
3. The information for patient profiles may be obtained from a patient's prescribing physician, hospital medical records, interviews with the patient, patient's family or agent, or a combination of the above.
4. Patient medication profiles shall be maintained for a period of not less than two years from the date of last entry or as necessary to comply with state or federal law.
B. Pharmacist's responsibilities. Upon receipt of each prescription and before dispensing the medication, a pharmacist shall perform prospective DUR based on his professional knowledge and the criteria and standards approved by the DUR Board, using the information contained in the patient's profile.
If an exception to one or more prospective DUR criteria is identified, a message will be transmitted to the pharmacist. Claims may be rejected due to the exceptions to one or more criteria. Pharmacists may be required to obtain prior authorization, defined as the process of reviewing drugs to determine if medically justified prior to the submission of a claim for payment by Medicaid, in order to dispense the medications.
Designated interventions may include provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.
C. Patient counseling. Consistent with federal law and regulation a pharmacist must offer to discuss in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls with each individual receiving benefits or the caregiver of such individual who presents a prescription, matters which in the exercise of the pharmacist's professional judgment are deemed to be significant. The offer to counsel shall be made consistent with the requirements in § 54.1-3319 B of the Code of Virginia.
The specific areas of counseling shall include those matters listed below that, in the exercise of his professional judgment, the pharmacist considers significant:
1. Name and description of the medication;
2. Dosage form and amount, route of administration, and duration of therapy;
3. Special directions for preparation, administration and use by the patient as deemed necessary by the pharmacist;
4. Common or severe side or adverse effects or interactions that may be encountered which may interfere with the proper use of the medication as was intended by the prescriber, and the action required if they occur;
5. Techniques for self-monitoring drug therapy;
6. Proper storage;
7. Prescription refill information;
8. Action to be taken in the event of a missed dose.
9. Any other matters the pharmacist considers significant.
Alternative forms of patient information may be used to supplement, but not replace, oral patient counseling.
A pharmacist shall not be required to provide oral consultation when a patient or a patient's agent refuses the pharmacist's attempt to consult.
When prescriptions are delivered to the patient or patient's agent who resides outside of the local telephone calling area of the pharmacy, the pharmacist shall either provide a toll free telephone number or accept collect calls from such patient or patient's agent.
Patient counseling as described in this part shall not be required for inpatients of a hospital or institution where a nurse or other person authorized by the Commonwealth is administering the medication.
D. Compliance monitoring. An ongoing program shall be developed for the purpose of monitoring pharmacists' compliance with the prospective DUR requirements of this part.
The director may establish the compliance monitoring program through agreements with other state agencies, the DUR Board or other organizations.
As determined to be appropriate by DMAS, the methods used to monitor compliance shall include but shall not be limited to:
1. On-site inspections,
2. Patient surveys,
3. Desk audits, or
4. Retrospective pharmacy profile reviews.
5. Electronic messages as well as rejection or denial of claims until there is resolution of the conflict with DUR criteria.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 5, eff. June 16, 1993; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
12VAC30-130-320. Criteria and standards for DUR.
The DUR Board shall establish and revise as necessary a list of approved criteria and standards which shall be consistent with the following:
1. Compendia which shall consist of at least the publications, as may be amended from time to time, that are referenced at 12VAC30-10-650 C.
2. The peer-reviewed medical literature; and
3. Commonly accepted standards of medical practice as used by practitioners across the Commonwealth
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 6, eff. June 16, 1993; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
12VAC30-130-330. Educational program.
A. DMAS shall develop an educational program designed to further educate physicians and pharmacists to ensure that prescriptions are appropriate, medically necessary, and are not likely to cause adverse actions. The purpose of such program shall be to:
1. Identify and reduce the frequency of patterns of fraud, abuse, overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and patients, or associated with specific drugs or groups of drugs;
2. Identify and reduce the potential and actual severe adverse reactions to drugs; and
3. Improve prescribing and dispensing practices.
Such program shall include education on therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions and clinical abuse/misuse.
B. The educational program shall be accomplished through the use of interventions. The interventions shall be directed to physicians and pharmacists and shall address therapy problems or individuals identified in the course of prospective and retrospective drug use reviews as having exceptional drug utilization patterns. The educational program shall have at least four types of interventions which shall be used as appropriate. These interventions shall include:
1. Information dissemination sufficient to ensure the ready availability to participating physicians and pharmacists of information concerning the DUR Board's duties, powers, and basis for its standards;
2. Written, oral, electronic, and telephonic reminders containing patient-specific or drug-specific (or both) information and suggested changes in prescribing or dispensing practices, which is communicated in a manner designed to ensure the privacy of patient-related information;
3. Face-to-face discussions between health care professionals who are experts in appropriate and medically necessary drug therapy and selected prescribers and pharmacists who have been targeted for intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up face-to-face discussions; and
4. Intensified review or monitoring of selected prescribers or dispensers.
C. DMAS may establish the educational program through contracts with accredited health care educational institutions, state medical societies or state pharmacists associations/societies or other organizations, which may include, but shall not necessarily be limited to, a pharmacy benefits manager. The educational program will use, but not be limited to, as a basis for its educational activities the compendia and literature referenced in these regulations and data obtained primarily from the prospective and retrospective DUR process, and provided by the DUR Board, on common drug therapy problems and other utilization and drug therapy issues listed in these regulations. The educational program shall be based on recommendations submitted by the DUR Board.
D. A report shall be prepared by the DUR Board and submitted to the director at least semi-annually evaluating the success of the interventions, determining if the interventions improved the quality of drug therapy, and making recommendations for modifications in the program, if appropriate.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 7, eff. June 16, 1993; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
12VAC30-130-335. Other interventions.
As permitted by all applicable federal and state laws and regulations, DMAS or its designee may intervene in the process of the adjudication of claims for payment of prescription drugs. Such interventions may entail, but shall not be limited to, electronic messages, rejecting claims pending further resolution, or requiring prior authorization for selected prospective DUR criteria.
Designated interventions may include provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
12VAC30-130-340. DUR Board.
A. The Director of DMAS shall establish the DUR Board either directly or through a contract with an outside vendor. The DUR Board shall submit recommendations on prospective and retrospective drug use review to the director. The director reserves the right to reject such recommendations and shall so notify the board consistent with federal requirements. The DUR Board shall adhere to all the requirements of client confidentiality with respect to patient specific information.
B. The DUR Board shall consist of 13 members. At least one-third of the members shall be pharmacists. At least one-third but no more than 51% of the members shall be physicians. There shall be at least one but no more than two nurse members. All pharmacist, physician and nurse members shall be licensed by the Commonwealth with such licenses in good standing. The Director of DMAS shall invite submission of candidates from each of these groups. Other individuals and groups interested in submitting names of candidates for the DUR Board shall indicate their interest to the director in writing. The director shall appoint the physician members from candidates submitted by the Medical Society of Virginia, the Old Dominion Medical Society, and each of the medical schools in the Commonwealth. The director shall appoint the pharmacist members from candidates submitted by the Medical College of Virginia/Virginia Commonwealth University School of Pharmacy, the Virginia Pharmaceutical Association, Virginia Chain Drug Store Association, and the Virginia Society of Consultant Pharmacists. The director shall appoint the nurse member or members from candidates submitted by the Virginia Nurses Association.
1. At least five of the physicians and pharmacists appointed to the DUR Board shall be licensed and actively practicing.
2. All individuals appointed to the DUR Board shall demonstrate knowledge and expertise in one or more of the following areas:
a. The clinically appropriate prescribing of covered outpatient drugs;
b. The clinically appropriate dispensing and monitoring of outpatient drugs;
c. Drug use review, evaluation, and intervention; and
d. Medical quality assurance.
C. Consistent with its by-laws, the DUR Board members shall serve at the pleasure of the director, for terms established by the director. Vacancies shall be filled in the same manner as the original appointment.
D. DMAS shall provide staff assistance to the DUR Board and its officers in the routine conduct of its business.
E. The DUR Board shall have the following duties:
1. The DUR Board shall meet no less than quarterly and, in addition, upon call by the director. A quorum for action by the DUR Board shall be seven voting members.
2. The DUR Board shall elect from among its members a chairperson and a vice-chairperson. Officers may be elected to successive terms.
3. A full record of the board's proceedings shall be kept. The record shall be open to public inspection at all reasonable times consistent with the DMAS' hours of operation.
4. The DUR Board shall establish such rules as are necessary to conduct its business.
5. The DUR Board shall review and approve the retrospective DUR criteria for consistency with the requirements set forth in these regulations.
6. The DUR Board shall establish a listing of criteria and standards for use in prospective drug use reviews. The criteria and standards may include commercial software packages, drug interaction handbooks, and other published and written criteria.
7. The DUR Board shall submit a report at least semi-annually evaluating the success of interventions and making recommendations for modifications to the educational program, if appropriate. The DUR Board shall evaluate the educational program developed by DMAS or DMAS' vendor pursuant to the requirements of these regulations and make recommendations concerning the appropriate mix of intervention approaches.
8. The DUR Board shall prepare a report on an annual basis for submission to the director which shall include a description of the activities of the DUR Board, including the nature and scope of the prospective and retrospective drug use review programs, a summary of the interventions used, an assessment of the impact of the interventions on quality of care, an estimate of the costs and savings generated as a result of such program and other information specified by the director. DMAS shall prepare and submit, on an annual basis, a report to the U.S. Secretary of Health and Human Services that incorporates the DUR Board's report and conforms to the requirements set forth in federal regulations.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 8, eff. June 16, 1993.
12VAC30-130-350. DUR Committee.
A. The director shall provide for the establishment of a DUR Committee either directly or through a contract with an outside vendor. The DUR Board may serve as the DUR Committee.
B. The membership of the DUR Committee shall include health care professionals who have recognized knowledge and expertise in one or more of the following:
1. The clinically appropriate prescribing of covered drugs;
2. The clinically appropriate dispensing and monitoring of covered drugs;
3. Drug use review, evaluation, and intervention; and
4. Medical quality assurance.
C. The membership of the DUR Committee shall include physicians, pharmacists, and other health care professionals.
D. Activities of the DUR Committee shall include, but not be limited to, the following:
1. The review of patient, pharmacist, and physician exceptional drug utilization profiles generated from retrospective reviews applying knowledge and experience as a professional and the retrospective criteria and standards approved by the DUR Board;
2. Develop and recommend modifications to the prospective and retrospective standards based on clinical experience, new literature findings, and communications from practitioners pursuant to the educational program;
3. In instances where an exceptional drug use pattern is suggestive of fraud or abuse, make referrals in a manner consistent with the rules adopted by the DUR Board to the appropriate intra agency division;
4. Provide technical expertise to assist DMAS staff in the compilation of reports and recommendations to be presented to the DUR Board and the director.
E. The DUR Committee shall adhere to all the requirements of client confidentiality with respect to patient specific information.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 9, eff. June 16, 1993.
12VAC30-130-360. Exemption of organized health care settings.
A. Covered outpatient drugs dispensed by health maintenance organizations, including those organizations that contract under § 1903(m) of the Act, are not subject to the requirements of this section.
B. A hospital (providing medical assistance under the Commonwealth's plan) that dispenses covered outpatient drugs using drug formulary systems, and bills DMAS no more than the hospital's purchasing costs for covered outpatient drugs (as determined under the State plan) shall not be subject to the requirements of this regulation.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2600 § 10, eff. June 16, 1993.
12VAC30-130-370. (Repealed.)
Historical Notes
Derived from VR460-04-4.2600 § 11, eff. June 16, 1993; repealed, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.
Part V
Drug Utilization Review in Nursing Facilities
12VAC30-130-380. Definitions.
The following words and terms, when used in this part, shall have the following meanings unless the context clearly indicates otherwise:
"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
"Drug utilization review" or "DUR" means a formal continuing program for assessing medical or drug use data against explicit standards and, as necessary, introducing remedial strategies.
"Drug Utilization Review Committee (DUR Committee)" means a committee composed of knowledgeable health care professionals who make recommendations for developing and modifying drug therapy review standards or criteria, participate in retrospective reviews, recommend remedial strategies, and evaluate the success of the interventions.
"Exceptional drug utilization pattern" means (i) a pattern of drug utilization within a nursing facility that differs substantially from predetermined standards established pursuant to 12VAC30-130-400 B; (ii) individual resident's drug use patterns that differ from the established standards; or (iii) individual resident's drug use patterns that exhibit a high risk for drug therapy induced illness.
"Retrospective utilization drug review" means the drug utilization review process that is conducted using historic or archived medical or drug use data.
"Targeted facility" means a nursing facility where residents' patterns of drug utilization demonstrate an exceptional drug utilization pattern as defined herein.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-05-3000 § 1, eff. September 25, 1991; amended, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-130-390. Scope.
A. Medicaid shall conduct a drug utilization review program for covered drugs prescribed for nursing facility residents. The program shall help to ensure that prescriptions are appropriate, medically necessary, and are not likely to cause adverse actions. The primary objectives are (i) improvement in the quality of care: (ii) conserving program funds and individual expenditures: and (iii) maintaining program integrity (i.e., controlling problems of fraud and benefit abuse).
B. Retrospective drug utilization review will be conducted on an ongoing basis in targeted nursing facilities demonstrating exceptional drug utilization patterns.
C. With the aim of improving prescribing practices, the program shall provide for ongoing educational outreach programs to educate practitioners on common drug therapy problems.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-05-3000 § 2, eff. September 25, 1991.
12VAC30-130-400. Utilization review process.
A. The program shall provide, through its drug claims processing and information retrieval systems, for the ongoing periodic retrospective examination of claims data and other records for targeted facilities to identify patterns of inappropriate or medically unnecessary care for individuals receiving benefits under Title XIX of the Social Security Act.
B. The program shall, on an ongoing basis, assess data on drug use against predetermined standards (as described in this section) including, but not limited to, monitoring for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug/drug interactions, incorrect drug dosage or duration of treatment, clinical abuse/misuse, fraud, and, as necessary, introduce to physicians and pharmacists remedial strategies in order to improve the quality of care.
C. The Department of Medical Assistance Services may assess data on drug use against such standards as contained in the publications, as may be amended from time to time, that are referenced at 12VAC30-10-650 C and any other appropriate peer-reviewed medical literature.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-05-3000 § 3, eff. September 25, 1991; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
12VAC30-130-410. (Repealed.)
Historical Notes
Derived from VR460-05-3000 § 4, eff. September 25, 1991; repealed, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-130-420. Medical quality assurance.
A. Documentation of drug regimens in nursing facilities shall, at a minimum:
1. Be included in a plan of care that must be established and periodically reviewed by a physician;
2. Indicate all drugs administered to the resident in accordance with the plan with specific attention to frequency, quantity, and type and identify who administered the drug (include full name and title); and
3. Include the drug regimen review prescribed for nursing facilities in regulations implementing Section 483.60 of Title 42, Code of Federal Regulations.
B. Documentation specified in subsection A will serve as the basis for drug utilization reviews provided for in this part.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-05-3000 § 5, eff. September 25, 1991.
Part VI
Criteria for Intermediate Care for Mentally Retarded Persons
12VAC30-130-430. Introduction.
A. Utilization control regulations require that the level of care criteria be formulated for guidance for appropriate levels of care. Traditionally, intermediate care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.
B. The purpose of this chapter is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the client is in the appropriate level of care and when "active treatment" is being provided. An individual's need for care must meet these criteria before any authorization for payment by Medicaid will be made for either institutional or waivered rehabilitative services for the mentally retarded.
C. Intermediate care for the mentally retarded requires planned programs for habilitative needs or health related services which exceed the level or room, board, combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the retarded person. Examples of services will include training in the activities of daily living, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task learning level which the person can presently or potentially achieve.
D. The evaluation and reevaluation for intermediate care are based on the needs of the person, the reasonable expectations of the resident's capabilities, the appropriateness of programming, whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.
E. The final determination of a person's need for intermediate level of care is a professional decision based on total needs. Mentally retarded persons as individuals present an infinite variety of needs, making it virtually impossible to establish an evaluation system that will eliminate the need for professional judgement within the confines of program criteria.
F. The following criteria are divided into broad categories of needs, or services provided. These must be evaluated in detail to determine the abilities/skills which the client has acquired. The evaluation will then identify training needs/skills which will be the basis for the development of a plan of care.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.2 § 1, eff. December 26, 1985.
12VAC30-130-440. Definitions.
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"No assistance" means no help is needed.
"Often" means occurs two to three times a month.
"Prompting/structuring" means prior to the functioning, some verbal direction or rearrangement of the environment is needed.
"Rarely" means occurs quarterly or less.
"Regularly" means occurs weekly or more.
"Some direct assistance" means helper must be present and provide some physical guidance/support (with or without verbal direction).
"Sometimes" means occurs once a month.
"Supervision" means helper must be present during function and provide only verbal direction, gestural prompts, or guidance.
"Total assistance" means helper must perform all or nearly all of the functions.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.2 § 2, eff. December 26, 1985.
12VAC30-130-450. Patient assessment criteria.
A. The evaluation process will demonstrate a need for programming an array of skills and abilities or health care services. These have been organized into seven major categories. The level of functioning in each category is graded from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or ability to perform a given task.
The resident must meet the indicated dependency level in two or more of the categories 1 through 7.
1. Health status. To meet this category:
a. Two or more questions must be answered with a "4," or
b. Question 10 must be answered "yes".
2. Communication skills. To meet this category:
a. Three or more questions must be answered with a "3" or "4".
3. Task learning skills. To meet this category:
a. Three or more questions must be answered with a "3" or "4".
4. Personal care. To meet this category:
a. Question No. 1 must be answered with a "4" or "5", or
b. Question No. 2 must be answered with a "4" or "5", or
c. Questions No. 3 and 4 must be answered with a "4" or "5".
5. Mobility. To meet this category:
a. Any one question must be answered with a "4" or "5".
6. Behavior. To meet this category:
a. Any one question must be answered with a "3" or "4".
7. Community living. To meet this category:
a. Any two of the questions numbers 2, 5, or 7 must be answered with a "4" or "5", or
b. Three or more of questions 1 through 8 must be answered with a "4" or "5".
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.2 § 3, eff. December 26, 1985.
12VAC30-130-460. Directions for applying the criteria.
