12VAC30-50 Amount, Duration, and Scope of Medical and Remedial Care Services

REGULATIONS

Vol. 29 Iss. 12 - February 11, 2013

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCESERVICES

Chapter 50

Proposed Regulation

Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-130, 12VAC30-50-226).

12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-61, 12VAC30-60-143; adding 12VAC30-60-5).

12VAC30-130. Amount, Duration and Scope of Selected Services (adding 12VAC30-130-2000, 12VAC30-130-3000, 12VAC30-130-3010, 12VAC30-130-3020, 12VAC30-130-3030).

Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: April 12, 2013.

Agency Contact: Brian McCormick, Regulatory Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone [phone], FAX [phone], or email [e-mail].

Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance. Sections 32.1-324 and 32.1-325 of the Code of Virginia authorize the Director of Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by § 1902 (a) of the Social Security Act (42 USC § 1396a) provides governing authority for payments for services.

Item 297 YY of Chapter 890 of the 2011 Acts of Assembly gives DMAS authority to make programmatic changes in the provision of intensive in-home (IIH) services and community mental health services (CMHS) in order to ensure appropriate utilization, cost efficiency, and improved provider qualifications.

The proposed utilization control requirements are recommended consistent with the federal requirements at 42 CFR Part 456 Utilization Control. Specifically, 42 CFR 456.3, Statewide surveillance and utilization control program, provides: "The Medicaid agency must implement a statewide surveillance and utilization control program that—

(a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments;

(b) Assesses the quality of those services;

(c) Provides for the control of the utilization of all services provided under the plan in accordance with subpart B of this part; and

(d) Provides for the control of the utilization of inpatient services in accordance with subparts C through I of this part."

The 2011 Acts of Assembly also authorized DMAS to implement a coordinated care model for individuals in need of behavioral health services that are not currently provided through a managed care organization (Item 297 MMMM of Chapter 890).

The Code of Federal Regulations also provides, at 42 CFR 430.10, "…The State plan contains all information necessary for CMS to determine whether the plan can be approved to serve as a basis for Federal financial participation (FFP) in the State program." FFP is the federal matching funds that DMAS receives from the Centers for Medicare and Medicaid Services. Not performing utilization control of the services affected by these proposed regulations, as well as all Medicaid covered services, could subject DMAS' federal matching funds to a CMS recovery action.

Purpose: The agency proposes this regulatory action to comply with Item 297 YY of Chapter 890 of the 2011 Acts of Assembly. In recent years, the utilization of certain community-based mental health services has substantially increased. These changes are part of an agency review of the services being rendered and reimbursed to ensure that they are appropriately utilized and medically necessary.

Another purpose of this proposed regulatory action is to comply with Item 297 MMMM of Chapter 890 of the 2011 Acts of Assembly regarding coordination of care. The overall goals of this care coordination model are twofold: 1) improve the coordination of care for individuals who are receiving behavioral health services with acute and primary services and 2) improve the value of behavioral health services purchased by the Commonwealth without compromising access to these services for vulnerable populations. Pursuant to this directive, DMAS is soliciting a proposal for a behavioral health services administrator (BHSA) for members enrolled in Virginia's Medicaid/FAMIS Plus/FAMIS programs who are receiving behavioral health services not currently provided through a managed care organization but through the fee for service system. The selected BHSA will only provide administrative services including, but not limited to, care coordination activities, authorizing, monitoring, and encouraging appropriate behavioral health service utilization. The implementation of the new care coordination model will occur approximately six months after the BHSA contract is awarded.

This regulatory action is not essential to protect the health, safety, or welfare of all citizens. It is essential to protect the health, safety, and welfare of Medicaid individuals who require behavioral health services. In addition, these proposed changes are intended to promote improved quality of Medicaid-covered behavioral health services provided to individuals.

This regulatory action is also essential, based upon DMAS' anecdotal knowledge, to ensure that Medicaid individuals and their families are well informed about their behavioral health condition and service options prior to receiving these services. This ensures the services are medically necessary for the individual and are rendered by providers who do not engage in questionable patient recruitment and sales tactics.

The proposed changes are expected to improve the quality of the community-based mental health services provided to Medicaid participants while enabling DMAS to better control its expenditures in this rapidly expanding service area.

Substance: The regulations affected by this action are the Amount, Duration and Scope of Services (12VAC30-50-130 (skilled nursing facility services, EPSDT, and family planning) and 12VAC30-50-226 (community mental health services for children and adults)); Standards Established and Methods Used to Assure High Quality of Care (12VAC30-60-61 (utilization review of services related to the EPSDT program) and 12VAC30-60-143 (community mental health services for children and adults and mental health services utilization)). New regulations entitled Marketing Requirements and Restrictions (12VAC30-130-2000) and Behavioral Health Services (12VAC30-130-3000 et seq.) are being proposed.

DMAS has covered certain residential and community mental health services (including intensive in-home services to children and adolescents under age 21, therapeutic day treatment, community-based services for children and adolescents under 21 (Level A), therapeutic behavioral services (Level B), day treatment/partial hospitalization, psychosocial rehabilitation, crisis intervention, intensive community treatment, crisis stabilization, and mental health support services) for a number of years. These services are nontraditional mental health services and are typically only covered by Medicaid.

Since state fiscal year (SFY) 2007, the use of these services has grown dramatically with their related expenditures. For example, reimbursements for intensive in-home services grew one and a half times to $129,337,031 in SFY 2010. Therapeutic day treatment reimbursement increased more than three and one half times to $166,079,326 over the same time. Reimbursement for mental health support services (12VAC30-50-226) grew four and one half times to $138,190,634 over the same time period.

Some of the growth in service usage has been due to more community-based services being provided. The proposed changes included in this action are intended to improve the quality of rendered services, by requiring that providers meet specified licensing and qualification standards to be paid by Medicaid.

