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.