A. The references under the questions in the following categories indicate those items which are on the Behavior Development Survey (DMH 71 Revised 6/80). The absence of a reference indicates this question is not addressed on the BDS form. Some categories on the Behavior Development Survey are not incorporated since the information in that area of the evaluation will be reflected elsewhere in the criteria or the condition is not indicative of a functional deficit justifying a need for intermediate care.
| PATIENT ASSESSMENT CRITERIA. | ||||||||||||||||||||||
| 1. HEALTH STATUS -- To meet this category: | ||||||||||||||||||||||
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| a. | Two or more questions must be answered with a 4, or Question No. 10 must be answered yes. | ||||||||||||||||||||
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| Rarely | Some- | Often | Regu- |
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| b. | How often is nursing care or nursing supervision by a licensed nurse required for the following: | 1 | 2 | 3 | 4 |
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| 1. | Medication administration and/or evaluation for effectiveness of a medication regime? ((70) Receiving Medications and History of Seizures pg.4) | 1 | 2 | 3 | 4 |
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| 2. | Direct services: i.e., care for lesions, dressings, treatments, (other than shampoos, foot powder, etc.)? | 1 | 2 | 3 | 4 |
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| 3. | Seizures control? ((68) History of seizures pg.4) | 1 | 2 | 3 | 4 |
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| 4. | Teaching diagnosed disease control and care, including diabetes? | 1 | 2 | 3 | 4 |
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| 5. | Management of care of diagnosed circulatory or respiratory problems? | 1 | 2 | 3 | 4 |
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| 6. | Motor disabilities which interfere with all activities of daily living--bathing, dressing, mobility, toileting, etc.? | 1 | 2 | 3 | 4 |
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| 7. | Observation for choking/aspiration while eating, drinking? | 1 | 2 | 3 | 4 |
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| 8. | Supervision for use of adaptive equipment, i.e., special spoon, braces, etc.? (physical aids pg.4) | 1 | 2 | 3 | 4 |
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| 9. | Observation for nutritional problems (i.e., undernourishment, swallowing difficulties, obesity)? | 1 | 2 | 3 | 4 |
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| 10. | Is age 55 or older, has a diagnosis of a chronic disease and has been in an institution 20 years or more? | yes | no |
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| 2. COMMUNICATION -- To meet this category: | ||||||||||||||||||||||
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| a. | Three or more questions must be answered with a 3 or a 4. | ||||||||||||||||||||
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| No assis-tance | Prompt-ing/ | Super-vision | Some Direct Assis-tance | Total | |||||||||||||||||
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| b. | How often does this person: |
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| 1. | Indicate wants by pointing, vocal noises, or signs? ((62)(c) Preverbal Expression pg.2) | 1 | 2 | 3 | 4 |
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| 2. | Use simple words, phrases short sentences? ((67) Sentences pg.2) | 1 | 2 | 3 | 4 |
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| 3. | Ask for at least ten things using appropriate names? ((67) Vocabulary pg.1) | 1 | 2 | 3 | 4 |
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| 4. | Understand simple words, phrases or instructions containing prepositions: i.e., on in behind? ((27) Complex Instructions pg.3) | 1 | 2 | 3 | 4 |
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| 5. | Speak in an easily understood manner? ((66) Speech pg.1) | 1 | 2 | 3 | 4 |
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| 6. | Identify self, place of residence, and significant other, ((47) Awareness of Others, pg.3) | 1 | 2 | 3 | 4 |
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| a. | Three or more questions must be answered with a 3 or a 4. | ||||||||||||||||||||
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| b. | How often does this person: |
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| 1. | Pay attention to purposeful activities for 5 minutes? ((42)(2) Attention pg.3) | 1 | 2 | 3 | 4 |
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| 2. | Stay with a three-step task for more than 15 mintues? ((42) (5) Attention pg. 3) | 1 | 2 | 3 | 4 |
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| 3. | Tell time to the hour and understand time intervals? ((33) (b) Time pg. 3) | 1 | 2 | 3 | 4 |
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| 4. | Count more than 10 objects? ((31) (5) Numbers pg.3) | 1 | 2 | 3 | 4 |
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| 5. | Do simple addition, subtraction ((31) (6)Numbers pg.3) | 1 | 2 | 3 | 4 |
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| 6. | Write or print ten words? ((59) (3) Writing pg. 2) | 1 | 2 | 3 | 4 |
| ||||||||||||||
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| 7. | Discriminate shapes, sizes, or colors? | 1 | 2 | 3 | 4 |
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| 8. | Name people or objects when describing pictures? ((67) (4) Vocabulary pg. 1) | 1 | 2 | 3 | 4 |
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| 9. | Discriminate between one, many, lot? ((31) (2) Numbers pg. 3) | 1 | 2 | 3 | 4 |
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| 4. PERSONAL/SELF CARE -- To meet this category: | ||||||||||||||||||||||
|
| a. | Question No. 1 must be answered with a 4 or a 5, or | ||||||||||||||||||||
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| b. | Question No. 2 must be answered with a 4 or a 5, or | ||||||||||||||||||||
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| c. | Questions No. 3 and 4 must be answered with a 4 or a 5? | ||||||||||||||||||||
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| NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale. | |||||||||||||||||||||
|
| No Assis-tance | Prompt-ing/ | Super-vision | Some Direct Assis-tance | Total | |||||||||||||||||
|
| d. | With what type of assistance can this person currently: |
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|
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| |||||||||||||||
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| 1. | Perform toileting functions: i.e., maintain bladder and bowel continence, clean self? etc. ((31)(5) Toilet Training pg. 1) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
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|
|
| (a) has toileting accidents more than twice a day? ((31)(2) Toilet Training pg. 1) | yes |
| no |
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| ||||||||||||||
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|
| (b) has toileting accidents at night? | yes |
| no |
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| ||||||||||||||
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|
|
| (c) Flushes toilet, pulls up clothes? ((36) Self Care at Toilet pg. 2) | yes |
| no |
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| ||||||||||||||
|
|
| 2. | Perform eating/feeding functions: i.e., drinks liquids and eats with spoon or fork, etc? ((28)(3) Use of Table Utensils pg. 1) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
|
| (a) Feeds self with spoon neatly? ((28)(3) Use of Table Utensils) | yes |
| no |
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| ||||||||||||||
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|
|
| (b) Spilling? ((3) (3) Drinking pg. 1) | yes |
| no |
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| ||||||||||||||
|
|
| 3. | Perform bathing functions (i.e., bathe, runs bath, dry self, etc.)? ((44)(5) Bathing pg. 2) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
|
| (a) Washes hands and face with soap? ((39) (40) Washes Hands and Face pg. 2) | yes |
| no |
|
| ||||||||||||||
|
|
|
| (b) Dries hands and face? ((42) Washes Hands and Face pg. 2) | yes |
| no |
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| ||||||||||||||
|
|
|
| (c) Care for hair, nails, beard? | yes |
| no |
|
| ||||||||||||||
|
|
| 4. | Dress self completely i.e., including fastening, putting on clothes, etc. ((5) (6) Dressing pg. 2) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
|
| (a) Dresses upper body, but needs help with fastening? | yes |
| no |
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| ||||||||||||||
|
|
|
| (b) Dresses self but needs assistance with pulling, or | yes |
| no |
|
| ||||||||||||||
|
|
|
| (c) Putting on most clothing, fastening, shoes? ((50) (3) Dressing (52) Shoes pg. 2) | yes |
| no |
|
| ||||||||||||||
| 5. MOBILITY -- To meet this category: | ||||||||||||||||||||||
|
| a. | Any one question must be answered with a 4 or a 5. | ||||||||||||||||||||
|
| NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale. | |||||||||||||||||||||
|
| No Assis-tance | Prompt-ing/ | Super-vision | Some Direct Assis-tance | Total | |||||||||||||||||
|
| b. | With what type of assistance can this person currently: |
|
|
|
|
| |||||||||||||||
|
|
| 1. | Move (walking, wheeling) around environment? ((59) Ambulation pg. 1,(79) Physical Aids pg. 4) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
|
| (a) Walk with assistive device, person? ((59) Ambulation pg. 1, Physical Aids pg. 4) | yes |
| no |
|
| ||||||||||||||
|
|
|
| (b) Walk on level ground for 50 yards with or without assistive device? ((73, 74, 76) Physical Aids, pg. 4) | yes |
| no |
|
| ||||||||||||||
|
|
|
| (c) Transfer to/from a wheelchair? ((75) Physical Aids pg. 4) | yes |
| no |
|
| ||||||||||||||
|
|
| 2. | Rise from lying down to sitting positions, sits without support? ((27) Body Balance pg. 1) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 3. | Turn and position in bed, roll over? | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
| 6. BEHAVIOR -- To meet this category: | ||||||||||||||||||||||
|
| a. | Any one question must be answered with a 3 or a 4. | ||||||||||||||||||||
|
| Rarely | Some-times | Often | Regu- |
| |||||||||||||||||
|
| b. | How often does this person: |
|
|
|
|
| |||||||||||||||
|
|
| 1. | Engage in self-destructive behavior? ((61) Maladaptive Behavior pg. 4) | 1 | 2 | 3 | 4 |
| ||||||||||||||
|
|
| 2. | Threaten or do physical violence to others? ((52) Maladaptive Behavior pg. 4) | 1 | 2 | 3 | 4 |
| ||||||||||||||
|
|
| 3. | Throw things, damage property, have temper outbursts? ((53, 55) Maladaptive Behavior pg. 4) | 1 | 2 | 3 | 4 |
| ||||||||||||||
|
|
| 4. | Respond to others in a socially unacceptable manner (without undue anger, frustration or hostility)? ((50) Interactions with Others pg. 3) | 1 | 2 | 3 | 4 |
| ||||||||||||||
| 7. COMMUNITY LIVING SKILLS -- To meet this category: | ||||||||||||||||||||||
|
| a. | Any two of questions 2, 5, or 7 must be answered with a 4 or a 5, or | ||||||||||||||||||||
|
| b. | Three or more of questions 1 through 8 must be answered with a 4 or a 5. | ||||||||||||||||||||
|
| No Assis-tance | Prompt-ing/ | Super-vision | Some Direct Assis-tance | Total | |||||||||||||||||
|
| c. | With what type of assistance would this person currently be able to: |
|
|
|
|
| |||||||||||||||
|
|
| 1. | Prepare simple foods requiring no mixing or cooking? ((38) Food Preparation pg. 3) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 2. | Take care of personal belongings, room (excluding vacuuming, ironing, clothes washing/drying, wet mopping)? ((43) Personal Belongings pg. 3) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 3. | Add coins of various demonima1 nations up to one dollar? ((57) Money Handling pg. 2) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 4. | Use the telephone to call home, doctor, fire, police? | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 5. | Recognize survival signs/words: i.e., stop, go, traffic lights, police, men, women, restrooms, danger, etc.? ((68) Reading pg. 2) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 6. | Refrain from exhibiting unacceptable sexual behavior in public? ((63, 64, 65) Maladaptive Behavior pg. 4) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 7. | Go around cottage, ward, building, without running away, wandering off, or becoming lost? ((56) Sense of Direction pg. 2, (57) Maladaptive Behavior pg. 4) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
|
|
| 8. | Make minor purchases i.e., candy, soft drink, etc.? ((58, 4) Purchasing pg. 2) | 1 | 2 | 3 | 4 | 5 | ||||||||||||||
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.2 § 4, eff. December 26, 1985.
Part VII
Hospice Services [Repealed]
12VAC30-130-470. (Repealed.)
Historical Notes
Derived from VR460-04-8.8 §§ 1 to 7, eff. July 3, 1991; repealed, Virginia Register Volume 16, Issue 6, eff. January 5, 2000.
Part VIII
Community Mental Health and Mental Retardation Services
12VAC30-130-540. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 1, eff. April 20, 1994; amended, Virginia Register Volume 14, Issue 7, eff. January 22, 1998; Volume 25, Issue 14, eff. April 15, 2009; repealed, Virginia Register Volume 33, Issue 12, eff. April 1, 2017.
12VAC30-130-550. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 2, eff. April 20, 1994; amended, Virginia Register Volume 14, Issue 7, eff. January 22, 1998; repealed, Virginia Register Volume 20, Issue 7, eff. February 1, 2004.
12VAC30-130-560. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 3, eff. April 20, 1994; repealed, Virginia Register Volume 14, Issue 7, eff. January 22, 1998.
12VAC30-130-565. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 14, Issue 7, eff. January 22, 1998; amended, Virginia Register Volume 20, Issue 7, eff. February 1, 2004; repealed, Virginia Register Volume 33, Issue 12, eff. April 1, 2017.
12VAC30-130-570. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 4, eff. April 20, 1994; amended, Virginia Register Volume 14, Issue 7, eff. January 22, 1998; repealed, Virginia Register Volume 20, Issue 7, eff. February 1, 2004.
12VAC30-130-580. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 5, eff. April 20, 1994; repealed, Virginia Register Volume 33, Issue 12, eff. April 1, 2017.
12VAC30-130-590. (Repealed.)
Historical Notes
Derived from VR460-04-8.1500 § 6, eff. April 20, 1994; repealed, Virginia Register Volume 33, Issue 12, eff. April 1, 2017.
Part IX
Dmas-225 Adjustment Process
12VAC30-130-600. Definitions.
The following words and terms, when used in this part, shall have the following meanings, unless the context indicates otherwise:
"DMAS" or "the department" means the Virginia Department of Medical Assistance Services.
"DMAS-225" means the Medicaid Communication form used for the provider and the DSS eligibility worker to report changes including requests for adjustments to the patient pay.
"DSS" means the local Department of Social Services.
"Facility" means a nursing facility, intermediate care facility for the mentally retarded, or a long-stay acute care hospital enrolled in the Medicaid program.
"Medical necessity" means an item or service provided for the diagnosis or treatment of a patient's condition consistent with community standards of medical practice and in accordance with Medicaid policy.
"Preauthorization" means obtaining the approval necessary for receipt of a specified service from a specified provider for a specified recipient before the requested service is performed.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.16 § 1, eff. January 1, 1995; amended, Virginia Register Volume 37, Issue 26, eff. September 17, 2021.
12VAC30-130-610. Purpose and scope.
The department's payment to nursing facilities, intermediate care facilities for the mentally retarded, and long-stay acute care hospitals shall be reduced by the amount of the patient's income, less certain deductions (the patient pay amount) in conformance with 42 CFR 435 (rev. October 1, 1992). Amounts for medical or remedial care not subject to payment by a third party, including necessary medical or remedial care not covered under the State Plan for Medical Assistance (the Plan), shall be deducted during the calculation of patient pay amounts.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.16 § 2, eff. January 1, 1995.
12VAC30-130-620. Limitations.
A. A DMAS-225 adjustment request shall always be used as the last source of payment. If a recipient has other sources of possible payment (i.e., Medicare, major medical insurance, prescription insurance, dental insurance, etc.), payment must be sought first from those other sources.
B. The maximum amount for noncovered medically necessary items or services that can be allowed as adjustments to the patient pay amount for nursing facility residents shall be the amount specified in 12VAC30-40-235.
C. Only the cost of medically necessary, resident-specific, customized, noncovered items or services may be deducted from patient pay. This shall include, but not necessarily be limited to, electric, motorized, or customized wheelchairs and other equipment not regularly supplied to residents by the facility as part of the cost of care. Supplies, equipment, or services used in the direct care and treatment of residents are covered services and must be provided by the facility. Covered items and services include, but are not necessarily limited to, standard wheelchairs, recliners, geriatric chairs, special mattresses, humidifiers, cots, and routine podiatry care (e.g., trimming nails for onychauxis, cleaning and soaking the feet, and other services performed in the absence of localized illness, injury, or symptoms involving the foot). Expenses incurred by the facility for covered items and services are considered "allowable expenses" and are covered by Medicaid as part of reimbursement to the facility for the resident's care; these costs cannot be deducted from patient pay.
D. Extenuating circumstances shall be considered for the provision of podiatry care when corrective trimming is performed to prevent further complications in a patient who has a systemic condition that has resulted in severe circulation deficits or areas of desensitization in the legs or feet. Trimming of nails for a systemic condition is limited to once every 60 days and must be medically necessary. In such cases, the facility is not responsible for routine podiatry care.
E. DMAS-225 adjustments shall be allowed for the cost of medically or remedially necessary services provided prior to Medicaid eligibility or prior to admission. Any decision made by DMAS or DSS to deny a service may be appealed to DMAS. Appeals must be made in writing by the resident or his legally appointed representative, as provided for in DMAS Client Appeals Regulations (12VAC30-110).
F. The facility shall monitor the proper care of the resident's medical supplies and equipment. Requests for adjustment made because an item is lost or broken by facility staff must include documentation on the resident's interdisciplinary plan of care regarding proper care and treatment of the item. When loss or breakage is incurred as a result of facility staff following improper practices, the facility must replace the item.
G. All requests for DMAS-225 adjustments submitted by providers to either DMAS or DSS shall include:
1. The recipient's correct Medicaid identification number;
2. The current physician's orders for the noncovered service (not required for replacement of hearing aid batteries or eyeglass frames or for repair to hearing aids or eyeglasses);
3. Medical justification for the service being requested (see subsection H of this section);
4. The service description;
5. Actual cost information;
6. Documentation that the recipient continues to need the equipment for which a repair, replacement, or battery is requested;
7. A statement of proof of denial or noncoverage by other insurance; and
8. A copy of the most current, fully completed Minimum Data Set (MDS) and quarterly review.
H. Medical justification documentation as specified in subdivision G 3 of this section shall include the following:
1. Physician prescription;
2. Identification of the diagnosis related to the reason for the request;
3. Identification of the resident's functional limitation;
4. Identification of the quantity needed, frequency of use, estimated length of use; and
5. Identification of how the item or service will be used in the resident's environment.
I. Adjustments of a recipient's patient pay amount may only be authorized by DMAS or DSS.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.16 § 3, eff. January 1, 1995; amended, Virginia Register Volume 20, Issue 19, eff. August 1, 2004; Volume 37, Issue 26, eff. September 17, 2021.
Part X
New Drug Review Program Regulations [Repealed]
12VAC30-130-630. (Repealed.)
Historical Notes
Derived from VR460-05-2000.000 §§ 1.1 through 2.4, eff. November 7, 1990; repealed, Virginia Register Volume 11, Issue 18, eff. July 1, 1995.
Part XI
New Drugs Not Covered by Medicaid [Repealed]
12VAC30-130-730. (Repealed.)
Historical Notes
Derived from VR460-05-2000.1000, eff. February 1, 1990; repealed, Virginia Register Volume 11, Issue 18, eff. July 1, 1995.
Part XII
Health Insurance Premium Payment Program (Hipp)
12VAC30-130-740. General.
The requirements of this part shall operate in concert with the HIPP program requirements as contained in the State Plan for Medical Assistance, specifically Attachment 4.22-C (VR 460-02-4.2230).
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2230 § 1, eff. April 1, 1993.
12VAC30-130-750. Time frames for determining cost effectiveness.
A. The department (DMAS) shall determine eligibility for the program and shall provide notice to the recipient within 45 calendar days from the date of receiving an application that contains all information and verifications necessary to determine eligibility.
B. Incomplete applications shall be held for a period of 30 calendar days to enable applicants to provide outstanding information needed for an eligibility determination. Any applicant who fails to provide information or verifications necessary to determine eligibility within 30 calendar days of the receipt of the initial application shall have his application denied.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2230 § 2, eff. April 1, 1993; amended, Virginia Register Volume 25, Issue 20, eff. July 23, 2009.
12VAC30-130-760. Notices.
An adequate notice consistent with 42 CFR 431.210 shall be provided to the recipient, person carrying the group health plan policy or responsible person in the case under the following circumstances:
1. To inform the household of the decision on cost effectiveness and premium payment.
2. To inform the household that premium payments are being discontinued because Medicaid eligibility has been lost by all persons covered under the group health plan.
3. To inform the household that premium payments are being discontinued because the group health plan is no longer available to the family (e.g., the employer drops insurance coverage or the plan is terminated by the insurance company).
4. To inform the household that premium payments are being discontinued because DMAS has determined it is no longer cost effective to pay the premiums.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2230 § 3, eff. April 1, 1993.
12VAC30-130-770. [Reserved]. (Reserved)
12VAC30-130-780. (Repealed.)
Historical Notes
Derived from VR460-04-4.2230 § 5, eff. April 1, 1993; repealed, Virginia Register Volume 25, Issue 20, eff. July 23, 2009.
12VAC30-130-790. Information required of applicants and recipients.
All applicants and recipients shall be required to provide the information required on the prescribed DMAS HIPP applications forms and all requested information to determine eligibility and cost effectiveness.
Statutory Authority
§§32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-4.2230 § 6, eff. April 1, 1993; amended, Virginia Register Volume 25, Issue 20, eff. July 23, 2009.
Part XIII
Client Medical Management Programs
12VAC30-130-800. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Abuse" or "abusive activities" means practices by individuals or providers that are inconsistent with sound fiscal or medical practices and result in unnecessary costs to the Virginia Medicaid program.