The proposed changes are also intended to better ensure the appropriate utilization of services by requiring the completion of the new independent clinical assessments (ICA) by the community service boards (CSBs). DMAS believes that this new ICA step will significantly reduce, if not eliminate, the provision of these community mental health services by providers to individuals whose circumstances do not warrant such serious mental illness diagnoses. Having such serious mental illness diagnoses can negatively affect individuals' future access to educational and employment opportunities. For the application of this new ICA requirement, DMAS is proposing new regulations beginning with 12VAC30-130-3000.

These affected sections also set forth rules and penalties related to the marketing of Medicaid mental health services that are set out in 12VAC30-130-2000 (Part XVII of 12VAC30-130). This action also implements the results of a federal review of residential and community mental health services for children and adults. After reviewing records, the Centers for Medicare and Medicaid Services (CMS) expressed concern about recipients not meeting the established criteria for children's mental health services. This federal review also cited the issue of providers merely copying individuals' progress notes across multiple dates of service and not providing any differentiation across different dates of service. The elements that will be required for service-specific provider assessments are being enumerated so that providers' documentation about individuals' problems and issues adequately supports the providers' reimbursement claims. Provider documentation that does not support reimbursement claims have been subject to payment recoveries.

This action also makes technical corrections such as changing the name of the Department of Mental Health, Mental Retardation, and Substance Abuse Services to the Department of Behavioral Health and Developmental Services (DBHDS).

12VAC30-50-130 B contains the Medicaid requirements for the coverage of services under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Pursuant to 42 CFR 440.40(b) and 441.50 et seq., these controlling federal regulations set out the requirements for this program of well-child preventive health services for Medicaid individuals from birth through the age of 21 years. In 1989, in the context of the federal Omnibus Budget Reconciliation Act of 1989 (§ 6403), Congress established that Medicaid programs were required to provide all medically necessary services, identified as needed as a result of an EPSDT screening, without regard to whether or not the needed services were otherwise covered under that state's State Plan for Medical Assistance. Services provided under the authority of this regulation can only be covered for children.

The changes proposed for this regulation remove the coverage of a week of intensive in-home services without prior authorization and instead require service authorization at the onset of this service. This is intended to eliminate claims processing issues that have delayed payments to providers. Requirements for service-specific provider assessments and individual service plans are also proposed. The categories of licensed professionals who will be reimbursed for these services are specified.

Service (prior) authorization is proposed for therapeutic day treatment for children and adolescents to reflect the current policies.

A new provision is added that services rendered that are based on old (more than a year old) information, or missing or incomplete assessments/individual service plans will be denied payments. A new Definition section is proposed. DMAS is incorporating by reference several professional definitions from regulations of DBHDS.

Providers that are appropriate to render specific services are listed.

12VAC30-50-226 provides for community mental health services, including day treatment/partial hospitalization, psychosocial rehabilitation, crisis intervention, intensive community treatment, crisis stabilization, and mental health support services. These services are covered for both children/adolescents and adults. In this proposed action, DMAS is specifying the types of licensed professionals, consistent with DBHDS' licensing standards, who will be permitted to render these services for purposes of claiming Medicaid reimbursement. The Definition section is expanded to provide for terms used in this section, such as individual service plan and service authorization. This section requires that service-specific provider assessments (as defined in 12VAC30-50-130) be prepared to document how the individual to be treated meets the criteria for this service. Absent such documentation, DMAS cannot determine if the rendered services were appropriate for the individual's diagnosed medical needs and therefore retracts payments to providers. References to case management are changed to care coordination, as part of the intensive community treatment package of services, in response to comments from CMS. A few nonsubstantive, technical edits are proposed for purposes of regulatory parallel construction across subsections.

12VAC30-60-5 is newly created to contain several overarching requirements that will be applied to utilization reviews of all Medicaid covered services. This new section specifically reiterates the general applicability of the Chapter 60 utilization review requirements to all Medicaid covered services without regard to whether these requirements are repeated for each specific covered service.

12VAC30-60-61 provides the utilization review requirements for EPSDT services (as set out in 12VAC30-50-130) that must be met by providers to claim reimbursement from Medicaid. These proposed changes require: (i) enhanced provider documentation and supervision requirements; (ii) completion of an individual service plan within a specified time period; (iii) individual-specific provider progress notes; (iv) provider licensure by DBHDS; (v) provider enrollment with DMAS; (vi) maintaining currency of the individual service plan; (vii) provider compliance with DMAS' marketing requirements; and (viii) provider collaboration with the individual's primary care provider. A new Definition subsection is created.

This proposed action also sets out the elements that must be included, for purposes of Medicaid reimbursement, in the service-specific provider assessments to justify why and how a Medicaid individual requires these covered mental health services. This proposed action requires that the initial service-specific provider assessment for intensive in-home (IIH) services be conducted in the home and that they be appropriately reviewed and signed and dated. IIH service providers must be licensed by DBHDS as well as being enrolled with DMAS. Claims for services based on outdated or incomplete provider assessments will not be paid. If there is a lapse in services for an individual of more than 31 consecutive calendar days, the provider must discharge the individual from his care. If this discharged individual continues to need these services, then the provider must conduct a new assessment for readmission and must obtain a new service authorization. Providers of IIH services will be required to document coordination of services with case management service providers. Providers of IIH services will be required to adhere to DMAS marketing requirements and limitations.

Providers of therapeutic day treatment (TDT) services will be required to be licensed by DBHDS as well as being enrolled with DMAS. TDT providers must prepare service-specific provider assessments, before the onset of services, which must also be appropriately reviewed and signed/dated. This proposed action requires documented coordination with providers of case management services. Providers are required to adhere to DMAS' marketing requirements set out in 12VAC30-130-2000 for the purpose of receiving Medicaid reimbursement for services rendered. Provision is made for how lapses in services are to be handled.

