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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 12. Health |
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Agency 30. Department of Medical Assistance Services |
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Chapter 80. Methods and Standards for Establishing Payment Rates; Other Types of Care |
Section 32. Reimbursement for substance abuse services
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1. Outpatient psychotherapy services for assessment and evaluation or treatment of substance abuse furnished by physicians shall be reimbursed using the methodology in 12VAC30-80-190. For nonphysicians, they shall be reimbursed at the same levels specified in 12VAC30-50-140 and 12VAC30-50-150.
2. Rates for other substance abuse services shall be based on the agency fee schedule for 15 minute units of service. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payments shall be consistent with economy, efficiency, and quality of care. For each level of professional necessary to provide services described in 12VAC30-50-228 and 12VAC30-50-491, separate rates shall be established for licensed professionals, qualified substance abuse professionals (QSAP) and paraprofessionals. The same rates shall be paid to public and private providers.
3. Community substance abuse services: Rehabilitation services. Rates for community substance abuse rehabilitation services shall be based on the agency fee schedule for 15 minute units of service. Separate rates shall be established for licensed professionals, qualified substance abuse professionals (QSAP) and paraprofessionals as described in 12VAC30-50-228. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payments shall be consistent with economy, efficiency, and quality of care. The same rates shall be paid to governmental and private providers. The agency's rates were set as of July 1, 2007, and are effective for services on or after that date. All rates are published on the DMAS website at: www.dmas.virginia.gov.
4. Outpatient substance abuse services: Physician services. Outpatient psychotherapy services for assessment and evaluation or treatment of substance abuse furnished by physicians, as described in 12VAC30-50-140, shall be reimbursed using the methodology described in this section and in 12VAC30-80-190. The same rates shall be paid to governmental and private providers. These services are reimbursed based on the Common Procedural Terminology (CPT) Codes. The agency's rates were set as of July 1, 2007, and are updated as described in 12VAC30-80-190. All rates are published on the DMAS website at: www.dmas.virginia.gov.
5. Outpatient substance abuse services: Other providers, including Licensed Mental Health Professionals (LMHP). Outpatient substance abuse services furnished by other licensed practitioners, as described in 12VAC30-50-150, shall be reimbursed using the methodology described in section 12VAC30-80-30 and in 12VAC30-80-190 and based upon the percentages set forth below. The same rates shall be paid to governmental and private providers. The agency's rates were set as of July 1, 2007, and are updated as described in 12VAC30-80-190. All rates are published on the DMAS website website at: www.dmas.virginia.gov.
a. Services of a licensed clinical psychologist shall be reimbursed at 90% of the reimbursement rate for psychiatrists.
b. Services provided by independently enrolled licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, psychiatric nurse practitioners, licensed substance abuse treatment practitioner, or licensed clinical nurse specialists‑psychiatric shall be reimbursed at 75% of the reimbursement rate for licensed clinical psychologists.
6. Substance abuse services: Clinic services. Outpatient psychotherapy services for assessment and evaluation or treatment of substance abuse furnished by clinics as described in 12VAC30-50-150, shall be reimbursed using the methodology described in 12VAC30-80-30 and in 12VAC30-80-190. The fee schedule in effect, as of July 1, 2007, is an aggregate that is approximately 80% of the Medicare rates for these services. The same rates shall be paid to governmental and private providers. The agency's rates were set as of July 1, 2007, and are updated as described in 12VAC30-80-190. All rates are published on the DMAS website at: www.dmas.virginia.gov.
7. Substance abuse services: Case management services. Substance abuse case management services furnished by professionals as described in 12VAC30-50-140, 12VAC30-50-150 and in 12VAC30-50-491, shall be reimbursed based on the agency fee schedule for 15 minute units of service. The Medicaid and commercial rates for similar services as well as the cost for providing services shall be considered when establishing the fee schedules so that payments shall be consistent with economy, efficiency, and quality of care. The same rates shall be paid to governmental and private providers. The agency's rates were set as of July 1, 2007, and are effective for services on or after that date. All rates are published on the DMAS website at: www.dmas.virginia.gov.
Historical Notes
Derived from Volume 26, Issue 08, eff. January 21, 2010.