"Card-sharing" means (i) the intentional sharing of an individual's eligibility card for use by someone other than the individual for whom it was issued or (ii) unauthorized use of an individual's eligibility card by one or more persons other than the individual for whom it was issued due to the failure of the individual to safeguard the card.
"Client Medical Management Program for individuals" or "CMM Program for individuals" means the individuals' utilization control program designed to prevent abuse and promote improved and cost efficient medical management of essential health care for noninstitutionalized individuals through restriction to one primary care provider or one pharmacy, or any combination of these designated providers.
"Client Medical Management Program for providers" or "CMM Program for providers" means the providers' utilization control program designed to complement the individual abuse and utilization control program in promoting improved and cost efficient medical management of essential health care.
"Controlled substance" means a substance that has a potential for abuse because physical and psychic dependence and tolerance may develop upon repeated administration and that is classified as a Schedules I through V drug.
"Covering provider" means a provider designated by the primary provider to render health care services in the temporary absence of the primary provider.
"DMAS" or "the department" means the Department of Medical Assistance Services.
"Dental services" means covered dental services available to Medicaid or FAMIS eligible children as well as the limited, emergency services available to Medicaid eligible adults.
"Designated physician or pharmacy" means the provider who agrees to be the designated physician or pharmacy from whom the restricted individual must first attempt to seek medical or pharmaceutical services. Other providers may be established as designated physician or pharmacy providers with the approval of DMAS.
"Diagnosis" means (i) the process of determining by examination the nature and circumstances of a diseased condition or injury and (ii) the decision reached from such examination.
"Diagnostic category" means the broad classification of diseases and injuries found in the International Classification of Diseases (ICD), which is commonly used by providers in billing for medical services.
"Drug" means a substance or medication intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease as defined by the Virginia Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia).
"Duplicative medical care" means two or more practitioners are concurrently treating the same or similar medical problems or conditions falling into the same diagnostic category, but excluding confirmation for diagnosis, evaluation, or assessment.
"Duplicative medications" means more than one prescription of the same drug or more than one drug in the same therapeutic class.
"Education" means providing individuals with information regarding DMAS' identification of inappropriate utilization and what is appropriate access to Medicaid covered services according to the policies and procedures of the CMM Program for individuals and the CMM Program for providers. Education shall not include providing a professional opinion regarding an individual's medical or mental health.
"Eligibility card" means the document issued to each Medicaid individual listing the name and Medicaid number, either the identification or billing number, of the eligible individual, which may be in the form of a plastic card magnetically encoded, allowing electronic access to inquiries for eligibility status.
"Emergency hospital services" means those hospital services that are necessary to treat a medical emergency. Hospital treatment of a medical emergency necessitates the use of the most accessible hospital available that is equipped to furnish the required services.
"EPSDT" means the Early and Periodic Screening, Diagnosis, and Treatment Program that is federally mandated for eligible individuals younger than 21 years of age.
"Essential medical services" means quality medical services, including but not limited to preventive care, emergency services, maternity care, hospital and physician services, and prescription drug services as set out in the State Plan for Medical Assistance.
"Excessive medical care" means obtaining greater than necessary services such that health risks to the individual or unnecessary costs to the Virginia Medicaid Program may ensue from the accumulation of services or obtaining duplicative services.
"Excessive medications" means obtaining medication in greater than generally acceptable maximum therapeutic dosage regimens or obtaining duplicative medication from one or more practitioners.
"FAMIS" means the Family Access to Medical Insurance Security program as created by Title XXI of the Social Security Act.
"Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state laws.
"Health care" means any covered service, including equipment or supplies provided by any person, organization, or entity that participates in the Virginia Medical Assistance Program.
"Home and community-based services" means a range of community services approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to § 1915(c) of the Social Security Act to be offered to individuals as an alternative to institutionalization.
"Hospice services" means services, pursuant to § 1905(o) of the Act, that are reasonable and necessary for the palliation or management of a terminal illness if the terminal illness runs its normal course.
"Immunization" means the creation of immunity against a particular disease using a vaccination.
"Individual" means the recipient of Medicaid-covered services that are provided under the authority of Titles XIX and XXI of the Social Security Act.
"Java-Server Utilization Review System" or "JSURS" means a computer subsystem of the Virginia Medicaid Management Information System (VAMMIS) that collects claims data and computes statistical profiles of individual and provider activity and compares such profiles with the appropriate peer group.
"Managed care organization" or "MCO" means an entity that meets the participation and solvency criteria defined in 42 CFR Part 438 and has an executed agreement with the department to provide services covered under (i) the Medallion II programs, pursuant to 12VAC30-120-360 et seq., or any successor programs and (ii) the FAMIS programs, pursuant to 12VAC30-141, or any successor programs.
"Medical emergency" means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that in the absence of immediate medical attention could reasonably be expected to result in (i) placing the individual's health in serious jeopardy, (ii) serious impairment of the individual's bodily functions, or (iii) serious dysfunction of the individual's bodily organs or parts.
"Medically necessary" means services that are reasonable and necessary for the diagnosis or treatment of an illness, condition, or injury, or to improve the function of a disability, consistent with community standards of medical practice and in accordance with Medicaid or FAMIS policies.
"Noncompliance" means failing to follow Client Medical Management Program policies and procedures, or a pattern of utilization that is inconsistent with sound fiscal or medical practices. Noncompliance includes, but is not limited to, failure to follow a recommended treatment plan or drug regimen; failure to disclose to a provider any treatment or services provided by another provider; or requests for medical services or medications that are not medically necessary.
"Pattern" means a combination of qualities, acts, or tendencies that result in duplication or frequent occurrence.
"Practitioner" means a health care provider licensed, registered, or otherwise permitted by law to distribute, dispense, prescribe, and administer drugs or otherwise treat medical conditions.
"Primary care provider" or "PCP" means a physician or nurse practitioner practicing in accordance with state law who is responsible for supervising, coordinating, and providing initial and primary medical care to patients; for initiating written referrals for specialist care; and for maintaining the continuity of patient care.
"Provider" means a person, organization, or institution with a current, valid license or certification, as applicable, and participation agreement with DMAS who or that will (i) render service to Medicaid individuals who are eligible for covered services, (ii) submit a claim or claims for the rendered services, and (iii) accept as payment in full the amount paid by the Virginia Medicaid or FAMIS program.
"Psychotropic drugs" means drugs that alter the mental activity, behavior, or perception. Examples of such drugs include morphine, barbiturates, hypnotics, antianxiety agents, antidepressants, and antipsychotics.
"Renal dialysis services" means services that aid the process of diffusing blood across a semi-permeable membrane to remove substances that a normal kidney would eliminate, including poisons, drugs, urea, uric acid, and creatinine. Renal dialysis services help to restore electrolytes and correct acid-base imbalances.
"Restrict" or "restriction" means an administrative action imposed on an individual that limits access to specific types of health care services through a designated primary provider or an administrative action imposed on a provider to prohibit participation as a designated primary provider, referral, or covering provider for restricted individuals.
"Social Security Act" or "the Act" means the statute, enacted by the 74th Congress on August 14, 1935, and as amended, that provides for the general welfare by establishing a system of federal old age benefits, and by enabling the states to make more adequate provisions for aged persons, blind persons, dependent children who have disabilities, maternal and child welfare, public health, and the administration of their unemployment compensation laws.
"State Plan for Medical Assistance" or "the Plan" means the comprehensive written statement submitted by the department to the Centers for Medicare and Medicaid Services (CMS) for approval describing the nature and scope of the Virginia Medicaid program and giving assurance that it will be administered in conformity with the requirements, standards, procedures, and conditions for obtaining federal financial participation.
"Therapeutic class" means a group of drugs with similar pharmacologic actions and uses.
"Under-use" or "under-utilization" means an occurrence where there is evidence that an individual did not receive a service or procedure whose benefits exceeded the risks.
"Utilization control" means the control of covered health care services to assure the use of cost efficient, medically necessary or appropriate services.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.3 § 1, eff. January 1, 1993; amended, Virginia Register Volume 14, Issue 10, eff. March 4, 1998; Volume 25, Issue 14, eff. April 15, 2009; Volume 32, Issue 4, eff. December 3, 2015.
12VAC30-130-810. Client Medical Management Program for individuals.
A. Purpose. The Client Medical Management Program for individuals is designed to assist and educate Medicaid individuals in appropriately using essential medical and pharmacy services. Individuals who use these services excessively or inappropriately as determined by DMAS may be assigned to a single primary care provider or pharmacy, or both. The CMM Program for individuals also monitors individual compliance with program guidelines.
B. Authority.
1. The Act and federal regulations at 42 CFR 456.3 require the Medicaid agency to implement a statewide surveillance and utilization control program that (i) safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments, (ii) assesses the quality of those services, (iii) provides for the control of the utilization of all services provided under the Plan, and (iv) provides for the control of the utilization of inpatient services.
2. Federal regulations at 42 CFR 431.54(e) allow states to restrict individuals to designated providers when the individuals have utilized services at a frequency or an amount that is not medically necessary in accordance with utilization guidelines established by the state.
C. Identification of participants for inclusion in the CMM Program for individuals. DMAS shall identify individuals for review from computerized reports such as but not limited to individual Java-Server Utilization Review System (JSURS), VAMMIS, Oracle or by written referrals from agencies, health care professionals, or other persons. Certain individuals who are reviewed may not be restricted when evidence indicates that the prescription or medical service utilization patterns, or both, are for appropriate therapy. Only individuals who are excluded, pursuant to 12VAC30-120-370 B, from receiving care from a managed care organization shall be reviewed and evaluated for restriction under the CMM Program for individuals.
D. Individual evaluation for restriction.
1. DMAS shall utilize data as indicated in subsection C of this section to conduct a review of individuals to determine if services are being utilized at a frequency or amount that results in a level of utilization or a pattern of services which is not medically necessary or which are excessive medical services or excessive medications, or both, as established by the department. Evaluation of utilization patterns can include but is not limited to review by the department of medical records or computerized reports, or both, generated by the department reflecting claims submitted for physician visits, drugs or prescriptions, outpatient and emergency room visits, lab or diagnostic procedures, or both, and hospital admissions.
2. Restricted individuals shall have reasonable access to all essential medical services. These restrictions shall not apply to hospital emergency services.
3. Abusive activities shall be investigated and, if appropriate, the individual shall be reviewed for educational intervention or restriction, or both.
a. If DMAS' review determines that an individual's data indicates (i) inappropriate use of Medicaid services, (ii) questionable patterns of utilization, or (iii) unreasonable levels of utilization, the department shall initiate the individual's restriction to either a physician or pharmacy, or both.
b. Once an individual is restricted, the restriction period shall last for 24 months from the enrollment date. During this restriction period, the individual shall be required to use the services of the designated physician or designated pharmacy, or both.
c. The individual may visit physicians or specialists other than those who are designated only by a written referral from the designated PCP.
d. The individual may obtain prescriptions from pharmacies other than the designated pharmacy only (i) in an emergency, (ii) when the designated pharmacy is closed, (iii) when the designated pharmacy does not stock the required medication, or (iv) when the designated pharmacy is not able to obtain the required medication in a timely manner.
E. Determination of restriction. DMAS may restrict an individual if any of the following activities or patterns or levels of utilization are identified. These activities, patterns, or levels of utilization include, for example:
1. Two occurrences of having prescriptions for the same drugs filled two or more times on the same or the subsequent day.
2. Utilizing services from three or more prescribers and three or more dispensing pharmacies in a three-month period.
3. Receiving more than 24 prescriptions in a three-month period.
4. Receiving more than 12 psychotropic prescriptions or more than 12 analgesic prescriptions or more than 12 prescriptions for controlled drugs with potential for abuse in a three-month period.
5. Exceeding the maximum therapeutic dosage of the same drug or multiple drugs in the same therapeutic class, which have been prescribed by two or more practitioners, for a period exceeding four weeks.
6. Receiving two or more drugs, duplicative in nature or potentially addictive (even within acceptable therapeutic levels), dispensed by more than one pharmacy or prescribed by more than one practitioner for a period exceeding four weeks.
7. Receiving narcotic prescriptions from two or more prescribers without supporting diagnoses indicative of use.
8. Utilizing three or more different physicians of the same type or specialty in a three-month period for treatment of the same or similar condition or conditions.
9. Two or more occurrences of seeing two or more physicians of the same type or specialty on the same or subsequent day for the same or similar diagnosis.
10. Duplicative, excessive, or contraindicated utilization of medications, medical supplies, or appliances dispensed by or prescribed by more than one provider for the time period specified by DMAS.
11. Use of emergency hospital services for three or more emergency room visits for nonemergency care during a three-month period.
12. One or more providers recommend restriction for medical management because the recipient has demonstrated inappropriate utilization practices.
13. A pattern of noncompliance that is inconsistent with sound fiscal or medical practices. For example, noncompliance may be characterized by:
a. Failure to disclose to a provider any treatment or services provided by another provider;
b. Failure to follow a drug regimen or other recommended treatment;
c. Requests for medical services or medications that are not medically necessary;
d. Use of hospital emergency services via self-referral for nonacute episodes of care or solely for nonacute management of the medical condition; or
e. Under-use or under-utilization of medically necessary services that results in higher costs for the management of the medical condition.
14. Any documented occurrences of use of the eligibility card to obtain drugs under false pretenses, which includes, but is not limited to the purchase or attempt to purchase drugs via a forged or altered prescription.
15. Any documented occurrences of card-sharing.
16. Any documented occurrences of alteration of the recipient eligibility card.
17. One or more documented occurrences of paying cash for controlled substances, analgesic drugs, or psychotropic drugs in addition to the use of the eligibility card to obtain similar or duplicative controlled substances.
F. Individual restriction procedures.
1. DMAS shall advise affected individuals by written notice of the proposed restriction under the CMM Program for individuals. Written notice shall include an explanation of restriction procedures and the individual's right to appeal the proposed action.
2. The individual shall have the opportunity to select a designated physician or pharmacy, or both. If an individual fails to respond by the date specified in the restriction notice, DMAS shall select a designated physician or pharmacy, or both.
3. DMAS shall not implement restriction if a valid appeal, consistent with 12VAC30-110-210, is noted. (See subsection K of this section.)
4. DMAS shall restrict individuals to their designated physician or pharmacy, or both, for 24 months.
G. Designated providers.
1. A designated physician or pharmacy, or both, must be a provider that is enrolled in Virginia Medicaid and that is unrestricted by DMAS. Providers who are restricted pursuant to 12VAC30-130-820 D and E shall not serve as designated providers for restricted individuals and shall not serve as referral or covering providers for restricted individuals.
2. Physicians or pharmacy providers, or both, who are under the CMM Program for providers shall not serve as designated providers, shall not provide services through referral, and shall not serve as covering providers for restricted individuals.
3. Physicians with practices limited to the delivery of emergency room services may not serve as designated primary providers.
4. Other physicians or pharmacies, or both, may be established as designated providers as needed but only with the approval of DMAS.
H. Provider reimbursement.
1. DMAS shall reimburse for covered medical or pharmaceutical services, or both, and physician services for restricted individuals only when they are provided by the designated providers, or by physicians seen on a written referral from the designated PCP, or in a medical emergency consistent with the methodologies established for such services in the State Plan for Medical Assistance.
2. DMAS shall require a written referral, in accordance with published procedures, from the designated PCP for payment of covered outpatient services by nondesignated practitioners unless there is a medical emergency requiring immediate hospital treatment. Services exempt from these written referral requirements include:
a. Family planning services;
b. Annual or routine vision examinations for individuals under the age of 21 years;
c. Dental services for individuals under the age of 21 years;
d. Emergency services;
e. EPSDT well-child exams/screenings for individuals under the age of 21 years;
f. Immunizations for individuals under the age of 21 years;
g. Home and community-based care services such as private duty nursing or respite services;
h. Renal dialysis services;
i. Expanded prenatal services, including prenatal group education, nutrition services, and homemaker services for pregnant women and care coordination for high-risk pregnant women and infants up to age two years; and
j. Hospice services.
3. Designated primary care providers (PCPs) shall receive a monthly case management fee for each assigned individual.
I. Changes in designated providers.
1. DMAS must give prior approval to all changes of designated providers.
2. The individual or the designated provider may initiate requests for change for the following reasons:
a. Relocation of the individual or provider.
b. Inability of the provider to meet the routine health or pharmaceutical needs of the individual.
c. Breakdown of the individual/provider relationship.
3. If the designated provider initiates the request and the individual does not select a new physician or pharmacy, or both, by established deadlines, DMAS shall select a provider, subject to concurrence from the provider or providers.
4. If DMAS denies the individual's request for a particular physician or pharmacy, or both, the individual shall be notified in writing and given the right to appeal the decision. (See subsection K of this section.)
J. Review of individual restriction status.
1. During the restriction period, DMAS shall monitor an individual's utilization no less frequently than every 12 months and follow up with the individual to promote appropriate utilization patterns.
2. DMAS shall also review an individual's utilization prior to the end of the restriction period to determine restriction termination or continuation.
a. DMAS shall extend utilization control restrictions for 12 months if any one of the following conditions is identified:
(1) The individual's utilization patterns include one or more conditions listed in subsection E of this section.
(2) The individual has not complied with procedures of the CMM Program for individuals resulting in services or medications received from any nondesignated provider, as demonstrated by his submitted claims, without a written referral or in the absence of a medical emergency.
(3) The individual has not complied with procedures of the CMM Program for individuals as demonstrated by a pattern of documented attempts to receive medications from any nondesignated pharmacy (i) in the absence of a medical emergency, (ii) when the designated pharmacy is closed, (iii) when the designated pharmacy does not stock the required medication, or (iv) when the designated pharmacy is unable to obtain the required medication in a timely manner.
(4) One or more of the designated providers recommends continued restriction status because the individual has demonstrated noncompliant behavior which is being controlled by restrictions within the CMM Program for individuals.
(5) Any changes of designated provider have been made due to the breakdown of the individual/provider relationship as a result of the individual's noncompliance.
b. DMAS shall notify the individual and designated physician or pharmacy, or both, in writing of the review decision. If restrictions are continued, written notice shall include the individual's right to appeal the proposed action. (See subsection K of this section.)
c. DMAS shall not implement the continued individual restriction if a valid appeal is noted pending the completion of the appeal action. Should the outcome of the appeal action support implementation of the restriction, the restriction shall be promptly implemented.
K. Individual appeals.
1. Individuals shall have the right to appeal any action, as defined in 42 CFR 431.201, that is taken by DMAS under this part.
2. Individual appeals shall be held pursuant to the provisions of Part I (12VAC30-110-10 et seq.) of 12VAC30-110, Eligibility and Appeals.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.3 § 2, eff. January 1, 1993; amended, Virginia Register Volume 14, Issue 10, eff. March 4, 1998; Volume 32, Issue 4, eff. December 3, 2015.
12VAC30-130-820. Client Medical Management Program for providers.
A. Purpose. The CMM Program for providers is a utilization control program designed to promote improved and cost-efficient medical management of essential health care.
B. Authority.
1. Federal regulations at 42 CFR 456.3 require the Medicaid agency to implement a statewide surveillance and utilization control program and at 42 CFR 455.1 through 455.16 require the Medicaid agency to conduct investigations of abuse by providers.
2. Federal regulations at 42 CFR 431.54(f) allow states to restrict providers' participation in the Medicaid program if the agency finds that providers of items or services under the State Plan have provided items or services at a frequency or amount not medically necessary in accordance with utilization guidelines established by the state or have provided items or services of a quality that do not meet professionally recognized standards of health care.
C. Identification of participants for inclusion in the CMM Program for providers. DMAS shall identify providers for review through computerized reports such as but not limited to JSURS, Oracle, VAMMIS, or by written referrals from agencies, health care professionals, or other individuals.