Providers of Level A residential treatment services, called community-based services for children and adolescents, must be licensed by the Department of Social Services or the Department of Juvenile Justice. Service authorization is required for all Level A services before the services will be reimbursed. Service-specific provider assessments and individual service plans must be developed, appropriately reviewed, signed/dated, and kept up to date as the individual's condition changes over time. Services based upon incomplete, missing, or outdated assessments or individual service plans shall be denied reimbursement. Coordination with case managers and primary care providers is also required.

Providers of Level B residential treatment services, called therapeutic behavioral services for children and adolescents, must be licensed by DBHDS. Service authorization is required for all Level B services before the services will be reimbursed. Service-specific provider assessments and individual service plans must be developed, appropriately reviewed, signed/dated, and kept up to date as the individual's condition changes over time. Services based upon incomplete, missing, or outdated assessments or individual service plans shall be denied reimbursement. Coordination with case managers and primary care providers is also required.

12VAC30-60-143 sets out the utilization review requirements, for the purpose of claiming Medicaid reimbursement, applicable to day treatment/partial hospitalization, psychosocial rehabilitation, crisis intervention, case management (relative to the populations reflected at 12VAC30-50-420 and 12VAC30-50-430), intensive community treatment for adults, crisis stabilization, and mental health support services (the services defined in 12VAC30-50-226). Providers of all services are required to secure and maintain a DMAS provider enrollment agreement. Providers of these community mental health services must collaborate with case management providers, if any, in sharing individual status information. Types of licensed professionals who may perform these services, for purposes of Medicaid reimbursement, are specified. To improve the quality of service delivery, provider documentation and supervision requirements are detailed. Providers are restricted by 12VAC30-130-2000 marketing limitations to protect Medicaid individuals and their families from inappropriate provider marketing activities. Outdated references to the Department of Mental Health, Mental Retardation, and Substances Abuse Services are changed to the current DBHDS.

12VAC30-130-2000 contains requirements and limits for providers' marketing plans and activities. These provisions are required to limit the frequency and manner in which providers approach potential clients and seek to engage such clients in their services. DMAS has been made aware that some providers may have engaged in questionable and inappropriate marketing tactics to boost their Medicaid patient load thereby increasing their Medicaid reimbursements. DMAS must, pursuant to the 42 CFR 431.51 guarantee of freedom of choice of providers, protect Medicaid individuals and their families from potential coercion to sign up for treatment with certain providers.

12VAC30-130-3000 contains requirements for independent clinical assessments (ICA) and establishes the entities that will be responsible for completing them as the ICA applies to intensive in-home services, therapeutic day treatment, and mental health support services for children and adolescents. After the ICA is conducted, the individual or the parent/legal guardian must be given free choice in selecting a provider of the needed services in conformance with the federal freedom of provider choice requirements of 42 CFR 431.52. Recommendations for services contained in these new ICAs will not be subject to appeal actions. Such recommendations will be issued by independent assessors as employees or subcontractors with CSBs/behavioral health authority (BHAs) or the behavioral health services administrator (BHSA) and are akin to physician diagnoses that are also not subject to appeal.

In instances when parents/legal guardians want their children/adolescents to receive certain mental health services that are not supported by the results of the ICA, a process is created for the service provider to provide additional documentation, beyond the ICA, to DMAS' service authorization designee for further consideration. Should the parentally requested service be denied, then the parent/legal guardian will have the right to appeal this service denial via the existing client appeals process at 12VAC30-110.

This proposed action also allows for a BHSA, a new contractor for DMAS, to manage and administer these services. DMAS is currently undergoing a procurement action to permit the contracting out of this function.

Issues: The proposed regulations increase provider qualifications, set out assessment components, require an independent assessment, and require providers to be licensed by the appropriate licensing agency. These actions will ensure that providers are qualified and employ qualified staff to work with children, adults, and families. Also, assessments and recommendations for services are standardized. Services will be provided that are appropriate to clinical needs.

The disadvantages of these changes are that some persons who previously qualified to provide services and receive Medicaid reimbursement may no longer qualify for Medicaid payments. If this occurs, there may be possible delays in access to care due to the need for a referral to alternative treatment resources. The number of children receiving certain services may decrease as they are expected to be referred to less intensive services, which may reduce the demand for the more intensive and more highly reimbursed services.

The Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The proposed regulations implement programmatic changes in the provision of various community mental health services, such as intensive in-home services, therapeutic day treatment services, psychosocial rehabilitation services, crisis intervention services, mental health support services, crisis stabilization services, intensive community treatment services, and early and periodic screening, diagnosis, and treatment services to ensure appropriate utilization and cost efficiency.

Result of Analysis. There is insufficient data to accurately compare the magnitude of the benefits versus the costs. Detailed analysis of the benefits and costs can be found in the next section.

Estimated Economic Impact. Chapter 890, Item 297 YY, of the 2011 Acts of Assembly directed the Department of Medical Assistance Services to implement programmatic changes in the provision of certain community mental health services to ensure appropriate utilization and cost efficiency. These services include intensive in-home services, therapeutic day treatment services, psychosocial rehabilitation services, crisis intervention services, mental health support services, crisis stabilization services, intensive community treatment services, and early and periodic screening, diagnosis, and treatment services.

According to data provided by DMAS, since fiscal year (FY) 2007, the use of some of these services has grown dramatically with their related expenditures. For example, reimbursements for intensive in-home services grew over two times to $177 million in FY 2010. Therapeutic day treatment reimbursements increased more than three times to $145 million over the same time. Reimbursement for mental health support services grew two and one half times to $79 million over the same time period.

Pursuant to the statutory mandate, DMAS implemented emergency regulations in July 2011. The proposed changes will make the emergency regulations permanent.