D. Provider evaluation for restriction.
1. DMAS shall review providers to determine if health care services are being provided at a frequency or amount that is not medically necessary or that are not of a quality to meet professionally recognized standards of health care. Evaluation of utilization patterns can include but is not limited to review by the department of medical records or computerized reports generated by the department reflecting claims submitted for physician visits, drugs or prescriptions, outpatient and emergency room visits, lab or diagnostic procedures, hospital admissions, and referrals.
2. DMAS may restrict providers if any one or more of the following conditions is identified in a significant number or proportion of cases. These conditions include but shall not be limited to the following:
a. Visits billed at a frequency or level exceeding that which is medically necessary;
b. Diagnostic tests billed in excess of what is medically necessary;
c. Diagnostic tests billed which are unrelated to the diagnosis;
d. Medications prescribed or prescriptions dispensed in excess of recommended dosages;
e. Medications prescribed or prescriptions dispensed unrelated to the diagnosis; or
f. The provider's license to practice in any state has been revoked or suspended.
E. Provider restriction procedures.
1. DMAS shall advise affected providers by written notice of the proposed restriction under the CMM Program for providers. Written notice shall include an explanation of the basis for the decision, request for additional documentation, if any, and notification of the provider's right to appeal the proposed action.
2. DMAS shall restrict providers from being the designated provider, a referral provider, or a covering provider for individuals in the CMM Program for providers for 24 months.
3. DMAS shall notify the Centers for Medicare and Medicaid Services (CMS) and the general public of the restriction and its duration.
4. DMAS shall not implement provider restriction if a valid appeal is noted.
F. Review of provider restriction status.
1. DMAS shall review a restricted provider's claims history record prior to the end of the restriction period to determine restriction termination or continuation (See subsection D of this section). DMAS shall extend provider restriction for 24 months in one or more of the following situations:
a. Where abuse by the provider is identified.
b. Where the practices which led to restriction continue.
2. In cases where the provider has submitted an insufficient number of claims during the restriction period to enable DMAS to conduct a claims history review, DMAS shall continue restriction until a reviewable six-month claims history is available for evaluation.
3. If DMAS continues restriction following the review, the provider shall be notified of the agency's proposed action, the basis for the action, and appeal rights. (See subsection E of this section).
4. If the provider continues a pattern of inappropriate health care services, DMAS may make a referral to the appropriate peer review group or regulatory agency for recommendation and action as appropriate.
G. Provider appeals.
1. Providers shall have the right to appeal any action taken by the department under this part pursuant to § 32.1-325.1 of the Code of Virginia.
2. Provider appeals shall be held pursuant to the provisions of Article 3 (§ 2.2-4018 et seq.) of the Administrative Process Act.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.3 § 3, eff. January 1, 1993; amended, Virginia Register Volume 14, Issue 10, eff. March 4, 1998; Volume 25, Issue 14, eff. April 15, 2009; Volume 32, Issue 4, eff. December 3, 2015.
Part XIV
Residential Psychiatric Treatment for Children and Adolescents (Repealed)
12VAC30-130-850. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 33, Issue 12, eff. March 8, 2017; repealed, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.
12VAC30-130-860. (Repealed.)
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 22, Issue 8, eff. January 25, 2006; repealed, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.
12VAC30-130-870. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 22, Issue 8, eff. January 25, 2006; repealed, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.
12VAC30-130-880. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; Errata, 17:6 VA.R. 932 December 4, 2000; amended, Virginia Register Volume 22, Issue 8, eff. January 25, 2006; repealed, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.
12VAC30-130-890. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 22, Issue 8, eff. January 25, 2006; Volume 25, Issue 14, eff. April 15, 2009; Volume 33, Issue 12, eff. March 8, 2017; repealed, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.
Part XV
Case Management Treatment Foster Care Services
12VAC30-130-900. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context indicates otherwise:
"Case management" means an activity that assists Medicaid eligibles in gaining and coordinating access to necessary care and services appropriate to his needs.
"Child" means any individual less than 18 years of age or under 21 if placed by a local department of social services or through referral from a Family Assessment and Planning Team.
"Child's family" means the birth or adoptive parent or parents, legal guardian or guardians, or family to whom the child may return.
"Child placing agency," "agency" or "agencies" means any person who places children in foster homes, adoptive homes, child-caring institutions or independent living arrangements in response to §§ 63.1-204, 63.1-205, and 63.1-219.28 of the Code of Virginia or a local board of public welfare or social services that places children in foster homes or adoptive homes pursuant to §§ 63.1-56, 63.1-204, and 63.1-219.28 of the Code of Virginia. Officers, employees, or agents of the Commonwealth, or of any county, city, or town, acting within the scope of their authority as such, who serve as or maintain a child-placing agency shall not be required to be licensed if authorized by the Code of Virginia to provide the services of a child-placing agency.
"Client" means Medicaid-eligible and enrolled individual.
"Community Planning and Management Team" means a team described in § 2.1-750 of the Code of Virginia.
"Comprehensive Services Act" means § 2.1-745 et seq. of the Code of Virginia.
"Department" or "DMAS" means the Department of Medical Assistance Services.
"Family Assessment and Planning Team" means a team described in §§ 2.1-753, 2.1-754, and 2.1-755 of the Code of Virginia.
"Foster care placement" means placement of a child through (i) an agreement between the parents or guardians and the local board or the public agency designated by the community policy and management team where legal custody remains with the parents or guardians or (ii) an entrustment or commitment of the child to the local board or child-placing agency.
"Foster care services" means the provision of a full range of casework, treatment and community services for a planned period of time to a child under age 21 who is abused or neglected as defined, except for age, in § 63.1-248.2 of the Code of Virginia or in need of services as defined in § 16.1-228 of the Code of Virginia and to his family when the child (i) has been identified as needing services to prevent or eliminate the need for foster care placement, (ii) has been placed through an agreement between the local board of social services or the public agency designated by the community policy and management team and the parents or guardians, and (iii) has been committed or entrusted to a local board of social services or child-placing agency.
"Foster home" means the place of residence of any individual or individuals approved by a local department of social services or licensed child placing agency in which any child other than a child by birth or adoption resides as a member of the household.
"Initial plan of care" means a written plan that delineates the services that are to be provided to the child at admission.
"Records" means the written information assembled in a file relating to the agency, staff, volunteers, the child, the child's birth family, the child's foster family, the child's treatment foster family, and the child's adoptive family.
"Treatment" is the coordinated provision of services and use of professionally developed and supervised interventions designed to produce a planned outcome in a person's behavior, attitude, emotional functioning or general condition.
"Treatment and service plan" means a written comprehensive plan of care, based on an assessment of the medical, psychological, social, behavioral and developmental aspects of the child's situation, containing measurable goals, procedures and interventions for achieving them, and a process for assessing the results. The treatment plan must state the treatment objectives; prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; and must include coordination with related community services to ensure continuity of care with the child's family, school and community.
"Treatment foster care (TFC)" means a community-based program where services are designed to address the special needs of children. Services to the children are delivered primarily by treatment foster parents who are trained, supervised, and supported by agency staff. Treatment is primarily foster family based and is planned and delivered by a treatment team.
Treatment foster care focuses on a continuity of services, is goal-directed and results oriented, and emphasizes permanency planning for the child in care.
"Treatment team" means the group that may consist of the child, professional agency staff, other professionals, the child's family members (where appropriate), and the child-placing agency and treatment foster parents who provide mutual support, evaluate treatment, and design, implement and revise the treatment and service plan.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 23, Issue 12, eff. March 21, 2007.
12VAC30-130-910. Targeted case management for foster care children in treatment foster care (TFC) covered services.
Service description. Case management is a component of TFC through which a case manager monitors the treatment plan and links the child to other community resources as necessary to address the special identified needs of the child. Services to the children shall be delivered primarily by treatment foster parents who are trained, supervised and supported by professional child-placing agency staff. TFC case management focuses on a continuity of services, is goal directed and results oriented. Services shall not include room and board. The following activities are considered covered services related to TFC case management services:
1. Care planning, monitoring of the plan of care, and discharge planning;
2. Case management; and
3. Evaluation of the effectiveness of the child's plan of treatment.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 23, Issue 12, eff. March 21, 2007; Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-130-920. Provider qualifications.
A. License or certification. Treatment foster care case management shall be provided by child-placing agencies with treatment foster care programs that are licensed or certified by the Virginia Department of Social Services to be in compliance with the Minimum Standards for Licensed Child-Placing Agencies (22VAC40-130-10 et seq.) and meet the provider qualifications for treatment foster care set forth in this part.
B. Caseload size.
1. The treatment foster care case manager shall have a maximum of 12 children in his caseload for a full-time professional staff person. The caseload shall be adjusted downward if:
a. The caseworker's job responsibilities exceed those listed in the agency's job description for a caseworker, as determined by the supervisor; or
b. The difficulty of the client population served requires more intensive supervision and training of the treatment foster parents.
c. Exception: A caseworker may have a maximum caseload of 15 children as long as not more than 10 of the children are in treatment foster care and the above criteria for adjusting the caseload downward do not apply.
2. There shall be a maximum of six children in the caseload for a beginning trainee that may be increased to nine by the end of the first year and 12 by the end of the second year.
3. There shall be a maximum of three children in a caseload for a student intern if any student intern works in the agency.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001.
12VAC30-130-930. Organization and administration requirements.
A. These standards shall be met by any enrolled provider signing an agreement with DMAS to provide case management services to children in treatment foster care.
B. A Medicaid enrolled treatment foster care case management provider must be licensed by the Department of Social Services (DSS) as a child-placing agency with treatment foster care as defined in this part or shall be certified by DSS as designated by DMAS to meet all the requirements of this part. Officers, employees, or agents of the Commonwealth, or of any county, city, or town acting within the scope of their authority as such, who serve as or maintain a child-placing agency shall not be required to be licensed but shall be required to be certified to meet all the requirements of this part by the DSS.
C. Treatment and service plans in treatment foster care.
1. The treatment foster care case management provider shall prepare and implement an individualized treatment and service plan for each child in its care. When available, the parents shall be consulted unless parental rights have been terminated. If the parents cannot be consulted, the agency shall document the reason in the child's record.
2. When the treatment foster care case management provider holds custody of the child, a service plan shall be filed with the court within 60 days after the agency receives custody unless the court grants an additional 60 days, or the child is returned home or placed for adoption within 60 days. Providers with legal custody of the child shall follow the requirements of §§ 16.1-281 and 16.1-282 of the Code of Virginia.
3. The permanency planning goals and the requirements and procedures in the Department of Social Services Service Programs Manual, Volume VII, Section III, Chapter B, "Preparing the Initial Service Plan" may be consulted.
4. The initial plan of care for services to the child must be developed within two weeks of placement.
5. Comprehensive treatment and service plan. The case manager and other designated child-placing agency staff shall develop and implement for each child in care an individualized comprehensive treatment and service plan within the first 45 days of placement that shall include:
a. A comprehensive assessment of the child's emotional, behavioral, educational, nutritional, and medical needs;
b. The treatment goals and objectives including the child's specific problems, behaviors and skills to be addressed, the criteria for achievement and target dates for each goal and objective;
c. The treatment foster care case management provider's program of therapies, activities and services, including the specific methods of intervention and strategies designed to meet the above goals and objectives, and describing how the provider is working with related community resources, including the child's primary care physician, to provide a continuity of care;
d. The discharge goals and objectives, services to be provided for their achievement, and plans for reunification of the child and the child's family, where appropriate. Unless specifically prohibited by court order, foster children shall have access to regular contact with their families.
e. The target date for discharge from treatment foster care case management;
f. For children age 16 and over, the plan shall include a description of the programs and services that will help the child transition from foster care to independent living; and
g. The dated signature of the case manager and the identity of all members of the treatment team that participated in the plan's development.
6. The case manager shall include and work with the child, the custodial agency, the treatment foster parents and the parents, where appropriate, in the development of the treatment and service plan and a copy shall be provided to the custodial agency. A copy shall be provided to the treatment foster parents as long as confidential information about the child's birth family is not revealed. A copy shall be provided to the parents, if appropriate, as long as confidential information about the treatment foster parents is not revealed. If any of these parties do not participate in the development of the treatment and service plan, the case manager shall document the reasons in the child's record.
7. The case manager shall provide support and guidance to foster families in implementing the treatment and service plan for the child.
D. Progress report and ongoing services plans.
1. The case manager shall complete written progress reports beginning 90 days after the date of the child's placement and every 90 days thereafter.
2. The progress report shall specify the time period covered and include:
a. Progress on the child's specific problems and behaviors and any changes in the methods of intervention and strategies to be implemented:
(1) Description of the treatment goals and objectives met, goals and objectives to be continued or added, the criteria for achievement and target dates for each goal and objective;
(2) Description of the therapies, activities, and services provided during the previous 90 days toward the treatment goals and objectives; and
(3) Any changes needed for the next 90 days;
b. Services provided during the last 90 days towards the discharge goals, any changes in these goals, the criteria for achievement and target dates for each goal and objective, and services to be provided during the next 90 days;
c. The child's assessment of his progress and his description of services needed, where appropriate;
d. Contacts between the child and the child's family, where appropriate;
e. Medical needs, specifying medical treatment provided and still needed and medications provided;
f. An update to the discharge plans, including the projected discharge date; and
g. A description of the programs and services provided to children ages 16 and older to help the child transition from foster care to independent living, where appropriate.
3. Annually, the progress report shall address the above requirements as well as evaluate and update the comprehensive treatment and service plan for the upcoming year.
4. The case manager shall date and sign each progress report.
5. The case manager shall include each child who has the ability to understand in the preparation of the child's treatment and service plans and progress reports or document the reasons this was not possible. The child's comments shall be recorded in the report.
6. The case manager shall include and work with the child, the treatment foster parents, the custodial agency and the parents, where appropriate, in the development of the progress report. A copy shall be provided to the placing agency worker and, if appropriate, to the treatment foster parents.
E. Contacts with child.
1. There shall be face-to-face contact between the case manager and the child, based upon the child's treatment and service plan and as often as necessary to ensure that the child is receiving safe and effective services.
2. Face-to-face contacts shall be no less than twice a month, one of which shall be in the foster home. One of the contacts shall include the child and at least one treatment foster parent and shall assess the relationship between the child and the treatment foster parents.
3. The contacts shall assess the child's progress, provide training and guidance to the treatment foster parents, monitor service delivery, and allow the child to communicate concerns.
4. A description of all contacts shall be documented in the narrative.
5. Children who are able to communicate shall be interviewed privately at least once a month.
6. Unless specifically prohibited by court or custodial agency, foster children shall have access to regular contact with their families as described in the treatment and service plan.
7. The case manager shall work actively to support and enhance child/family relationships and work directly with the child's family toward discharge as specified in the treatment and service plan.
8. The case manager shall record all medications prescribed for each child and all reported side effects or adverse reactions.
F. Professional clinical or consultative services. In consultation with the custodial agency, the case manager or caseworker shall provide or arrange for a child to receive psychiatric, psychological, and other clinical services if the need for them has been recommended or identified.
G. Narratives in the child's record. Narratives shall be in chronological order and current within 30 days. Narratives shall include areas specified in this part and shall cover:
1. Treatment and services provided;
2. All contacts related to the child;
3. Visitation between the child and the child's family; and
4. Other significant events.
H. Treatment teams in treatment foster care.
1. The treatment foster care case management provider shall ensure that a professional staff person provides leadership to the treatment team that includes:
a. Managing team decision making regarding the care and treatment of the child and services to the child's family;
b. Providing information and training as needed to treatment team members; and
c. Involving the child and the child's family in treatment team meetings, plans, and decisions, and keeping them informed of the child's progress, whenever possible.
2. Treatment team members shall consult as often as necessary, but at least on a quarterly basis.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001; amended, Virginia Register Volume 23, Issue 12, eff. March 21, 2007.
12VAC30-130-940. Discharge from care.
A. A discharge summary shall be developed for each child and placed in the child's record within 30 days of discharge. It shall include the date of and reason for discharge, the name of the person with whom the child was placed or to whom he was discharged, and a description of the services provided to the child and progress made while the child was in care. Written recommendations for aftercare shall be made for each child prior to the child's discharge. Such recommendations shall specify the nature, frequency, and duration of aftercare services to be provided to the child and the child's family.
B. The summary shall also include an evaluation of the progress made toward the child's treatment goals.
C. Discharge planning shall be developed with the treatment team and with the child, the child's parents or guardian, and the custodial agency.
D. Children in the custody of a local department of social services or private child-placing agency shall not be discharged without the knowledge, consultation, and notification of the custodial agency.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001.
12VAC30-130-950. Entries in case records.
All entries shall be dated and shall identify the individual who performed the service. If a treatment foster care case management provider has offices in more than one location, the record shall identify the office that provided the service. Each child's record shall contain documentation that verifies the services rendered for billing.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 17, Issue 5, eff. January 1, 2001.
Part XVI
Pharmacy Services Prior Authorization
12VAC30-130-1000. Pharmacy services prior authorization.
A. Definitions. The following words and terms used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Contractor" means an independent contractor that implements and administers, pursuant to its contract, the department's pharmacy prior authorization programs as set out in the Title XIX State Plan.
"Grandfather clause" means procedure by which selected therapeutic classes or drugs as designated by the P&T Committee may be automatically approved if the patient is currently and appropriately receiving the drug.
"Pharmacy and Therapeutics Committee," "P&T Committee" or "committee" means the committee formulated to review therapeutic classes, conduct clinical reviews of specific drugs, recommend additions or deletions to the preferred drug list, and perform other functions as required by the department. The Pharmacy and Therapeutics Committee shall be composed of eight to 12 members, including the Commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services, or his designee. Other members shall be selected or approved by the department. The membership shall include a ratio of physicians to pharmacists of 2:1. Physicians on the committee shall be licensed in Virginia, one of whom shall be a psychiatrist, and one of whom specializes in care for the aging. Pharmacists on the committee shall be licensed in Virginia, one of whom shall have clinical expertise in mental health drugs, and one of whom has clinical expertise in community-based mental health treatment.
B. DMAS shall operate, in conjunction with the Title XIX State Plan for Medical Assistance (12VAC30-50-210 et seq.), a program of prior authorization of pharmacy services. This program shall include, but not necessarily be limited to, the use of a preferred drug list.
C. Medicaid Pharmacy and Therapeutics Committee.
1. The department shall utilize a Pharmacy and Therapeutics Committee to assist in the development and ongoing administration of the preferred drug list and other pharmacy program issues. The committee may adopt bylaws that set out its make up and functioning. A quorum for action of the committee shall consist of seven members.
2. Vacancies on the committee shall be filled in the same manner as original appointments. The department shall appoint individuals for the committee that assures a cross-section of the physician and pharmacy community.
3. Duties of the committee.
a. The committee shall receive and review clinical and pricing data related to the drug classes. The committee's medical and pharmacy experts shall make recommendations to DMAS regarding various aspects of the pharmacy program. For the PDL program, the committee shall select those drugs to be deemed preferred that are safe and clinically effective, as supported by available clinical data, and meet pricing standards.
b. Cost effectiveness or any pricing standard shall be considered only after a drug is determined to be safe and clinically effective. The committee shall recommend to the department:
(1) Which therapeutic classes of drugs should be subject to the preferred drug list program and prior authorization requirements;
(2) Specific drugs within each therapeutic class to be included on the preferred drug list;
(3) Appropriate exclusions for medications, including atypical anti-psychotics, used for the treatment of serious mental illnesses such as bi-polar disorders, schizophrenia, and depression;
(4) Appropriate exclusions for medications used for the treatment of certain brain disorders, cancer and HIV-related conditions;
(5) Appropriate exclusions for therapeutic classes in which there is only one drug in the therapeutic class or there is very low utilization, or for which it is not cost effective to include in the preferred drug list program;
(6) Appropriate grandfather clauses when prior authorization would interfere with established complex drug regimens that have proven to be clinically effective;
(7) Other clinical criteria that may be included in the pharmacy program; and
(8) Guidance and recommendations regarding the department's pharmacy programs.
c. As the United States Food and Drug Administration (FDA) approves new drug products, the department shall ensure that the Pharmacy and Therapeutics Committee will evaluate the drug for clinical effectiveness and safety. Based on clinical information and pricing standards, the P&T Committee will determine if the drug will be included in the PDL or require prior authorization.
(1) If the new drug product falls within a drug class previously reviewed by the P&T Committee, until the review of the new legend drug is completed, it will be classified as nonpreferred, requiring prior authorization in order to be dispensed. The new legend drug will be evaluated for inclusion in the PDL no later than at the next review of the drug class.
(2) If the new drug product does not fall within a drug class previously reviewed by the P&T Committee, the new drug shall be treated in the same manner as the other drugs in its class.
d. To the extent feasible, the P&T Committee shall review all drug classes included in the PDL at least every 12 months and may recommend additions to and deletions from the PDL.
D. Pharmacy contractor. The department may contract for pharmaceutical benefit management services to manage, implement and administer the Medicaid pharmacy benefits preferred drug list, as directed, authorized, and as may be amended from time to time, by DMAS.
1. The department, as the sole Title XIX authority for the Commonwealth, shall retain final administrative authority over all pharmacy services.
2. The department shall not offer or pay directly or indirectly any material inducement, bonus, or other financial incentive to a program contractor based on the denial or administrative delay of medically appropriate prescription drug therapy, or on the decreased use of a particular drug or class of drugs, or a reduction in the proportion of beneficiaries who receive prescription drug therapy under the Medicaid program. Bonuses shall not be based on the percentage of cost savings generated under the benefit management of services.
E. Supplemental rebates. The department shall have the authority to seek supplemental rebates from drug manufacturers. The contract regarding supplemental rebates shall exist between the manufacturer and the Commonwealth. Rebate agreements between the Commonwealth and a pharmaceutical manufacturer shall be separate from the federal rebates and in compliance with federal law, §§ 1927(a)(1) and 1927(a)(4) of the Social Security Act. All rebates collected on behalf of the Commonwealth shall be collected for the sole benefit of the state share of costs. One hundred percent (100%) of the supplemental rebates collected on behalf of the state shall be remitted to the state. Supplemental drug rebates received by the Commonwealth in excess of those required under the national drug rebate agreement will be shared with the federal government on the same percentage basis as applied under the national drug rebate agreement.
F. Appeals. The department shall provide an expedient reconsideration process and initiate and fully participate in the DMAS' appeal process pursuant to 12VAC30-110, Part I, Client Appeals, for providers and recipients.
G. Annual report. The department shall report to the Governor and the Chairmen of the House Appropriations and Senate Finance Committees on an annual basis.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia; Item 325 ZZ of Chapter 1042 of the 2003 Acts of Assembly.
Historical Notes
Derived from Virginia Register Volume 21, Issue 6, eff. January 3, 2005.
Part XVII
Marketing of Provider Services
12VAC30-130-2000. Marketing requirements and restrictions.
A. Purpose. The purpose of these rules shall be to define how providers shall be permitted to market their services to potential Medicaid or FAMIS beneficiaries and individuals who may or may not be currently enrolled with the particular provider. This shall apply to providers of community mental health services (12VAC30-50-226) and Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) community mental health services (12VAC30-50-130) with the exception of Part C services.
B. Definitions.
"Beneficiaries" means individuals of any age and their families who are using or who may use community mental health rehabilitative services.
"DMAS" means the Department of Medical Assistance Services.
"FAMIS" means Family Access to Medical Insurance Security.
"Marketing materials" means any material created to promote services through any media including written materials, television, radio, websites, and social media.
"Provider" means an individual or organizational entity that is appropriately licensed as required and enrolled as a DMAS provider of community mental health and substance abuse services.
C. Requirements.
1. Marketing and promotional activities (including provider promotional activities) shall comply with all applicable federal and state laws.
2. Providers shall provide clearly written materials that completely and accurately describe the Medicaid or FAMIS behavioral health services offered, the beneficiary eligibility requirements to receive the services, applicable fees and other charges, and all other information required for beneficiaries and their families to make fully informed decisions about enrollment into the services offered by the provider that is marketing its services.
3. Providers shall distribute their marketing materials only in the service locations approved within the license issued by the Licensing Division of the Department of Behavioral Health and Developmental Services.
D. Limits and prohibitions.
1. Providers shall not offer cash or noncash incentives to their enrolled or prospective members for the purposes of marketing, retaining beneficiaries within the providers' services, or rewarding behavior changes in compliance with goals and objectives stated in beneficiaries' individual service plans.
2. While engaging in marketing activities, providers shall not:
a. Engage in any marketing activities that could misrepresent the service or DMAS;
b. Assert or state that the beneficiary must enroll with the provider in order to prevent the loss of Medicaid or FAMIS benefits;
c. Conduct door-to-door, telephone, unsolicited school presentations, or other cold call marketing directed at potential or current beneficiaries;
d. Conduct any marketing activities or use marketing materials that are not specifically approved by DMAS;
e. Make home visits for direct or indirect marketing or enrollment activities except when specifically requested by the beneficiary or family;
f. Collect or use Medicaid or FAMIS confidential information or Medicaid or FAMIS protected health information (PHI), as that term is defined in Health Insurance Portability and Accountability Act of 1996 (HIPAA), that may be either provided by another entity or obtained by marketing provider, to identify and market services to prospective beneficiaries;
g. Violate the confidential information or confidentiality of PHI by sharing or selling lists of information about beneficiaries for any purposes other than the performance of the provider's obligations relative to its DMAS provider agreement;
h. Contact, after the effective date of disenrollment, beneficiaries who choose to disenroll from the provider except as may be specifically required by DMAS;
i. Conduct service assessment or enrollment activities at any marketing or community event; or
j. Assert or state (either orally or in writing) that the provider is endorsed either by the Centers for Medicare and Medicaid Services, DMAS, or any other federal or state governmental entities.
E. Termination. Providers that (i) violate any of the prohibitions in this section or (ii) fail to meet requirements shall be subject to termination of their provider agreements for the services affected by the marketing plan or activity. Providers whose contracts are terminated shall be afforded the right of appeal pursuant to the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).
Statutory Authority
§32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from Virginia Register Volume 31, Issue 9, eff. January 30, 2015; amended, Virginia Register Volume 35, Issue 22, eff. August 8, 2019.
12VAC30-130-3000. (Repealed.)
(Repeal)
Historical Notes
Derived from Virginia Register Volume 31, Issue 9, eff. January 30, 2015; repealed, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.
12VAC30-130-3010. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 31, Issue 9, eff. January 30, 2015; repealed, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.
12VAC30-130-3020. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 31, Issue 9, eff. January 30, 2015; repealed, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.
12VAC30-130-3030. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 31, Issue 9, eff. January 30, 2015; repealed, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.
Part XX
Addiction and Recovery Treatment Services
12VAC30-130-5000. Addiction and recovery treatment services.
The services provided for in this part shall be known as either addiction and recovery treatment services or substance use disorder services.
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.
12VAC30-130-5010. Addiction and recovery treatment services; purpose.
The purpose of this part shall be to establish coverage of treatment for substance use disorders as defined in the American Society of Addiction Medicine (ASAM) Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, Third Edition, as published by the American Society of Addiction Medicine including outpatient physician, nurse practitioner, and clinic services that include evidence-based medication assisted treatment, intensive outpatient services, partial hospitalization services, residential treatment services, and inpatient withdrawal management services as defined in 12VAC30-130-5040 through 12VAC30-130-5150.
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.
12VAC30-130-5020. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Abstinence" means the intentional and consistent restraint from the pathological pursuit of reward or relief, or both, that involves the use of substances.
"Addiction" means a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction is defined as the inability to consistently abstain, impairment in behavioral control, persistence of cravings, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
"Addiction-credentialed physician" means a physician who holds a board certification in addiction medicine from the American Board of Addiction Medicine, a subspecialty board certification in addition to certification in psychiatry from the American Board of Psychiatry and Neurology, or subspecialty board certification in addiction medicine from the American Osteopathic Association. DMAS also recognizes physicians treating addiction who have specialty training or experience in addiction medicine or addiction psychiatry. If treating adolescents, "addiction-credentialed physician" means an addiction-credentialed physician who also has experience and specialty training with adolescent medicine.
"Adherence" means the individual receiving treatment has demonstrated ability to cooperate with, follow, and take personal responsibility for the implementation of treatment plans.
"Adolescent" means an individual from 12 years of age to 20 years of age.
"Allied health professional" means counselor aides or group living workers who meet the DBHDS licensing requirements for unlicensed staff in residential settings.
"ARTS" means addiction and recovery treatment services.
"ARTS care coordinator" means an employee of DMAS, its contractor, or an MCO who is a licensed practitioner of the healing arts, including a physician or medical director, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed substance abuse treatment practitioner, licensed marriage and family therapist, nurse practitioner, or registered nurse with two years of clinical experience in the treatment of substance use disorders. The ARTS care coordinator performs independent assessments of requests for all ARTS intensive outpatient programs (ASAM Level 2.1); partial hospitalization programs (ASAM Level 2.5); residential treatment services (ASAM Levels 3.1, 3.3, 3.5, and 3.7); and inpatient services (ASAM Levels 3.7 and 4.0).
"ASAM" means the American Society of Addiction Medicine.
"ASAM criteria" means the six different life areas used by the ASAM Patient Placement Criteria to develop a holistic biopsychosocial assessment of an individual that is used for service planning, level of care, and length of stay treatment decisions.
"BHA" means behavioral health authority.
"Biomedical" means biological or physical aspects of a member's condition that require assessment and services that are delivered by appropriately credentialed medical staff, who are available to assess and treat co-occurring biomedical disorders that may be the result of, or independent of, a substance use disorder.
"Care coordination" means collaboration and sharing of information among health care providers who are involved with an individual's health care to assist in improving the care of the individual. This includes e-consultations from primary care providers to specialists.
"Certified substance abuse counselor" or "CSAC" means the same as that term is defined in § 54.1-3507.1 of the Code of Virginia.
"Certified substance abuse counseling assistant" or "CSAC-A" means the same as that term is defined in § 54.1-3507.2 of the Code of Virginia.
"Certified substance abuse counselor-supervisee" means an individual who has completed the educational requirements described in clause (i) of § 54.1-3507.1 C of the Code of Virginia, but who has not completed the practice hours described in clause (ii) of § 54.1-3507.1 C of the Code of Virginia.
"Child" means an individual from birth to 12 years of age.
"Clinical experience" means, for the purpose of these ARTS requirements, practical experience in providing direct services to individuals with diagnoses of substance use disorder. Clinical experience shall include supervised internships, supervised practicums, or supervised field experience. Clinical experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience.
"Counseling" means the same as that term is defined in § 54.1-3500 of the Code of Virginia.
"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) physician extenders with experience or training in addiction medicine; (iii) a licensed psychiatrist; (iv) a licensed clinical psychologist; (v) a licensed clinical social worker; (vi) a licensed professional counselor; (vii) a certified psychiatric clinical nurse specialist; (viii) a licensed psychiatric nurse practitioner; (ix) a licensed marriage and family therapist; (x) a licensed substance abuse treatment practitioner; (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 is registered with the Virginia Board of Counseling; (xii) a resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology (18VAC125-20-10); or (xiii) a supervisee in social work who is under the supervision of a licensed clinical social worker and is registered with the Virginia Board of Social Work (18VAC140-20-10).
"CSB" means community services board.
"DBHDS" means the Department of Behavioral Health and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.) of Title 37.2 of the Code of Virginia.
"DEA" means Drug Enforcement Administration.
"DMAS" means the Department of Medical Assistance Services and its contractors consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
"DSM-5" means the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric Association.
"Evidence-based" means an empirically supported clinical practice or intervention with a proven ability to produce positive outcomes.
"Face-to-face" means encounters that occur in person or through telemedicine.
"FQHC" means federally qualified health center.
"Individual" means the patient, client, beneficiary, or member who receives services set out in 12VAC30-130-5000 et seq. These terms are used interchangeably.
"Individual service plan" or "ISP" means an initial and comprehensive treatment plan that is regularly updated and specific to an individual's unique treatment needs as identified in the assessment. An ISP contains an individual's treatment or training needs, the individual's goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, and an individualized discharge plan that describes transition to other appropriate services. An individual is included in the development of the ISP, and the ISP is signed by the individual. If the individual is a minor, the ISP is also signed by the individual's parent or legal guardian. 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.
"Induction phase" means the medically monitored initiation of buprenorphine, buprenorphine and naloxone, naltrexone, or methadone treatment performed in a qualified practitioner's office or licensed OTP. The goal of the induction phase is to find the individual's ideal dose of buprenorphine, buprenorphine and naloxone, naltrexone, or methadone. The ideal dose minimizes both side effects and drug craving.
"Licensed practical nurse" means a professional who is licensed by the Commonwealth as a practical nurse or holds a multistate licensure privilege to practice practical nursing according to 18VAC90-19-80.
"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the Code of Virginia, which means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis that (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with, or employed by the health carrier.
"Medication assisted treatment" or "MAT" means the same as that term is defined in 42 CFR 8.2.
"Multidimensional assessment" or "assessment" means the individualized, person-centered biopsychosocial assessment performed face-to-face, in which the provider obtains comprehensive information from the individual, and family members and significant others as needed, including history of the present illness; family history; developmental history; alcohol, tobacco, and other drug use or addictive behavior history; personal or social history; legal history; psychiatric history; medical history; spiritual history as appropriate; review of systems; mental status exam; physical examination; formulation and diagnoses; survey of assets, vulnerabilities, and supports; and treatment recommendations. The ASAM multidimensional assessment is a theoretical framework for this individualized, person-centered assessment that includes the following dimensions: (i) acute intoxication or likelihood of withdrawal, or both; (ii) medical conditions and complications, both historical and current; (iii) emotional, behavioral, or cognitive status and any identified issues; (iv) an individual's readiness to change; (v) risks for relapse or continued use; and (vi) home environment. The level of care determination, ISP, and recovery strategies development may be based upon this multidimensional assessment.
"Opioid" means any psychoactive chemical that resembles morphine in pharmacological effects, including opiates and synthetic or semisynthetic agents that exert their effects by binding to highly selective receptors in the brain where morphine and endogenous opioids affect their actions.
"Opioid treatment program" or "OTP" means the same as that term is defined in 42 CFR 8.2.
"Opioid treatment services" or "OTS" means preferred office-based opioid treatment (OBOT) and OTPs that encompass a variety of pharmacological and nonpharmacological treatment modalities, including substance use disorder counseling and psychotherapy.
"Overdose" means the inadvertent or deliberate consumption of a dose of a chemical substance much larger than either habitually used by the individual or ordinarily used for treatment of an illness that is likely to result in a serious toxic reaction or death.
"Physician extenders" means licensed nurse practitioners as defined in § 54.1-3000 of the Code of Virginia and licensed physician assistants as defined in § 54.1-2900 of the Code of Virginia.
"Preferred office-based opioid treatment" or "preferred OBOT" means addiction treatment services for individuals with a primary opioid use disorder provided by physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, working in collaboration with CATPs providing psychotherapy and substance use disorder counseling in public and private practice settings.
"Program of assertive community treatment" or "PACT" means the same as that term is defined in 12VAC35-105-20.
"Psychoeducation" means (i) a specific form of education aimed at helping individuals who have a substance use disorder or mental illness and their family members or caregivers to access clear and concise information about substance use disorders or mental illness and (ii) a way of accessing and learning strategies to deal with substance use disorders or mental illness and its effects in order to design effective treatment plans and strategies.
"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, conditions, attitudes, and behaviors that are emotionally, intellectually, or socially ineffectual or maladaptive.
"Recovery" means a process of sustained effort that addresses the biological, psychological, social, and spiritual disturbances inherent in addiction and consistently pursues abstinence, behavior control, dealing with cravings, recognizing problems in one's behaviors and interpersonal relationships, and more effective coping with emotional responses leading to reversal of negative, self-defeating internal processes and behaviors and allowing healing of relationships with self and others. The concepts of humility, acceptance, and surrender are useful in this process.
"Registered nurse" or "RN" means the same as "professional nurse" is defined in § 54.1-3000 of the Code of Virginia.
"Relapse" means a process in which an individual who has established abstinence or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pursuit of reward or relief through the use of substances and other behaviors often leading to disengagement from recovery activities. Relapse can be triggered by exposure to (i) rewarding substances and behaviors, (ii) environmental cues to use, and (iii) emotional stressors that trigger heightened activity in brain stress circuits. The event of using or acting out is the latter part of the process, which can be prevented by early intervention.
"RHC" means rural health clinic.
"SBIRT" means screening, brief intervention, and referral to treatment. SBIRT services are an evidence-based and community-based practice designed to identify, reduce, and prevent problematic substance use disorders.
"Service authorization" means the process to approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by DMAS or its contractor, or an MCO prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS and DMAS contractor criteria for reimbursement. Service authorization does not guarantee payment for the service.
"Substance use care coordinator" means staff in an OTP or preferred OBOT setting who have:
1. At least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, or human services counseling, and at least either (i) one year of substance use disorder related direct experience or training or a combination of experience or training in providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience or training in working with individuals with co-occurring diagnoses of substance use disorder and mental illness;
2. Licensure by the Commonwealth as a registered nurse with at least either (i) one year of direct experience or training or a combination of experience and training in providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience or training or a combination of experience and training in working with individuals with co-occurring diagnoses of substance use disorder and mental illness; or
3. Certification as a CSAC or a CSAC-A.
"Substance use case management" means the same as set out in 12VAC30-50-491.
"Substance use disorder" or "SUD" means a substance-related addictive disorder, as defined in the DSM-5 with the exception of tobacco-related disorders and non-substance-related disorders, marked by a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use, is seeking treatment for the use of, or is in active recovery from the use of alcohol or other drugs despite significant related problems.
"Substance use disorder counseling" means the same as "substance abuse counseling" is defined in 18VAC115-30-10.
"Telemedicine" means 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.
"Tolerance" or "tolerate" means a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time.
"Withdrawal management" means services to assist an individual's withdrawal from the use of substances.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5030. Eligible individuals.
Children and adults who participate in Medicaid managed care plans and Medicaid fee for service and meet ASAM medical necessity criteria shall be eligible for ARTS.
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 34, Issue 10, eff. February 7, 2018; Volume 36, Issue 11, eff. March 5, 2020.
12VAC30-130-5040. Covered services: requirements; limits; standards.
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 (ii) be accurately reflected in provider medical record documentation and on 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. 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.
2. These ARTS services, with their service definitions, shall be covered in all levels of care: (i) medically managed intensive inpatient services (ASAM Level 4); (ii) substance use residential or inpatient services (ASAM Levels 3.1, 3.3, 3.5, and 3.7); (iii) substance use intensive outpatient and partial hospitalization programs (ASAM Levels 2.1 and 2.5); (iv) opioid treatment services (opioid treatment programs and preferred office-based opioid treatment); (v) substance use outpatient services (ASAM Level 1.0); (vi) early intervention services (ASAM Level 0.5); (vii) substance use care coordination; (viii) substance use case management services; and (ix) withdrawal management services, which shall be provided when medically necessary.