One of the proposed utilization and cost efficiency measures is the requirement for an Independent Clinical Assessment (ICA) to authorize the use of intensive in-home, therapeutic day treatment, and mental health support services for children and adolescents. ICAs are currently performed by the Community Services Boards (CSBs) for $250 per assessment. In 2011, before the implementation of the ICA program, DMAS estimated the total cost of assessments to be about $8 million per year and total savings of averted services to be about $13.7 million per year, producing an estimated net savings of about $5.7 million annually. However, actual net savings appear to be much higher. Recent data suggest that the total assessment fee paid to CSBs was approximately $5.6 million and a preliminary estimate of the actual savings from averted services in FY 2012 is in the range of $50 million.

The main economic effect of the ICA is reducing expenditures for intensive in-home, therapeutic day treatment, and mental health support services by curbing demand for such services. Thus, providers of these services are expected to experience some revenue losses while the Virginia Medicaid program realizes savings. Also, the CSBs are likely to see an increase in their revenues for conducting ICAs and the Medicaid program will see a corresponding increase in expenditures for such assessments. Since the Virginia Medicaid program is financed 50% by the state and 50% by the federal government, one half of any savings and new costs will accrue to or be borne by the Commonwealth.

Another significant economic effect of ICA has to do with improving allocative efficiency of limited Medicaid funds. ICA is expected to ensure that utilization of services is clinically justified. By reducing the consumption of services that cannot be supported by the clinical assessment, these proposed changes help reallocate the limited state and federal funds to uses with greater need.

While separate fiscal estimates are not available for each of the remaining proposed changes, two of them aim to limit utilization by reducing demand. One of these changes is removing the coverage of a week of intensive in-home services without prior authorization and instead requiring service authorization at the onset of this service. The second change is establishing various marketing limitations to prevent inappropriate advertising practices. The likely economic impact of these two changes is a reduction in the demand for related services. In addition, these measures are expected to help achieve more appropriate utilization of these services. Thus, the providers of these services are likely to experience some revenue losses while the Virginia Medicaid program is likely to realize savings.

Two other proposed changes seem to target reduction in utilization through supply side restrictions. One change establishes more stringent staff qualifications and another improves the clarity of regulations to help enforce utilization reviews and licensing standards. The likely impact of these two changes is a reduction in the supply of related services. Some providers may incur additional compliance costs to meet new staff qualifications and enforcement of clearer standards and/or be subject to payment retractions. These changes are also expected to improve the quality of services offered.

Finally, the proposed changes also update the regulatory language to be compatible with the functions of the Behavioral Health Services Administrator if and when this position is filled or contracted out by DMAS. This position is authorized by Chapter 890, Item 297 MMMM, of the 2011 Acts of Assembly.

Businesses and Entities Affected. In FY 2012, approximately 772 providers of community mental health rehabilitative services provided services to approximately 28,000 recipients. Also, there are 40 CSBs currently performing ICAs.

Localities Particularly Affected. The proposed regulations are not expected to affect any particular locality more than others.

Projected Impact on Employment. The proposed demand and supply side restrictions are expected to reduce the consumption of behavioral health services provided; consequently, reducing the demand for labor. However, savings are anticipated to stem from the more appropriate use of services and improved allocation of economic resources among alternative uses. One exception is the proposed ICA requirement which is expected to increase the labor demand by CSBs.

Effects on the Use and Value of Private Property. The proposed regulations do not have direct effects on the use and value of private property. However, proposed changes may reduce provider revenues or add to their compliance costs both of which would have a negative impact on their asset values.

Small Businesses: Costs and Other Effects. Most of the providers are expected to be small businesses. Thus, the costs and other effects to them are the same as discussed above.

Small Businesses: Alternative Method that Minimizes Adverse Impact. There is no known alternative that minimizes the adverse impact while achieving the same results.

Real Estate Development Costs. No effects on real estate development costs are expected.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget regarding the regulations concerning 2011 Mental Health Services Program Changes for Appropriate Utilization and Provider Qualifications. The agency concurs with this analysis.

Summary:

The department is proposing amendments to comply with items in the budget bill that require changes in the provisions of intensive in-home services and community mental health services to ensure appropriate utilization, cost efficiency, and provider qualifications appropriate to render these services. This action includes: (i) changes to provider qualifications including meeting licensing standards; (ii) marketing requirements and restrictions; (iii) new assessment requirements; and (iv) language enhancements for utilization review requirements to help providers avoid payment retractions. New independent clinical assessments, conducted by local community services boards or behavioral health authorities, are required prior to the onset of specified services until the department's behavioral health services administrator contractor can assume this responsibility. Providers that are permitted to claim Medicaid reimbursement for specific services are specified by license type.

12VAC30-50-130. Skilled nursing facility services, EPSDT, school health services, and family planning.

A. Skilled nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Service must be ordered or prescribed and directed or performed within the scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities, and the accompanying attendant physician care, in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination.

2. Routine physicals and immunizations (except as provided through EPSDT) are not covered except that well-child examinations in a private physician's office are covered for foster children of the local social services departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically necessary to correct a visual defect identified by an EPSDT examination or evaluation. The department shall place appropriate utilization controls upon this service.

4. Consistent with the Omnibus Budget Reconciliation Act of 1989 § 6403, early and periodic screening, diagnostic, and treatment services means the following services: screening services, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in Social Security Act § 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services and which are medically necessary, whether or not such services are covered under the State Plan and notwithstanding the limitations, applicable to recipients ages 21 and over, provided for by the Act § 1905(a).

5. Community mental health services.

a. Definitions. The following words and terms when used in these regulations shall have the following meanings unless the context clearly indicates otherwise:

"Activities of daily living" means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.

"Adolescent or child" means the individual receiving the services described in this section.

"Behavioral health services administrator" or "BHSA" means an entity that manages or directs a behavioral health benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care.

"Certified pre-screener" means an employee of either DMAS, a BHSA, or the local community services board or behavioral health authority, or its designee, who is skilled in the assessment and treatment of mental illness and has completed a certification program approved by the Department of Behavioral Health and Developmental Services.

"Clinical experience" means, for the purpose of Medicaid reimbursement of (i) intensive in-home services, (ii) day treatment for children and adolescents, (iii) community-based residential services for children and adolescents who are younger than 21 (Level A), and (iv) therapeutic behavioral services (Level B), providing direct behavioral health services to children and adolescents who have diagnoses of mental illness and includes supervised internships, supervised practicums, and supervised field experience. Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience.

"DBHDS" means the Department of Behavioral Health and Developmental Services.

"DMAS" means the Department of Medical Assistance Services and its contractor or contractors.

"Human services field" means, for the purpose of (i) intensive in-home, (ii) day treatment for children and adolescents, (iii) community-based residential services for children and adolescents younger than 21 (Level A), and (iv) therapeutic behavioral services (Level B), social work, psychology, sociology, counseling, special education, human child or family development, cognitive or behavioral sciences, marriage and family therapy, or art or music therapy.

"Individual service plan" or "ISP" means the same as the term is defined in 12VAC30-50-226.

"Licensed mental health professional" or "LMHP" means the same as the term is defined in 12VAC35-105-20.

"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes. Individualized and member-specific progress notes are part of the minimum documentation requirements and shall convey the individual's status, staff interventions, and, as appropriate, progress toward goals and objectives in the ISP. The progress notes shall also include, as a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units/hours required to deliver the service. The content of each progress note shall corroborate the time/units billed. Progress notes shall be documented for each service that is billed.

"Qualified mental health professional-child" or "QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified paraprofessional in mental health" or "QPPMH" means the same as the term is defined in 12VAC35-105-20.

"Service-specific provider assessment" means the face-to-face interaction in which the provider obtains information from the child or adolescent, and parent or other family member or members, as appropriate, about health status. It includes documented history of the severity, intensity, and duration of health care problems and issues and shall contain all of the following elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations, (iii) previous interventions by providers and timeframes and response to treatment, (iv) medical profile, (v) developmental history including history of abuse, if appropriate, (vi) educational/vocational status, (vii) current living situation and family history and relationships, (viii) legal status, (ix) drug and alcohol profile, (x) resources and strengths, (xi) mental status exam and profile, (xii) diagnosis, (xiii) professional assessment summary and clinical formulation, (xiv) recommended care and treatment goals, and (xv) the dated signature of the LMHP.

a. b. Intensive in-home services to children and adolescents under age 21 shall be time-limited interventions provided typically but not solely in the residence of a child an individual who is at risk of being moved into an out-of-home placement or who is being transitioned to home from an out-of-home placement due to a documented medical need of the child individual. These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child individual and his parents or guardians, as appropriate, to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); case management activities and care coordination with other required services; and 24-hour emergency response.

(1) These services shall be limited annually to 26 weeks. After an initial period, prior authorization is required for Medicaid reimbursement. Service authorization shall be required for Medicaid reimbursement prior to the onset of services. Services rendered before the date of authorization shall not be reimbursed.

(2) Service authorization shall be required for services to continue beyond the initial 26 weeks.

(3) Service-specific provider assessments shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider assessments or ISPs shall be denied reimbursement. Requirements for service-specific provider assessments and ISPs are set out in 12VAC30-50-130.

(4) These services may only be rendered by an LMHP or a QMHP-C.

b. c. Therapeutic day treatment shall be provided two or more hours per day in order to provide therapeutic interventions. Day treatment programs, limited annually to 780 units, provide evaluation; medication; education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills (e.g., problem solving, anger management, community responsibility, increased impulse control, and appropriate peer relations, etc.); and individual, group and family psychotherapy.

(1) Service authorization shall be required for Medicaid reimbursement.

(2) Service-specific provider assessments shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider assessments or ISPs shall be denied reimbursement. Requirements for service-specific provider assessments and ISPs are set out in 12VAC30-50-130.

(3) These services may be rendered only by an LMHP or a QMHP-C.

c. d. Community-Based Services for Children and Adolescents under 21 (Level A).

(1) Such services shall be a combination of therapeutic services rendered in a residential setting. The residential services will provide structure for daily activities, psychoeducation, therapeutic supervision, care coordination, and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. DMAS will reimburse only for services provided in facilities or programs with no more than 16 beds. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual ® Criteria, or an equivalent standard authorized in advance by DMAS shall be required for this service.

(2) In addition to the residential services, the child must receive, at least weekly, individual psychotherapy that is provided by a licensed mental health professional an LMHP.

(3) Individuals must shall be discharged from this service when other less intensive services may achieve stabilization.

(4) Authorization is shall be required for Medicaid reimbursement. Services that were rendered before the date of service authorization shall not be reimbursed.

(5) Room and board costs are shall not be reimbursed. Facilities that only provide independent living services are not reimbursed. DMAS shall reimburse only for services provided in facilities or programs with no more than 16 beds.

(6) Providers These residential providers must be licensed by the Department of Social Services, Department of Juvenile Justice, or Department of Education Department of Behavioral Health Developmental Services under the Standards for Interdepartmental Regulation of Licensed Children's Residential Facilities (22VAC40-151), Standards for Interim Regulation of Children's Residential Facilities (6VAC35-51), or Regulations for Children's Residential Facilities (22VAC42-10) (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven psychoeducational activities per week. Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management.

(8) The facility/group home must coordinate services with other providers. Such care coordination shall be documented in the individual's medical record. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

(9) Service-specific provider assessments shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider assessments or ISPs shall be denied reimbursement. Requirements for assessments and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP, a QMHP-C, or a QPPMH.

d. e. Therapeutic Behavioral Services (Level B).

(1) Such services must be therapeutic services rendered in a residential setting that provides structure for daily activities, psychoeducation, therapeutic supervision, care coordination, and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. DMAS will reimburse only for services provided in facilities or programs with no more than 16 beds. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual ® Criteria, or an equivalent standard authorized in advance by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed.

(3) Room and board costs are shall not be reimbursed. Facilities that only provide independent living services are not reimbursed. DMAS shall reimburse only for services provided in facilities or programs with no more than 16 beds.