B. ARTS services shall be fully integrated with all physical health and behavioral health services for a complete continuum of care for all Medicaid individuals meeting the medical necessity criteria. In order to receive reimbursement for ARTS services, the individual shall be enrolled in Virginia Medicaid and shall meet the following medical necessity criteria:
1. The individual shall demonstrate at least one diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for substance-related and addictive disorders, with the exception of tobacco-related disorders and non-substance-related addictive disorders, marked by a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use, is seeking treatment for the use of, or is in active recovery from the use of alcohol or other drugs despite significant related problems. Individuals younger than 21 years of age may also qualify if they are assessed to be at risk for developing a substance use disorder.
2. The individual shall be assessed by a CATP or a CSAC under the supervision of a CATP who will determine if the individual meets the severity and intensity of treatment requirements for each service level defined by the most current version of the American Society of Addiction Medicine (ASAM) Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions (Third Edition, 2013). Medical necessity for ASAM levels of care shall be based on the outcome of the individual's documented multidimensional assessment.
3. For individuals younger than 21 years of age who do not meet the ASAM medical necessity criteria upon initial review, a second individualized review shall be conducted to determine if the individual needs medically necessary treatment under the early periodic screening diagnosis and treatment (EPSDT) benefit described in § 1905(a) of the Social Security Act to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening.
C. Determination of medical necessity based on ASAM criteria for addiction and recovery treatment services.
1. DMAS or its contractor shall employ or contract with licensed treatment professionals to apply the ASAM criteria to review and coordinate service needs when administering ARTS benefits.
2. The ARTS care coordinator or a licensed physician or medical director employed by DMAS or its contractor or an MCO shall perform an independent assessment of requests for all ARTS intensive outpatient services (ASAM Level 2.1), partial hospitalization services (ASAM Level 2.5), residential treatment services (ASAM Levels 3.1, 3.3, 3.5, and 3.7), and ARTS inpatient treatment services (ASAM Levels 3.7 and 4.0).
3. Length of treatment and service limits shall be determined by the ARTS care coordinator or a licensed physician or medical director employed by DMAS or its contractor or an MCO who is applying the ASAM criteria.
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.
12VAC30-130-5050. Covered services: clinic services - opioid treatment program services.
A. Settings for opioid treatment program (OTP) services. The agency-based OTP provider shall be licensed by DBHDS and contracted by DMAS or its contractor or an MCO. The staffing requirements for OTP providers shall follow the DBHDS licensing requirements set forth in 12VAC35-105-925 and in the DBHDS guidance document entitled "Opioid Medication Assisted Treatment License and Oversight" (March 2017). The interdisciplinary team shall include CATPs acting within the scope of practice in accordance to their professional regulatory board and state and federal requirements, including an addiction-credentialed physician as defined in 12VAC30-130-5020. OTP services are allowed simultaneously for members in other ASAM Levels, including 1.0 through 3.7 (excluding inpatient services). OTPs shall meet the service components, staff requirements, and risk management requirements.
B. OTP service components.
1. Linking the individual to psychological, medical, and psychiatric consultation as necessary to meet the individual's needs.
2. Access to emergency medical and psychiatric care through connections with more intensive levels of care.
3. Access to evaluation and ongoing primary care.
4. Ability to conduct or arrange for appropriate laboratory and toxicology tests including drug screenings, using either urine or blood serums.
5. Physicians who are available to evaluate and monitor (i) use of methadone, buprenorphine products, or naltrexone products and (ii) pharmacists and nurses to dispense and administer these medications and who follow the Board of Medicine guidance for treatment of individuals with buprenorphine for addiction.
6. Individualized, patient-centered assessment and treatment.
7. Ability to assess, order, administer, reassess, and regulate medication and dose levels appropriate to the individual; supervise withdrawal management from opioid analgesics, including methadone, buprenorphine products, or naltrexone products; and oversee and facilitate access to appropriate treatment for opioid use disorder.
8. Medication for other physical and mental health illness is provided as needed either on site or through collaboration with other providers.
9. Cognitive, behavioral, and other substance use disorder-focused psychotherapies and substance use disorder counseling by a CATP reflecting a variety of treatment approaches, provided to the individual on an individual, group, or family basis. CSACs and CSAC-supervisees are recognized to provide substance use disorder counseling in these settings as allowed within scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
10. Optional substance use care coordination that includes integrating behavioral health into primary care and specialty medical settings through interdisciplinary care planning and monitoring individual progress and tracking individual outcomes; supporting conversations between physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and behavioral health professionals to develop and monitor individualized treatment plans; linking individuals with community resources to facilitate referrals and respond to social service needs; and tracking and supporting individuals when they obtain medical, behavioral health, or social services outside the practice.
11. Provision of onsite screening or the ability to refer for screening for infectious diseases such as human immunodeficiency virus, hepatitis B and C, 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.
12. Onsite medication administration treatment during the induction phase, which must be provided by a physician, nurse practitioner, physician assistant, or registered nurse. Medication administration during the maintenance phase may be provided either by a registered nurse or licensed practical nurse.
13. Prescription of naloxone for each member receiving methadone, buprenorphine products, or naltrexone products.
14. Ability to provide pregnancy testing for women of childbearing age.
15. For individuals of childbearing age, the ability to provide family planning services or to refer the individual for family planning services.
C. OTP staff requirements.
1. Staff requirements shall meet the licensing requirements of 12VAC35-105-925. The interdisciplinary team shall include CATPs trained in the treatment of opioid use disorder, including an addiction credentialed physician or physician extender and CATPs as defined in 12VAC30-130-5020. OTPs may utilize CSACs and CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia. OTPs may also utilize CSAC-As pursuant to § 54.1-3507.2 of the Code of Virginia as well as registered peer recovery specialists within their scopes of practice. A registered peer recovery specialist shall meet the definition in § 54.1-3500 of the Code of Virginia.
2. Staff shall be knowledgeable in the assessment, interpretation, and treatment of the biopsychosocial dimensions of alcohol or other substance use disorders.
3. A physician or physician extender as defined in 12VAC30-130-5020 shall be available during medication dispensing and clinical operating hours in person or by telephone.
D. OTP risk management shall be clearly and adequately documented in each individual's record and shall include:
1. Random drug screening, using either urine or blood serums, for all individuals, conducted at least eight times during a 12-month period as described in 12VAC35-105-980. Definitive screenings shall only be utilized when clinically indicated. Outcomes of the drug screening shall be used to support positive patient outcomes and recovery.
2. A check of the Virginia Prescription Monitoring Program prior to initiation of buprenorphine products or naltrexone products and at least quarterly for all individuals.
3. Prescription of naloxone.
4. Opioid overdose prevention education, including the purpose of and the administration of naloxone and the impact of polysubstance use. Education shall include discussion of the role of medication assisted treatment and the opportunity to reduce harm associated with polysubstance use. The goal is to help individuals remain in treatment to reduce the risk for harm.
5. Clinically indicated infectious disease testing for diseases such as HIV; hepatitis A, B, and C; syphilis; and tuberculosis at treatment initiation and then annually or more frequently, depending on the clinical scenario and the patient's risk. Those who test positive shall be treated either on site or through referral.
6. For individuals without immunity to the hepatitis B virus, vaccination, either on site or through referral, shall be offered.
7. For individuals without HIV infection, pre-exposure prophylaxis to prevent HIV infection, either on site or through referral, shall be offered.
8. Pregnancy testing for women of childbearing age, and contraceptive services, either on site or through referral, shall be offered.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5060. Covered services: clinic services - preferred office-based addiction treatment.
A. Preferred office-based addiction treatment (OBAT) shall be provided by a physician or physician extender who has a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and may be provided in a variety of practice settings, including primary care clinics, outpatient health system clinics, psychiatry clinics, FQHCs, CSBs, BHAs, local health department clinics, and physician offices. The practitioner shall be contracted by DMAS or its contractor or an MCO to perform OBAT services. OBAT services shall meet the criteria established in this section.
B. OBAT service components.
1. Access to emergency medical and psychiatric care.
2. Affiliations with more intensive levels of care such as intensive outpatient programs and partial hospitalization programs to which individuals can be referred when clinically indicated.
3. Individualized, patient-centered multidimensional assessment and treatment.
4. Assessing, ordering, administering, reassessing, and regulating medication and dose levels appropriate to the individual; supervising withdrawal management from opioid analgesics and other substances; and overseeing and facilitating access to appropriate treatment for substance use disorder.
5. Medication for other physical and mental health disorders shall be provided as needed either on site or through collaboration with other providers.
6. Assurance that medications for opioid use disorder and alcohol use disorder are only dispensed on site during the induction phase. After the induction phase, medications shall be prescribed to the member.
7. Assurance that buprenorphine monoproduct is only prescribed in accordance with Board of Medicine rules related to the prescribing of buprenorphine for addiction.
8. Cognitive, behavioral, and other substance use disorder-focused counseling and psychotherapies, reflecting a variety of treatment approaches, shall be provided to the individual on an individual, group, or family basis and shall be provided by CATPs working in collaboration with a physician or physician extender who has a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs. These therapies can be provided via telemedicine as long as they meet DMAS requirements for an OBAT and for the use of telemedicine. Preferred OBATs may utilize CSACs and CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scope of practice as defined in § 54.1-3507.1 of the Code of Virginia.
9. Substance use care coordination provided, including interdisciplinary care planning between the physicians or physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and the treatment team to develop and monitor individualized and personalized treatment plans focused on the best outcomes for the individual. This care coordination includes monitoring individual progress, tracking individual outcomes, linking the individual with community resources to facilitate referrals and respond to social service needs, and tracking and supporting the individual's medical, behavioral health, or social services received outside the practice.
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.
11. Onsite medication administration treatment during the induction phase, which shall be provided by a physician, nurse practitioner, physician assistant, registered nurse, or licensed practical nurse.
12. Ability to provide pregnancy testing for women of childbearing age.
13. For individuals of childbearing age, the ability to provide family planning services or to refer the individual for family planning services.
C. OBAT staff requirements.
1. Physicians or physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, are required.
2. CATPs are required and shall work in collaboration with a physician or physician extender who has a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs. This collaboration can be in person or via telemedicine as long as it meets the department's requirements for the OBAT setting and for telemedicine. CSACs, CSAC-supervisees, and CSAC-As are also recognized in the preferred OBAT 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.
D. OBAT risk management shall be documented in each individual's record and shall include:
1. Random 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.
2. A check of the Virginia Prescription Monitoring Program prior to initiation of buprenorphine products or naltrexone products and at least quarterly for all individuals thereafter.
3. Prescription of naloxone.
4. Overdose prevention education, including the purpose of and the administration of naloxone and the impact of polysubstance use. Education shall include discussion of the role of medication assisted treatment and the opportunity to reduce harm associated with polysubstance use. The goal is to help individuals remain in treatment to reduce the risk for harm.
5. Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.
6. Clinically indicated infectious disease testing for diseases such as HIV; hepatitis A, B, and C; syphilis; and tuberculosis at treatment initiation and then annually or more frequently, depending on the clinical scenario and the patient's risk. Those individuals who test positive shall be treated either on site or through referral.
7. For individuals without immunity to the hepatitis B virus, vaccination either on site or through referral.
8. For patients without HIV infection, pre-exposure prophylaxis to prevent HIV infection shall be offered either on site or through referral.
9. Women of child-bearing age shall be tested for pregnancy and shall be offered contraceptive services either on site or through referral.
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; Volume 39, Issue 5, eff. December 8, 2022; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5070. Covered services: practitioner services - early intervention/screening brief intervention and referral to treatment (ASAM Level 0.5).
A. Early intervention (ASAM Level 0.5) settings for screening, brief intervention, and referral to treatment (SBIRT) services shall include health care settings, including local health departments, FQHCs, RHCs, CSBs, BHAs, health systems, emergency departments, pharmacies, physician offices, and outpatient clinics. Providers shall be licensed by the Department of Health Professions and either directly contracted by DMAS or its contractor or an MCO to perform the interpretation and intervention for this level of care or shall be employed by organizations that are contracted by DMAS or its contractor or an MCO.
B. Early intervention or SBIRT (ASAM Level 0.5) service components shall include:
1. Identifying individuals who may have alcohol or other substance use problems using an evidence-based screening tool.
2. Following administration of the evidence-based screening tool, a brief intervention by a CATP acting within the scope of the CATP's practice shall be provided to educate individuals about substance use, alert these individuals to possible consequences, and if needed, begin to motivate individuals to take steps to change their behaviors. Billing shall occur through the licensed provider or agency.
C. Early intervention or SBIRT (ASAM Level 0.5) staff requirements. Physicians, pharmacists, and other CATPs shall administer the evidence-based screening tool with the individual and provide the counseling and intervention. Licensed providers may delegate administration of the evidence-based screening tool to other clinical staff as allowed by their scope of practice, such as a CSAC, a CSAC-supervisee, a licensed registered nurse, or a licensed practical nurse. The physician may delegate the counseling and intervention but shall be available for review as needed. Billing for SBIRT shall occur through the licensed provider or agency.
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.
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.
12VAC30-130-5090. Covered services: community based services - intensive outpatient services (ASAM Level 2.1).
A. Intensive outpatient services (ASAM Level 2.1) shall be a structured program of skilled treatment services for adults, children, and adolescents delivering a minimum of three service hours per service day for adults to achieve an average of nine to 19 hours of services per week and a minimum of two service hours per service day for children and adolescents to achieve an average of six to 19 hours of services per week. Withdrawal management services may be provided as necessary. The following service components shall be provided weekly as directed by the ISP for reimbursement:
1. Medical, psychological, psychiatric, laboratory, and toxicology services, which are available through consultation or referral.
2. Psychiatric and other individualized treatment planning.
3. Individual, family, and group psychotherapy, substance use disorder counseling, medication management, and psychoeducation.
4. Medication assisted treatment that is provided on site or through referral.
5. Occupational and recreational therapies, motivational interviewing, enhancement, and engagement strategies to inspire an individual's motivation to change behaviors.
6. Psychiatric and medical consultation, which shall be available within 24 hours of the requested consult by telephone and preferably within 72 hours of the requested consult in person or via telemedicine.
7. Psychopharmacological consultation.
8. Addiction medication management and 24-hour crisis services.
9. Medical, psychological, psychiatric, laboratory, and toxicology services.
B. Intensive outpatient services (ASAM Level 2.1) shall be provided by agency-based providers that shall be licensed by DBHDS as a substance abuse intensive outpatient service for adults, children, and adolescents and contracted with DMAS or its contractor or an MCO to provide this service. Intensive outpatient service providers shall meet the ASAM Level 2.1 service components and staff requirements as follows:
1. Interdisciplinary team of CATPs shall be required. ASAM Level 2.1 may utilize CSACs or CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
2. Generalist physicians or physicians with experience in addiction medicine are permitted to provide general medical evaluations and concurrent or integrated general medical care.
3. Physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, who are either employed by or contracted with the agency or through referral arrangements with the agency.
4. Staff who shall be cross-trained to understand signs and symptoms of psychiatric disorders and be able to understand and explain the uses of psychotropic medications and understand interactions with substance use and other addictive disorders.
5. Emergency services, which shall be available, when necessary, by telephone 24 hours per day and seven days per week when the treatment program is not in session.
6. Direct affiliation with, or close coordination through referrals to, higher and lower levels of care and supportive housing services.
C. Intensive outpatient services (ASAM Level 2.1) co-occurring enhanced programs.
1. Co-occurring capable programs offer these therapies and support systems in intensive outpatient services described in this section to individuals with co-occurring addictive and psychiatric disorders who are able to tolerate and benefit from a planned program of therapies.
2. Individuals who are not able to benefit from a full program of therapies will be offered enhanced program services to match the intensity of hours in ASAM Level 2.1, including substance use case management, program of assertive community treatment (PACT), medication management, and psychotherapy.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5100. Covered services: community based care - partial hospitalization services (ASAM Level 2.5).
A. Partial hospitalization services (ASAM Level 2.5) components. Partial hospitalization services components shall include the following, as defined in the ISP and provided on a weekly basis:
1. Individualized treatment planning.
2. A minimum of 20 hours per week and at least five service hours per service day of skilled treatment services with a planned format, including individual and group psychotherapy, substance use disorder counseling, medication management, education groups, occupational and recreational therapy, and other therapies. Withdrawal management services may be provided as necessary. Time not spent in skilled, clinically intensive treatment is not billable.
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.
4. Motivational interviewing, enhancement, and engagement strategies.
5. Medication assisted treatment that is provided on site or through referral.
B. Partial hospitalization services (ASAM Level 2.5). The substance use partial hospitalization service provider shall be licensed by DBHDS as a substance abuse partial hospitalization program or substance abuse or mental health partial hospitalization program and contracted with DMAS or its contractor or an MCO. Partial hospitalization service providers shall meet the ASAM Level 2.5 support systems and staff requirements as follows:
1. Interdisciplinary team comprised of CATPs, which shall include an addiction-credentialed physician or physician with experience in addiction medicine, or physician extenders as defined in 12VAC30-130-5020. ASAM Level 2.5 may utilize CSACs or CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
2. Physicians shall have specialty training or experience, or both, in addiction medicine or addiction psychiatry. Physicians who treat adolescents shall have experience with adolescent medicine.
3. Physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, who are either employed by or contracted with the agency.
4. Program staff shall be cross-trained to understand signs and symptoms of mental illness and be able to understand and explain the uses of psychotropic medications and understand interactions with substance use and other addictive disorders.
5. Medical, psychological, psychiatric, laboratory, and toxicology services that are available by consult or referral.
6. Psychiatric and medical formal agreements to provide medical consult within eight hours of the requested consult by telephone or within 48 hours in person or via telemedicine.
7. Emergency services are available 24 hours a day and seven days a week.
8. Direct affiliation with or close coordination through referrals to higher and lower levels of care and supportive housing services.
C. Partial hospitalization services (ASAM Level 2.5) co-occurring enhanced programs shall offer:
1. Therapies and support systems as described in this section to individuals with co-occurring addictive and psychiatric disorders who are able to tolerate and benefit from a full program of therapies. Other individuals who are not able to benefit from a full program of therapies (who are severely or chronically mentally ill) will be offered enhanced program services to constitute intensity of hours in ASAM Level 2.5, including substance use case management, PACT, medication management, and psychotherapy.
2. Psychiatric services as appropriate to meet the individual's mental health condition. Services may be available by telephone and on site, or closely coordinated off site, or via telemedicine within a shorter time than in a co-occurring capable program.
3. Clinical leadership and oversight and, at a minimum, capacity to consult with an addiction psychiatrist via telephone, via telemedicine, or in person.
4. CATPs with experience assessing and treating co-occurring mental illness.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5110. Covered services: clinically managed low intensity residential services (ASAM Level 3.1).
A. Clinically managed low intensity residential services (ASAM Level 3.1). The agency-based residential group home services (ASAM Level 3.1) shall be licensed by DBHDS as a mental health and substance abuse group home service for adults or children or licensed by DBHDS as a supervised living residence for adults and contracted by DMAS or its contractor or an MCO. Clinically directed program activities constituting at least five hours per week of professionally directed treatment shall be designed to stabilize and maintain substance use disorder symptoms and to develop and apply recovery skills. Activities shall include relapse prevention, interpersonal choice exploration, and development of social networks in support of recovery. This service shall not include settings where clinical treatment services are not provided. ASAM Level 3.1 clinically managed low intensity residential service providers shall meet the service components and staff requirements of this section.
B. Clinically managed low intensity residential services (ASAM Level 3.1) service components.
1. Physician consultation and emergency services, which shall be available 24 hours a day and seven days per week.
2. Arrangements for medically necessary procedures including laboratory and toxicology tests that are appropriate to the severity and urgency of an individual's condition.