(4) Providers These residential providers must be licensed by the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) Behavioral Health and Developmental Services (DBHDS) under the Standards Regulations for Interdepartmental Regulation of Children's Residential Facilities (22VAC42-10) (12VAC35-46).

(5) Daily progress notes shall document that a minimum of seven psychoeducational activities per week occurs. Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management. This service may be provided in a program setting or a community-based group home.

(6) The child individual must receive, at least weekly, individual psychotherapy and, at least weekly, group psychotherapy that is provided as part of the program.

(7) Individuals must shall be discharged from this service when other less intensive services may achieve stabilization.

(8) Service-specific provider assessments shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services that are based upon incomplete, missing, or outdated service-specific provider assessments or ISPs shall be denied reimbursement. Requirements for assessments and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP, a QMHP-C, or a QPPMH.

(10) The facility/group home shall coordinate necessary services with other providers. Documentation of this care coordination shall be maintained by the facility/group home in the individual's record. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

6. Inpatient psychiatric services shall be covered for individuals younger than age 21 for medically necessary stays for the purpose of diagnosis and treatment of mental health and behavioral disorders identified under EPSDT when such services are rendered by:

a. A psychiatric hospital or an inpatient psychiatric program in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations; or a psychiatric facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation Facilities, the Council on Accreditation of Services for Families and Children or the Council on Quality and Leadership.

b. Inpatient psychiatric hospital admissions at general acute care hospitals and freestanding psychiatric hospitals shall also be subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25. Inpatient psychiatric admissions to residential treatment facilities shall also be subject to the requirements of Part XIV (12VAC30-130-850 et seq.) of this chapter.

c. Inpatient psychiatric services are reimbursable only when the treatment program is fully in compliance with 42 CFR Part 441 Subpart D, as contained in 42 CFR 441.151 (a) and (b) and 441.152 through 441.156. Each admission must be preauthorized and the treatment must meet DMAS requirements for clinical necessity.

7. Hearing aids shall be reimbursed for individuals younger than 21 years of age according to medical necessity when provided by practitioners licensed to engage in the practice of fitting or dealing in hearing aids under the Code of Virginia.

C. School health services.

1. School health assistant services are repealed effective July 1, 2006.

2. School divisions may provide routine well-child screening services under the State Plan. Diagnostic and treatment services that are otherwise covered under early and periodic screening, diagnosis and treatment services, shall not be covered for school divisions. School divisions to receive reimbursement for the screenings shall be enrolled with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall receive screenings from those organizations. School divisions shall not receive reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's Individualized Education Program (IEP) and covered under one or more of the service categories described in § 1905(a) of the Social Security Act. These services are necessary to correct or ameliorate defects of physical or mental illnesses or conditions.

3. Service providers shall be licensed under the applicable state practice act or comparable licensing criteria by the Virginia Department of Education, and shall meet applicable qualifications under 42 CFR Part 440. Identification of defects, illnesses or conditions and services necessary to correct or ameliorate them shall be performed by practitioners qualified to make those determinations within their licensed scope of practice, either as a member of the IEP team or by a qualified practitioner outside the IEP team.

a. Service providers shall be employed by the school division or under contract to the school division.

b. Supervision of services by providers recognized in subdivision 4 of this subsection shall occur as allowed under federal regulations and consistent with Virginia law, regulations, and DMAS provider manuals.

c. The services described in subdivision 4 of this subsection shall be delivered by school providers, but may also be available in the community from other providers.

d. Services in this subsection are subject to utilization control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services described in subdivision 4 of this subsection are medically necessary and that the treatment prescribed is in accordance with standards of medical practice. Medical necessity is defined as services ordered by IEP providers. The IEP providers are qualified Medicaid providers to make the medical necessity determination in accordance with their scope of practice. The services must be described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for individuals with speech, hearing, and language disorders, performed by, or under the direction of, providers who meet the qualifications set forth at 42 CFR 440.110. This coverage includes audiology services;.

b. Skilled nursing services are covered under 42 CFR 440.60. These services are to be rendered in accordance to the licensing standards and criteria of the Virginia Board of Nursing. Nursing services are to be provided by licensed registered nurses or licensed practical nurses but may be delegated by licensed registered nurses in accordance with the regulations of the Virginia Board of Nursing, especially the section on delegation of nursing tasks and procedures. the licensed practical nurse is under the supervision of a registered nurse.

(1) The coverage of skilled nursing services shall be of a level of complexity and sophistication (based on assessment, planning, implementation and evaluation) that is consistent with skilled nursing services when performed by a licensed registered nurse or a licensed practical nurse. These skilled nursing services shall include, but not necessarily be limited to dressing changes, maintaining patent airways, medication administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and specifically related to an active, written plan of care developed by a registered nurse that is based on a written order from a physician, physician assistant or nurse practitioner for skilled nursing services. This order shall be recertified on an annual basis.

c. Psychiatric and psychological services performed by licensed practitioners within the scope of practice are defined under state law or regulations and covered as physicians' services under 42 CFR 440.50 or medical or other remedial care under 42 CFR 440.60. These outpatient services include individual medical psychotherapy, group medical psychotherapy coverage, and family medical psychotherapy. Psychological and neuropsychological testing are allowed when done for purposes other than educational diagnosis, school admission, evaluation of an individual with mental retardation prior to admission to a nursing facility, or any placement issue. These services are covered in the nonschool settings also. School providers who may render these services when licensed by the state include psychiatrists, licensed clinical psychologists, school psychologists, licensed clinical social workers, professional counselors, psychiatric clinical nurse specialist, marriage and family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and performed by persons qualified under this subsection. The personal care assistant is supervised by a DMAS recognized school-based health professional who is acting within the scope of licensure. This practitioner develops a written plan for meeting the needs of the child, which is implemented by the assistant. The assistant must have qualifications comparable to those for other personal care aides recognized by the Virginia Department of Medical Assistance Services. The assistant performs services such as assisting with toileting, ambulation, and eating. The assistant may serve as an aide on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.

e. Medical evaluation services are covered as physicians' services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR 440.60. Persons performing these services shall be licensed physicians, physician assistants, or nurse practitioners. These practitioners shall identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53 and described at State Plan Attachment 3.1-D. Transportation shall be rendered only by school division personnel or contractors. Transportation is covered for a child who requires transportation on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Transportation shall be listed in the child's IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess the need for medical services in a child's IEP and shall be performed by any of the above licensed practitioners within the scope of practice. Assessments and reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that duplication of services will be monitored. School divisions have a responsibility to ensure that if a child is receiving additional therapy outside of the school, that there will be coordination of services to avoid duplication of service.

D. Family planning services and supplies for individuals of child-bearing age.

1. Service must be ordered or prescribed and directed or performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services that delay or prevent pregnancy. Coverage of such services shall not include services to treat infertility nor services to promote fertility.

12VAC30-50-226. Community mental health services.

A. Definitions. The following words and terms when used in these regulations shall have the following meanings unless the context clearly indicates otherwise:

"Certified prescreener" means an employee of either the local community services board community services board/behavioral health authority, behavioral health service administrator or its designee who is skilled in the assessment and treatment of mental illness and who has completed a certification program approved by DBHDS.

"Clinical experience" means, for the purpose of rendering (i) mental health day treatment/partial hospitalization, (ii) intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental health support, (v) crisis stabilization, and (vi) crisis intervention services, practical experience in providing direct services on a full-time basis to individuals with medically-documented diagnoses of mental illness or mental retardation intellectual/developmental disability or the provision of direct geriatric services or full-time special education services. Experience may shall include supervised internships, supervised practicums, and or supervised field experience. Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience. This required clinical experience shall be calculated as set forth in 12VAC35-105-20.

"Code" means the Code of Virginia.

"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.

"DMAS" means the Department of Medical Assistance Services and its contractor or contractors consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

"Human services field" means for the purpose of (i) mental health day treatment/partial hospitalization, (ii) intensive community treatment, (iii) psychosocial rehabilitation, (iv) mental health support, (v) crisis stabilization, and (vi) crisis intervention services, social work, gerontology, psychology, psychiatric rehabilitation, special education, sociology, counseling, vocational rehabilitation, behavioral sciences, marriage and family therapy, art or music therapy, and human services counseling or other degrees deemed equivalent by DMAS.

"Individual" means the patient, client, or recipient of services set out herein described in this section.

"Individual service plan" or "ISP" means a comprehensive and regularly updated statement treatment plan specific to the individual being treated containing, but not necessarily limited to, his treatment or training needs, his 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 estimated timetable for achieving the goals and objectives. The provider shall include the individual in the development of the ISP. To the extent that the individual's condition requires assistance for participation, assistance shall be provided. The ISP shall be updated as the needs and progress of the individual changes. individual's unique treatment needs as identified in the clinical assessment. The ISP contains his treatment or training needs, his goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, the estimated timetable for achieving the goals and objectives, and an individualized discharge plan that describes transition to other appropriate services. The ISP shall be signed by the individual. If the individual is a minor child, the ISP shall also be signed by the individual's parent/legal guardian. Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP.

"Licensed Mental Health Professional" or "LMHP" means an individual licensed in Virginia as a physician, a clinical psychologist, a professional counselor, a clinical social worker, or a psychiatric clinical nurse specialist the same as defined in 12VAC35-105-20.

"Qualified mental health professional" or "QMHP" means a clinician in the human services field who is trained and experienced in providing psychiatric or mental health services to individuals who have a psychiatric diagnosis. If the QMHP is also one of the defined licensed mental health professionals, the QMHP may perform the services designated for the Licensed Mental Health Professionals unless it is specifically prohibited by their licenses. These QMHPs may be either a:

1. Physician who is a doctor of medicine or osteopathy and is licensed in Virginia;

2. Psychiatrist who is a doctor of medicine or osteopathy, specializing in psychiatry and is licensed in Virginia;

3. Psychologist who has a master's degree in psychology from an accredited college or university with at least one year of clinical experience;

4. Social worker who has a master's or bachelor's degree from a school of social work accredited or approved by the Council on Social Work Education and has at least one year of clinical experience;

5. Registered nurse who is licensed as a registered nurse in the Commonwealth and has at least one year of clinical experience; or

6. Mental health worker who has at least:

a. A bachelor's degree in human services or a related field from an accredited college and who has at least one year of clinical experience;

b. Registered Psychiatric Rehabilitation Provider (RPRP) registered with the International Association of Psychosocial Rehabilitation Services (IAPSRS) as of January 1, 2001;

c. A bachelor's degree from an accredited college in an unrelated field with an associate's degree in a human services field. The individual must also have three years clinical experience;

d. A bachelor's degree from an accredited college and certification by the International Association of Psychosocial Rehabilitation Services (IAPSRS) as a Certified Psychiatric Rehabilitation Practitioner (CPRP);

e. A bachelor's degree from an accredited college in an unrelated field that includes at least 15 semester credits (or equivalent) in a human services field. The individual must also have three years clinical experience; or

f. Four years clinical experience.

"Qualified mental health professional-adult" or "QMHP-A" means the same as defined in 12VAC35-105-20.

"Qualified mental health professional-child" or "QMHP-C" means the same as defined in 12VAC35-105-20.

"Qualified paraprofessional in mental health" or "QPPMH" means an individual who meets at least one of the following criteria: the same as defined in 12VAC35-105-20.