3. Arrangements for pharmacotherapy for psychiatric needs.
4. Medication assisted treatment that is provided onsite or through referral.
5. Arrangements for higher and lower levels of care and other services.
C. The following services shall be provided as directed by the ISP:
1. Clinically-directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life;
2. Addiction pharmacotherapy and drug screening;
3. Motivational enhancement and engagement strategies;
4. Substance use disorder counseling and clinical monitoring;
5. Regular monitoring of the individual's medication adherence;
6. Recovery support services;
7. Services for the individual's family and significant others, as appropriate to advance the individual's treatment goals and objectives identified in the ISP; and
8. Education on benefits of medication assisted treatment and referral to treatment as necessary.
D. Clinically managed low intensity residential services (ASAM Level 3.1) staff requirements.
1. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
2. Clinical staff who are experienced and knowledgeable about the biopsychosocial and psychosocial dimensions and treatment of substance use disorders. Clinical staff shall be able to identify the signs and symptoms of acute psychiatric conditions and decompensation.
3. An addiction-credentialed physician or physician with experience in addiction medicine or a physician extender acting within his scope of practice shall review the residential group home admission if the multidimensional assessment indicates medical concerns or systems in ASAM Dimension 1 or 2, to confirm medical necessity for services and a team of CATPs who shall develop and shall ensure delivery of the ISP. For ASAM Level 3.1, the ISP may be completed by a CSAC or CSAC-supervisee if the CATP signs and dates the ISP within one business day.
4. Coordination with community physicians to review treatment as needed.
5. Appropriately credentialed medical staff shall be available to assess and treat co-occurring biomedical disorders and to monitor the individual's administration of prescribed medications.
E. Clinically managed low intensity residential services (ASAM Level 3.1) co-occurring enhanced programs as required by ASAM.
1. In addition to the ASAM Level 3.1 service components listed in this section, programs for individuals with both unstable substance use and psychiatric disorders shall offer appropriate psychiatric services, including medication evaluation and laboratory services. Such services are provided either onsite, via telemedicine, or closely coordinated with an offsite provider, as appropriate to the severity and urgency of the individual's mental health condition.
2. Certified addiction treatment professionals shall be cross-trained in addiction and mental health to (i) understand the signs and symptoms of mental illness and (ii) understand and be able to explain to the individual the purpose of psychotropic medications and interactions with substance use.
3. The therapies described in this section shall be offered as well as planned clinical activities (either onsite or with an offsite provider) that are designed to stabilize and maintain the individual's mental health program and psychiatric symptoms.
4. Goals of therapy shall apply to both the substance use disorder and any co-occurring mental illness.
5. Medication education and management shall be provided.
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.
12VAC30-130-5120. Covered services: clinically managed population - specific high intensity residential service (ASAM Level 3.3).
A. Clinically managed population-specific high intensity residential service (ASAM Level 3.3). The facility-based provider shall be licensed by DBHDS as (i) a supervised residential treatment service for adults; (ii) a substance abuse residential treatment service for adults; (iii) a substance abuse residential treatment service for women with children; (iv) a substance abuse and mental health residential treatment service for adults that has substance abuse listed on its license or within the "licensed as" statement or be a Level C (psychiatric residential treatment facility) service provider; or (v) a "mental health residential-children" provider that has substance abuse listed on its license or within the "licensed as" statements. All providers shall be contracted by DMAS or its contractor or an MCO. ASAM Level 3.3 settings do not include sober houses, boarding houses, or group homes where treatment services are not provided. Residential treatment service providers for clinically managed population-specific high intensity residential service (ASAM Level 3.3) shall meet the service components and staff requirements in this section.
B. Clinically managed population-specific high intensity residential service (ASAM Level 3.3) service components.
1. Clinically managed population-specific high intensity residential service components shall include:
a. Access to a consulting physician or physician extender who is either employed by or contracted with the agency or through referral arrangements with the agency and who has a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and emergency services 24 hours a day and seven days a week;
b. Arrangements for higher and lower levels of care;
c. Arrangements for laboratory and toxicology services appropriate to the severity of need; and
d. Arrangements for addiction pharmacotherapy, including medication assisted treatment that is provided on site or through referral.
2. The following therapies shall be provided as directed by the ISP for reimbursement:
a. Clinically directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life;
b. Addiction pharmacotherapy, including medication assisted treatment that is provided on site or through referral;
c. Drug screening, using either urine or blood serums;
d. A range of cognitive and behavioral psychotherapies administered individually and in family and group settings as appropriate to the individual's needs to assist the individual in initial involvement or re-engagement in regular productive daily activity;
e. Substance use disorder counseling and psychoeducation activities provided individually or in family and group settings to promote recovery;
f. Recreational therapy, art, music, physical therapy, and vocational rehabilitation;
g. Motivational enhancement and engagement strategies;
h. Regular monitoring of the individual's medication adherence;
i. Recovery support services;
j. Services for the individual's family and significant others, as appropriate to advance the individual's treatment goals and objectives identified in the ISP;
k. Education on benefits of medication assisted treatment and referral to treatment as necessary; and
l. Withdrawal management services may be provided as necessary.
C. Clinically managed population-specific high intensity residential service (ASAM Level 3.3) staff requirements.
1. The interdisciplinary team shall include CATPs and allied health professionals in an interdisciplinary team. ASAM Level 3.3 may utilize CSACs or CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
2. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
3. Clinical or credentialed staff shall be experienced and knowledgeable about the biopsychosocial dimensions and treatment of substance use disorders and who are available on site or by telephone 24 hours per day. Licensed clinical staff shall be able to identify acute psychiatric conditions and decompensation.
4. Substance use case management is included in this level of care.
5. Appropriately credentialed medical staff shall be available to assess and treat co-occurring biomedical disorders and to monitor the individual's administration of prescribed medications.
D. Clinically managed population-specific high intensity residential service co-occurring enhanced programs, as required by ASAM.
1. Appropriate psychiatric services, including medication evaluation and laboratory services, shall be provided on site or through a closely coordinated offsite provider, as appropriate to the severity and urgency of the individual's mental condition.
2. CATPs shall be available to assess and treat co-occurring substance use and mental illness using specialized training in behavior management techniques.
3. Credentialed addiction treatment professionals shall be cross-trained in addiction and mental health to understand the signs and symptoms of mental illness and be able to provide education to the individual on the interactions with substance use and psychotropic medications.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5130. Covered services: clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5).
A. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) settings for services. The facility based residential treatment service provider (ASAM Level 3.5) shall be licensed as (i) a substance abuse residential treatment service for adults or children, (ii) a psychiatric unit that has substance abuse listed on its license or within the "licensed as" statements, (iii) a substance abuse residential treatment service for women with children, (iv) a substance abuse and mental health residential treatment service for adults and children that has substance abuse listed on its license or within the "licensed as" statements, (v) a Level C (psychiatric residential treatment facility) provider, or (vi) a "mental health residential-children" provider that has substance abuse on its license or within the "licensed as" statements and shall be contracted by DMAS or its contractor or an MCO. Residential treatment providers (ASAM Level 3.5) shall meet the service components and staff requirements in this section.
B. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) service components.
1. These residential treatment services, as required by ASAM, include:
a. Telephone or in-person consultation with a physician or physician extender who shall be available to perform required physician services. Emergency services shall be available 24 hours per day and seven days per week;
b. Arrangements for more and less intensive levels of care and other services such as sheltered workshops, literacy training, and adult education;
c. Arrangements for needed procedures, including medical, psychiatric, psychological, laboratory, and toxicology services appropriate to the severity of need; and
d. Arrangements for addiction pharmacotherapy, including medication assisted treatment that is provided on site or through referral.
2. The following therapies shall be provided as directed by the ISP for reimbursement:
a. Clinically directed treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies. Services shall promote personal responsibility and reintegration of the individual into the network systems of work, education, and family life. Activities shall be designed to stabilize and maintain substance use disorder symptoms and apply recovery skills and may include relapse prevention, interpersonal choice exploration, and development of social networks in support of recovery.
b. Range of cognitive, behavioral psychotherapies, and substance use disorder counseling administered individually and in family and group settings to assist the individual in initial involvement or re-engagement in regular productive daily activities, including education on medication management, addiction pharmacotherapy, and education skill building groups to enhance the individual's understanding of substance use and mental illness.
c. Psychoeducational activities.
d. Addiction pharmacotherapy and drug screening.
e. Recreational therapy, art, music, physical therapy, and vocational rehabilitation.
f. Motivational enhancements and engagement strategies.
g. Monitoring of the adherence to prescribed medications and over-the-counter medications and supplements.
h. Daily scheduled professional services and interdisciplinary assessments and treatment designed to develop and apply recovery skills.
i. Services for family and significant others, as appropriate, to advance the individual's treatment goals and objectives identified in the ISP.
j. Withdrawal management services may be provided as necessary.
C. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) staff requirements.
1. The interdisciplinary team shall include CATPs, physicians, or physician extenders and allied health professionals. Physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and who are either employed by or contracted with the agency or through referral arrangements with the agency. ASAM Level 3.5 may utilize CSACs or CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
2. Staff shall provide awake 24-hour onsite supervision. The provider's staffing plan must be in compliance with DBHDS licensing regulations for staffing plans set forth in 12VAC35-46-870 and 12VAC35-105-590.
3. Clinical staff who are experienced in and knowledgeable about the biopsychosocial dimensions and treatment of substance use disorders. Clinical staff shall be able to identify acute psychiatric conditions and decompensations.
4. Substance use case management shall be provided in this level of care.
5. Appropriately credentialed medical staff shall be available on site or by telephone 24 hours per day, seven days per week to assess and treat co-occurring biological and physiological disorders and to monitor the individual's administration of medications in accordance with a physician's prescription.
D. Clinically managed high intensity residential services (adult) and clinically managed medium intensity residential services (adolescent) (ASAM Level 3.5) co-occurring enhanced programs as required by ASAM.
1. Psychiatric services, medication evaluation, and laboratory services shall be provided. Such services shall be available by telephone within eight hours of requested service and on site or via telemedicine, or closely coordinated with an offsite provider within 24 hours of requested service, as appropriate to the severity and urgency of the individual's mental and physical condition.
2. Staff shall be CATPs who are able to assess and treat co-occurring substance use and psychiatric disorders.
3. Planned clinical activities shall be required and shall be designed to stabilize and maintain the individual's mental health problems and psychiatric symptoms.
4. Medication education and management shall be provided.
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; Volume 41, Issue 3, eff. October 23, 2024.
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 provider of ASAM Level 3.7 services shall be licensed by DBHDS as (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 service for women with children with a DBHDS managed withdrawal 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 DMAS or its contractor or the MCO. ASAM Level 3.7 providers shall meet the service components and staff requirements in this section.
B. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) service components. The following therapies shall be provided as directed by the ISP for reimbursement:
1. Daily clinical services provided by an interdisciplinary team to involve appropriate medical and nursing services, as well as individual, group, and family activity services. Activities may include pharmacological, including medication assisted treatment that is provided on site or through referral; withdrawal management; cognitive-behavioral; and other 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.
2. Counseling and clinical monitoring to facilitate re-involvement in regular productive daily activities and successful re-integration into family living if applicable.
3. Psychoeducational activities.
4. Random drug screens to monitor use and strengthen recovery and treatment gains.
5. Regular medication monitoring.
6. Planned clinical activities to enhance understanding of substance use disorders.
7. Health education associated with the course of addiction and other potential health related risk factors, including tuberculosis, human immunodeficiency virus, hepatitis B and C, and other sexually transmitted infections.
8. Evidence based practices, such as motivational interviewing to address an individual's readiness to change, designed to facilitate understanding of the relationship of the substance use disorder and life impacts.
9. Daily treatments to manage acute symptoms of biomedical substance use or mental illness.
10. Services to family and significant others as appropriate to advance the individual's treatment goals and objectives identified in the ISP.
11. Physician monitoring, nursing care, and observation shall be available. A physician shall be available to assess the individual in person or via telemedicine within 24 hours of admission and thereafter as medically necessary.
12. A licensed and registered nurse who shall conduct an alcohol or other drug-focused nursing assessment upon admission. A licensed registered nurse or licensed practical nurse shall be responsible for monitoring the individual's progress and for medication administration duties.
13. Additional medical specialty consultation; psychological, laboratory, and toxicology services shall be available on site, either through consultation or referral.
14. Coordination of necessary services shall be available on site or through referral to a closely coordinated offsite provider to transition the individual to lower levels of care.
15. Psychiatric services shall be available on site or through consultation or referral to a closely coordinated offsite provider when a presenting problem could be attended to at a later time. Such services shall be available within eight hours of requested service by telephone or within 24 hours of requested service in person or via telemedicine.
C. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) staff requirements.
1. The interdisciplinary team shall include CATPs and addiction-credentialed physicians or physicians with experience in addiction medicine to assess, treat, and obtain and interpret information regarding the individual's psychiatric and substance use disorders. Physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and who are either employed by or contracted with the agency or through referral arrangements with the agency. ASAM Level 3.7 may utilize CSACs or CSAC-supervisees to provide substance use disorder counseling and psychoeducational services within their scopes of practice as defined in § 54.1-3507.1 of the Code of Virginia.
2. Clinical staff shall be knowledgeable about the biological and psychosocial dimensions of substance use disorders and mental illnesses and their treatment. Clinical staff shall be able to identify acute psychiatric conditions, symptom increase or escalation, and decompensation.
3. Clinical staff shall be able to provide a planned regimen of 24-hour professionally directed evaluation, care, and treatment, including the administration of prescribed medications.
4. An addiction-credentialed physician or physician with experience in addiction medicine shall oversee the treatment process and ensure quality of care. Licensed physicians shall perform physical examinations for all individuals who are admitted. Staff shall supervise addiction pharmacotherapy integrated with psychosocial therapies. The professional may be a physician or a psychiatrist, or a physician extender as defined in 12VAC30-130-5020 if knowledgeable about addiction treatment.
D. Medically monitored intensive inpatient services (adult) and medically monitored high intensity inpatient services (adolescent) (ASAM Level 3.7) co-occurring enhanced programs as required by ASAM.
1. Appropriate psychiatric services, medication evaluation, and laboratory services shall be available.
2. A psychiatrist assessment of the individual shall occur within four hours of admission by telephone and within 24 hours following admission in person or via telemedicine, or sooner, as appropriate to the individual's behavioral health condition, and thereafter as medically necessary.
3. A behavioral health-focused assessment at the time of admission shall be performed by a registered nurse or licensed mental health clinician. A licensed registered nurse or licensed practical nurse supervised by a registered nurse shall be responsible for monitoring the individual's progress and administering or monitoring the individual's self-administration of medications.
4. Psychiatrists and CATPs who are able to assess and treat co-occurring psychiatric disorders and who have specialized training in the behavior management techniques and evidenced-based practices shall be available.
5. Access to an addiction-credentialed physician shall be available along with access to either a psychiatrist, a certified addiction psychiatrist, or a psychiatrist with experience in addiction medicine.
6. CATPs shall have experience and training in addiction and mental health to understand the signs and symptoms of mental illness and be able to provide education to the individual on the interaction of substance use and psychotropic medications.
7. Planned clinical activities shall be offered and designed to promote stabilization and maintenance of the individual's behavioral health needs, recovery, and psychiatric symptoms.
8. Medication education and management shall be offered.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5150. Covered services: medically managed intensive inpatient services (ASAM Level 4.0).
A. Medically managed intensive inpatient services (ASAM Level 4.0) settings for services. Acute care hospitals licensed by the Virginia Department of Health shall be the designated setting for medically managed intensive inpatient treatment and shall offer medically directed acute withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress resulting from, or occurring with, an individual's use of alcohol and other drugs. Such service settings shall offer medically directed acute withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress, or all of these, resulting from, or co-occurring with, an individual's use of alcohol or other drugs, with the exception of tobacco-related disorders, caffeine-related disorders or dependence or non-substance-related disorders.
B. Medically managed intensive inpatient services (ASAM Level 4.0) service components.
1. The service components of medically managed intensive inpatient services shall be:
a. An evaluation or analysis of substance use disorders shall be provided, including the diagnosis of substance use disorders and the assessment of treatment needs for medically necessary services.
b. Observation and monitoring the individual's course of withdrawal shall be provided. This shall be conducted as frequently as deemed appropriate for the individual and the level of care the individual is receiving. This may include, for example, observation of the individual's health status.
c. Medication services, including the prescription or administration related to substance use disorder treatment services or the assessment of the side effects or results of that medication, conducted by appropriate licensed staff who provide such services within their scope of practice or license.
2. The following therapies shall be provided for reimbursement:
a. Daily clinical services provided by an interdisciplinary team to stabilize acute addictive or psychiatric symptoms. Activities shall include pharmacological, cognitive-behavioral, and other psychotherapies or substance use disorder counseling administered on an individual or group basis and modified to meet the individual's level of understanding. For individuals with a severe biomedical disorder, physical health interventions are available to supplement addiction treatment. For the individual who has less stable psychiatric symptoms, ASAM Level 4.0 co-occurring capable programs offer individualized treatment activities designed to monitor the individual's mental health and to address the interaction of the mental health programs and substance use disorders.
b. Health education services.
c. Planned clinical interventions that are designed to enhance the individual's understanding and acceptance of illness of addiction and the recovery process.
d. Services for the individual's family, guardian, or significant other, as appropriate, to advance the individual's treatment and recovery goals and objectives identified in the ISP.
e. This level of care offers 24-hour nursing care and daily physician care for severe, unstable problems in any of the following ASAM dimensions: (i) acute intoxication or withdrawal potential; (ii) biomedical conditions and complications; and (iii) emotional, behavioral, or cognitive conditions and complications.
f. Discharge services shall be the process to prepare the individual for referral into another level of care, post treatment return or reentry into the community, or the linkage of the individual to essential community treatment, housing, recovery, and human services.
C. Medically managed intensive inpatient services (ASAM Level 4.0) staff requirements.
1. An interdisciplinary staff of appropriately credentialed clinical staff including, for example, addiction-credentialed physicians or physicians with experience in addiction medicine, licensed nurse practitioners, licensed physician assistants, registered nurses, licensed professional counselors, licensed clinical psychologists, or licensed clinical social workers who assess and treat individuals with severe substance use disorders or addicted individuals with concomitant acute biomedical, emotional, or behavioral disorders. Physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, and who are either employed by or contracted through the agency or through referral arrangements with the agency.
2. Medical management by physicians and primary nursing care shall be available 24 hours per day and counseling services shall be available 16 hours per day.
D. Medically managed intensive inpatient services (ASAM Level 4.0) co-occurring enhanced programs. These programs shall be provided by appropriately licensed or registered credentialed mental health professionals who assess and treat the individual's co-occurring mental illness and are knowledgeable about the biological and psychosocial dimensions of psychiatric disorders and his treatment.
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; Volume 41, Issue 3, eff. October 23, 2024.
12VAC30-130-5160. Peer support services and family support partners: definitions.
The following words and terms when used in this part shall have the following meanings:
"Behavioral health service" means treatments and services for mental or substance use disorders.
"Caregiver" means the family members, friends, or neighbors who provide unpaid assistance to a Medicaid member with a mental health or substance use disorder or co-occurring mental health and substance use disorder. "Caregiver" does not include individuals who are employed to care for the member.
"Direct supervisor" means the person who provides direct supervision to the peer recovery specialist. The direct supervisor (i) shall have two consecutive years of documented practical experience rendering peer support services or family support services, have certification as a PRS under a certifying body approved by DBHDS, and have documented completion of the DBHDS PRS supervisor training; (ii) shall be a practitioner who has documented completion of the DBHDS PRS supervisor training, meets the definition of "credentialed addiction treatment professional" found in 12VAC30-130-5020, and is acting within his scope of practice under state law; or (iii) shall be a certified substance abuse counselor (CSAC) as defined in § 54.1-3507.1 of the Code of Virginia who has documented completion of the DBHDS PRS supervisor training if he is acting under the supervision or direction of a licensed substance use treatment practitioner or licensed mental health professional. If a practitioner referenced in clause (ii) of this definition or a CSAC referenced in clause (iii) of this definition provides services before April 1, 2018, he shall have until April 1, 2018, to complete the DBHDS PRS supervisor training.
"Peer recovery specialist" or "PRS" means a person who has the qualifications, education, and experience established by the Department of Behavioral Health and Developmental Services in 12VAC35-250-10.
"Peer recovery support services" means the same as defined in 12VAC35-250-10.
"Person centered" means a collaborative process where the individual participates in the development of his treatment goals and makes decisions about the services provided.
"Recovery-oriented services" means providing support and assistance to an individual with mental health or substance use disorders or both so that the individual (i) improves his health, recovery, resiliency, and wellness; (ii) lives a self-directed life; and (iii) strives to reach his full potential.
"Recovery, resiliency, and wellness plan" means a written set of goals, strategies, and actions to guide the individual and the health care team to move the individual toward the maximum achievable independence and autonomy in the community. The documented comprehensive wellness plan shall be developed with the LMHP, LMHP-R, LMHP-RP, or LMHP-S who conducted the assessment and made the recommendation, along with the individual or caregiver, as applicable, the PRS, and the direct supervisor within 30 days of the initiation of services and shall describe how the plan for peer support services and activities will meet the individual's needs. This document shall be updated as the needs and progress of the individual change and shall document the individual's or caregiver's, as applicable, request for any changes in peer support services. The recovery, resiliency, and wellness plan is a component of the individual's overall plan of care and shall be maintained by the enrolled provider in the individual's medical record.
"Resiliency" means the ability to respond to stress, anxiety, trauma, crisis, or disaster.
"Self-advocacy" means an empowerment skill that allows the individual to effectively communicate preferences and choice.
"Strength-based" means to emphasize individual strengths, assets, and resiliencies.
"Supervision" means the ongoing process performed by a direct supervisor who monitors the performance of the PRS and provides regular documented consultation and instruction with respect to the skills and competencies of the PRS.
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; amended, Virginia Register Volume 37, Issue 14, eff. April 14, 2021.
12VAC30-130-5170. Peer support services and family support partners: service definitions.
A. ARTS peer support services and ARTS family support partners are peer recovery support services and are nonclinical, peer-to-peer activities that engage, educate, and support an individual's, and as applicable the caregiver's, self-help efforts to improve health recovery, resiliency, and wellness. These services shall be available to either:
1. Individuals 21 years of age or older with mental health or substance use disorders or co-occurring mental health and substance use disorders that are the focus of the support; or
2. The caregiver of individuals younger than 21 years of age with mental health or substance use disorders or co-occurring mental health and substance use disorders that are the focus of the support.
3. Individuals 18 through 20 years of age who meet the medical necessity criteria set forth in 12VAC30-130-5180 A who would benefit from receiving peer supports directly, and who choose to receive ARTS peer support services directly instead of through their family shall be permitted to receive peer support services by an appropriate PRS.
B. ARTS peer support services for adults is a person centered, strength-based, and recovery-oriented rehabilitative service for individuals 21 years of age or older provided by a peer recovery specialist successful in the recovery process with lived experience with substance use disorders or co-occurring mental health and substance use disorders who is trained to offer support and assistance in helping others in recovery to reduce the disabling effects of a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. Services assist the individual with developing and maintaining a path to recovery, resiliency, and wellness. Specific peer support service activities shall emphasize the acquisition, development, and enhancement of recovery, resiliency, and wellness. Services are designed to promote empowerment, self-determination, understanding, and coping skills through mentoring and service coordination supports, as well as to assist individuals in achieving positive coping mechanisms for the stressors and barriers encountered when recovering from their illness or disorder.
C. Family support partners is a peer recovery support service and a strength-based, individualized service provided to the caregiver of a Medicaid-eligible individual younger than 21 years of age with a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. The services provided to the caregiver and the individual must be directed exclusively toward the benefit of the Medicaid-eligible individual. Services are expected to improve outcomes for an individual younger than 21 years of age with complex needs who is involved with multiple systems and increase the individual's and family's confidence and capacity to manage their own services and supports while promoting recovery and healthy relationships. These services are rendered by a PRS who is (i) a parent of a minor or adult child with a similar substance use disorder or co-occurring mental health and substance use disorder or (ii) an adult with personal experience with a family member with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services. The PRS shall perform the service within the scope of his knowledge, lived experience, and education.
D. ARTS peer recovery support services shall be rendered on an individual basis or in a group.
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; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019; Volume 37, Issue 14, eff. April 14, 2021.
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.
12VAC30-130-5190. Peer support services and family support partners: provider and setting requirements.
A. Effective July 1, 2017, a peer recovery specialist shall have the qualifications, education, experience , and certification required by DBHDS show certification in good standing by the U.S. Department of Veterans Affairs, NAADAC - the Association of Addiction Professionals, a member board of the International Certification and Reciprocity Consortium, or any other certifying body or state certification with standards comparable to or higher than those specified by DBHDS to be eligible to register with the Board of Counseling on or after July 1, 2018. Upon the promulgation of regulations by the Board of Counseling, registration of peer recovery specialists by the Board of Counseling shall be required. in accordance with 12VAC35-250. Effective December 18, 2017, peer recovery specialists shall also be registered with the Board of Counseling.
B. Prior to service initiation, a documented assessment by a practitioner who meets the definition of "credentialed addiction treatment professional" found in 12VAC30-130-5020 and who is acting within his scope of practice under state law shall be required. A certified substance abuse counselor, as defined in § 54.1-3507.1 of the Code of Virginia, may also provide a documented assessment if he is acting under the supervision or direction of a licensed substance use treatment practitioner or licensed mental health professional. The PRS shall perform ARTS peer services under the oversight of the practitioner described in this subsection conducting the assessment and providing the clinical oversight of the recovery, resiliency, and wellness plan. The assessment shall verify that the individual meets the medical necessity criteria set forth in 12VAC30-130-5180 A or B, as applicable.
C. The PRS shall be employed by or have a contractual relationship with the enrolled provider licensed for one of the following:
1. Acute care general hospital (ASAM Level 4.0) licensed by the Department of Health as defined in 12VAC30-130-5150.
2. Freestanding psychiatric hospital or inpatient psychiatric unit (ASAM Levels 3.5 and 3.7) licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5130 and 12VAC30-130-5140.
3. Residential placements (ASAM Levels 3.1, 3.3, 3.5, and 3.7) licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5110 through 12VAC30-130-5140.
4. ASAM Levels 2.1 and 2.5, licensed by the Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5090 and 12VAC30-130-5100.
5. ASAM Level 1.0 as defined in 12VAC30-30-5080.
6. Opioid treatment services as defined in 12VAC30-130-5050.
7. Office-based opioid treatment as defined in 12VAC30-130-5060.
8. Hospital emergency department services licensed by the Department of Health.
9. Pharmacy services licensed by the Department of Health.
D. Only a licensed and enrolled provider referenced in subsection C of this section shall be eligible to bill and receive reimbursement from DMAS or its contractor for ARTS peer support services. Payments shall not be permitted to providers that fail to enter into an enrollment agreement with DMAS or its contractor. Reimbursement shall be subject to retraction for any billed service that is determined to not to be in compliance with DMAS requirements.
E. The direct supervisor, as defined in 12VAC30-130-5160, shall perform direct supervision of the PRS as needed based on the level of urgency and intensity of service being provided. The direct supervisor shall have an employment or contract relationship with the same provider entity that employs or contracts with the PRS. Direct supervisors shall maintain documentation of all supervisory sessions. In no instance shall supervisory sessions be performed less than as provided below:
1. If the PRS has less than 12 months of experience delivering ARTS peer support services or ARTS family support partners, he shall receive face-to-face, one-to-one supervisory meetings of sufficient length to address identified challenges for a minimum of 30 minutes, two times a month. The direct supervisor must be available at least by telephone while the PRS is on duty.
2. If the PRS has been delivering ARTS peer recovery services over 12 months and fewer than 24 months, he must receive monthly face-to-face, one-to-one supervision of sufficient length to address identified challenges for a minimum of 30 minutes. The direct supervisor must be available by telephone for consult within 24 hours of service delivery if needed for challenging situations.
F. The caseload assignment of a full-time PRS shall not exceed 15 individuals at any one time allowing for new case assignments as those on the existing caseload begin to self-manage with less support. The caseload assignment of a part-time PRS shall not exceed nine individuals at any one time. There are no minimum limits for full-time or part-time PRS caseloads.
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; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019; Volume 37, Issue 14, eff. April 14, 2021.
12VAC30-130-5200. Peer support services and family support partners: documentation of required activities.
A. The recommendation for services shall include the dated signature and credentials of the practitioner described in 12VAC30-130-5190 B who made the recommendation. The recommendation shall be included as part of the recovery, resiliency, and wellness plan and medical record. The recommendation shall verify that the individual meets the medical necessity criteria and shall be valid for no longer than 30 calendar days.
B. Under the clinical oversight of the practitioner making the recommendation described in 12VAC50-130-5190 B for ARTS peer support services or ARTS family support partners, the peer recovery specialist in consultation with his direct supervisor shall develop a recovery, resiliency, and wellness plan based on the recommendation for service, the individual's, and, as applicable the caregiver's, perceived recovery needs and multidisciplinary assessment as defined in this section within 30 calendar days of the initiation of service. Development of the recovery, resiliency, and wellness plan shall include collaboration with the individual and, as applicable, the identified family member or caregiver involved in the individual's recovery. Individualized goals and strategies shall be focused on the individual's identified needs for self-advocacy and recovery. The recovery, resiliency, and wellness plan shall also include documentation of how many days per week and how many hours per week are required to carry out the services in order to meet the goals of the plan. The recovery, resiliency, and wellness plan shall be completed, signed, and dated by the practitioner making the recommendation, the PRS, the direct supervisor, the individual, and, as applicable, the identified family member or caregiver involved in the individual's recovery within 30 calendar days of the initiation of service. The PRS shall act as an advocate for the individual, encouraging the individual, and as applicable the caregiver, to take a proactive role in developing and updating goals and objectives in the individualized recovery planning.
C. Services shall be delivered in accordance with the individual's goals and objectives as identified in the recovery, resiliency, and wellness plan and consistent with the recommendation of the referring practitioner who recommended services. As determined by the goals identified in the recovery, resiliency, and wellness plan, services may be rendered in the provider's office or in the community, or both. The level of services provided and total time billed by the enrolled provider for the week shall not exceed the frequency established in the recovery, resiliency, and wellness plan.
D. Under the clinical oversight of the practitioner described in 12VAC30-130-5190 B making the recommendation, the peer recovery specialist in consultation with his direct supervisor shall conduct and document a review of the recovery, resiliency, and wellness plan every 90 calendar days with the individual and the caregiver, as applicable. The review shall be signed by the PRS and the individual and, as applicable, the identified family member or caregiver. Review of the recovery, resiliency, and wellness plan means the PRS evaluates and updates the individual's progress every 90 days toward meeting the plan's goals and documents the outcome of this review in the individual's medical record. For DMAS to determine that these reviews are complete, the reviews shall (i) update the goals and objectives as needed to reflect any change in the individual's recovery as well as any newly identified needs, (ii) be conducted in a manner that enables the individual to actively participate in the process, and (iii) be documented by the PRS in the individual's medical record no later than 15 calendar days from the date of the review.
E. Progress notes as defined in 12VAC30-50-130 shall be required and shall record the date, time, place of service, participants, face-to-face or telephone contact, and circumstance of contact, regardless of whether or not a billable service was provided, and shall summarize the purpose and content of the session along with the specific strategies and activities utilized as related to the goals in the recovery, resiliency, and wellness plan. Documentation of specific strategies and activities shall fully disclose the details of services rendered and align with the recovery, resiliency, and wellness plan. Strategies and activities shall include at a minimum:
1. Person centered, strength-based planning to promote the development of self-advocacy skills;
2. Empowering the individual to take a proactive role in the development and updating of his recovery, resiliency, and wellness plan;
3. Crisis support; and
4. Assisting in the use of positive self-management techniques, problem‐solving skills, coping mechanisms, symptom management, and communication strategies identified in the recovery, resiliency, and wellness plan so that the individual:
a. Remains in the least restrictive setting;
b. Achieves his goals and objectives identified in the recovery resiliency and wellness plan;
c. Self-advocates for quality physical and behavioral health services; and
d. Has access to strength-based behavioral health services, social services, educational services, and other supports and resources.
F. Progress notes shall reflect collaboration between the PRS and the individual in the development of the progress notes. If contact with the individual cannot be made, the service is not billable. However, the progress notes shall reflect attempts to contact the individual. Progress notes shall contain the dated signature of the PRS who provided the service.
G. The enrolled provider shall ensure that documentation of all supervision sessions is maintained in a supervisor's log or the personnel file of the PRS.
H. The enrolled provider shall have oversight of the individual's record and maintain individual records in accordance with state and federal requirements. The enrolled provider shall ensure documentation of all activities and documentation of all relevant information about the Medicaid individuals receiving services. Such documentation shall fully disclose the extent of services provided in order to support providers claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered.
I. The enrolled provider may integrate an individual's peer support record with the individual's other records maintained within same provider agency or facility, provided all peer support documentation is clearly identified. Logs and progress notes documenting the provision of services shall corroborate billed services.
J. Collaboration shall be required with behavioral health service providers and shall include the PRS and the individual, or caregiver as applicable, and shall involve discussion regarding initiation of services and updates on the individual's status and changes in the individual's progress. Documentation of all collaboration shall be maintained in the individual's record.
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.
12VAC30-130-5210. Peer support services and family support partners: limitations and exclusions to service delivery.
A. An approved service authorization submitted by the enrolled provider shall be required prior to service delivery in order for reimbursement to occur. To obtain service authorization, all provider information supplied to the Department of Medical Assistance Services or its contractor shall be fully substantiated throughout the individual's record.
B. Service shall be initiated within 30 calendar days of the documented recommendation. The recommendation shall be valid for no longer than 30 calendar days.
C. Services rendered in a group setting shall have a ratio of no more than 10 individuals to one PRS, and progress notes shall be included in each individual's record.
D. General support groups that are made available to the public to promote education and global advocacy do not qualify as peer support services or family support partners.
E. Noncovered activities include transportation, recordkeeping or documentation activities (including progress notes, tracking hours and billing, and other administrative paperwork), services performed by volunteers, household tasks, chores, grocery shopping, on-the-job training, case management, outreach to potential clients, and room and board.
F. A unit of service shall be defined as 15 minutes. Peer support services and family support partners shall be limited to four hours per day (up to 16 units per calendar day) and 900 hours per calendar year. Service delivery limits may be exceeded based upon documented medical necessity and service authorization approval.
G. If a service recommendation for mental health peer support services or mental health family support partners as set forth in 12VAC30-50-130 or 12VAC30-50-226 is made in addition to a service recommendation for ARTS peer support services or ARTS family support partners as set forth in 12VAC30-130-5160 through 12VAC30-130-5210, the enrolled provider shall coordinate services to ensure the four-hour daily service limit is not exceeded. No more than a total of four hours of one type of service, or a total of four hours of a combination of service types, up to 16 units of total service, shall be provided per calendar day. The enrolled provider cannot bill DMAS separately for (i) mental health peer services (mental health peer support services or mental health family support partners) and (ii) ARTS peer services (peer support services or ARTS family support partners) rendered on the same calendar day unless the mental health peer services and ARTS peer services are rendered at different times. A separate annual service limit of up to 900 hours shall apply to mental health peer support services or mental health family support partners service and ARTS peer support services or ARTS family support partners.
H. The PRS shall document each 15-minute unit in which the individual was actively engaged in peer support services or family support partners. Meals and breaks and other noncovered services listed in this section shall not be included in the reporting of units of service delivered. Should an individual receive other services during the range of documented time in/time out for peer support hours, the absence of or interrupted services must be documented.
I. Service delivery shall be based on the individual's identified needs, established medical necessity criteria, and goals identified in the individual recovery resiliency and wellness plan.
J. Billing shall occur only for services provided with the individual present. Telephone time is supplemental rather than replacement of face-to-face contact and is limited to 25% or less of total time per recipient per calendar year. Justification for services rendered with the individual via telephone shall be documented. Any telephone time rendered over the 25% limit will be subject to retraction.
K. Peer support services or family support partners may operate in the same building as other day services; however, there must be a distinct separation between services in staffing, program description, and physical space. Peer support services shall be an ancillary service and shall not impede, interrupt, or interfere with the provision of the primary service setting.
L. Contact shall be made with the individual receiving peer support services or family support partners a minimum of twice each month. At least one of these contacts must be face-to-face and the second may be either face-to-face or telephone contact depending on the individual's support needs and documented preferences.
M. In the absence of the required monthly face-to-face contact and if at least two unsuccessful attempts to make face-to-face contact have been tried and documented, the provider may bill for a maximum of two telephone contacts in that specified month, not to exceed two units. After two consecutive months of unsuccessful attempts to make face-to-face contact, discharge shall occur.
N. Family support partners is not billable for siblings of the targeted individual for whom a need is specified unless there is applicability to the targeted individual or family. The applicability to the targeted individual must be documented.
O. Family support partners services shall not be billed for an individual who resides in a congregate setting in which the caregivers are paid, such as child caring institutions or any other living environment that is not comprised of more permanent caregivers. An exception would be for an individual actively preparing for transition back to a single-family unit, the caregiver is present during the intervention, and the service is directed to supporting the unification or reunification of the individual and his caregiver and takes place in that home and community. The circumstances surrounding the exception shall be documented.
P. Individuals with the following conditions are excluded from family support partners unless there is clearly documented evidence and diagnosis of a substance use disorder or mental health disorder overlaying the diagnosis: developmental disability including intellectual disabilities, organic mental disorder including dementia or Alzheimer's, or traumatic brain injury. There must be documented evidence that the individual is able to participate in the service and benefit from family support partners.
Q. Claims that are not adequately supported by appropriate up-to-date documentation may be subject to recovery of expenditures. Progress notes, as defined in 12VAC30-50-130, shall disclose the extent of services provided and corroborate the units billed. Claims not supported by corroborating progress notes shall be subject to recovery of expenditures.
R. The enrolled provider shall be subject to utilization reviews conducted by DMAS or its designated contractor.
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.
Forms (12VAC30-130)
Forms accompanying Part II of this chapter:
Virginia Uniform Assessment Instrument (eff. 1994)
Forms accompanying Part III of this chapter:
MI/IDD Supplement, DMAS-95, Level I PASRR Form and Instructions (rev 4/2019)
MI/IDD/Related Conditions Supplement Level II, DMAS-95 MI/IDD/RC Supplement (rev. 12/2015)
Forms accompanying Part VII of this chapter:
Request for Hospice Benefits, DMAS-420 (rev. 9/2019)
Forms accompanying Part IX of this chapter:
Patient Information Form Medicaid LTC Communication Form, DMAS-122, 225 (eff. 10/2011)
Documents Incorporated by Reference (12VAC30-130)
Virginia Medicaid Nursing Home Manual, Department of Medical Assistance Services.
Virginia Medicaid Rehabilitation Manual, Department of Medical Assistance Services.
Virginia Medicaid Hospice Manual, Department of Medical Assistance Services.
Virginia Medicaid School Division Manual, Department of Medical Assistance Services.
Policy Manual: Definitions of Priority Mental Health Populations, POLICY 1029(SYS)90 - 2