1. Registered with the International Association of Psychosocial Rehabilitation Services (IAPSRS) as an Associate Psychiatric Rehabilitation Provider (APRP), as of January 1, 2001;

2. Has an associate's degree in one of the following related fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and has at least one year of experience providing direct services to persons with a diagnosis of mental illness;

3. An associate's or higher degree, in an unrelated field and at least three years experience providing direct services to persons with a diagnosis of mental illness, gerontology clients, or special education clients. The experience may include supervised internships, practicums and field experience.

4. A minimum of 90 hours classroom training in behavioral health and 12 weeks of experience under the direct personal supervision of a QMHP providing services to persons with mental illness and at least one year of clinical experience (including the 12 weeks of supervised experience).

5. College credits (from an accredited college) earned toward a bachelor's degree in a human service field that is equivalent to an associate's degree and one year's clinical experience.

6. Licensure by the Commonwealth as a practical nurse with at least one year of clinical experience.

"Register" or "registration" means notifying DMAS or its contractor that an individual will be receiving either crisis stabilization or crisis intervention.

"Service authorization" means the final determination of Medicaid reimbursement made by either DMAS or its service authorization contractor for specified medical services for a specified individual to be rendered by a specified provider.

B. Mental health services. The following services, with their definitions, shall be covered: day treatment/partial hospitalization, psychosocial rehabilitation, crisis services, intensive community treatment (ICT), and mental health supports. Staff travel time shall not be included in billable time for reimbursement.

1. Day treatment/partial hospitalization services shall be provided in sessions of two or more consecutive hours per day, which may be scheduled multiple times per week, to groups of individuals in a nonresidential setting. These services, limited annually to 780 units, include the major diagnostic, medical, psychiatric, psychosocial, and psychoeducational treatment modalities designed for individuals who require coordinated, intensive, comprehensive, and multidisciplinary treatment but who do not require inpatient treatment. One unit of service shall be defined as a minimum of two but less than four hours on a given day. Two units of service shall be defined as at least four but less than seven hours in a given day. Three units of service shall be defined as seven or more hours in a given day. Authorization is required for Medicaid reimbursement.

a. Day treatment/partial hospitalization services shall be time limited interventions that are more intensive than outpatient services and are required to stabilize an individual's psychiatric condition. The services are delivered when the individual is at risk of psychiatric hospitalization or is transitioning from a psychiatric hospitalization to the community. The service-specific provider assessment, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual is at risk of psychiatric hospitalization or is transitioning from a psychiatric hospitalization to the community.

b. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis:

(1) Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness or isolation from social supports;

(2) Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;

(3) Exhibit such inappropriate behavior that requires the individual requires repeated interventions or monitoring by the mental health, social services, or judicial system that have been documented; or

(4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

c. Individuals shall be discharged from this service when they are no longer in an acute psychiatric state and other less intensive services may achieve psychiatric stabilization.

d. Admission and services for time periods longer than 90 calendar days must be authorized based upon a face-to-face evaluation by a physician, psychiatrist, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, or psychiatric clinical nurse specialist.

e. These services may only be rendered by either an LMHP, QMHP-A, QMHP-C, or a QPPMH.

2. Psychosocial rehabilitation shall be provided at least two or more hours per day to groups of individuals in a nonresidential setting. These services, limited annually to 936 units, include assessment, education to teach the patient about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. One unit of service is defined as a minimum of two but less than four hours on a given day. Two units are defined as at least four but less than seven hours in a given day. Three units of service shall be defined as seven or more hours in a given day. Authorization is required for Medicaid reimbursement. The service-specific provider assessment, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service.

a. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals: (i) who without these services would be unable to remain in the community or (ii) who meet at least two of the following criteria on a continuing or intermittent basis:

a. (1) Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports;

b. (2) Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;

c. (3) Exhibit such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial system are or have been necessary; or

d. (4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior.

b. These services may only be rendered by an LMHP, QMHP-A, QMHP-C, or QPPMH.

3. Crisis intervention shall provide immediate mental health care, available 24 hours a day, seven days per week, to assist individuals who are experiencing acute psychiatric dysfunction requiring immediate clinical attention. This service's objectives shall be to prevent exacerbation of a condition, to prevent injury to the client or others, and to provide treatment in the context of the least restrictive setting. Crisis intervention activities shall include assessing the crisis situation, providing short-term counseling designed to stabilize the individual, providing access to further immediate assessment and follow-up, and linking the individual and family with ongoing care to prevent future crises. Crisis intervention services may include office visits, home visits, preadmission screenings, telephone contacts, and other client-related activities for the prevention of institutionalization. The service-specific provider assessment, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. The provision of this service to an individual shall be registered with either DMAS or the BHSA to avoid duplication of services and to ensure informed care coordination. This registration shall transmit to DMAS or its contractor: (i) the individual's name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code, begin date of the service, and the amount of the service that will be provided; and (iii) the provider's name and NPI, a provider contact name and phone number, and email address.

a. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization. Individuals must meet at least two of the following criteria at the time of admission to the service:

(1) Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports;

(2) Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;

(3) Exhibit such inappropriate behavior that immediate interventions documented by mental health, social services, or the judicial system are or have been necessary; or

(4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior.

b. The annual limit for crisis intervention is 720 units per year. A unit shall equal 15 minutes.

c. These services may only be rendered by an LMHP, QMHP-A, or QMHP-C and a certified pre-screener.

4. Intensive community treatment (ICT), initially covered for a maximum of 26 weeks based on an initial service-specific provider assessment with continuation reauthorized for an additional 26 weeks annually based on written assessment and certification of need by a qualified mental health provider (QMHP), shall be defined as medical psychotherapy, psychiatric assessment, medication management, and case management care coordination activities offered to outpatients outside the clinic, hospital, or office setting for individuals who are best served in the community. The annual unit limit shall be 130 units with a unit equaling one hour. Authorization is required for Medicaid reimbursement.

a. To qualify for ICT, the individual must meet at least one of the following criteria:

a. (1) The individual must be at high risk for psychiatric hospitalization or becoming or remaining homeless due to mental illness or require intervention by the mental health or criminal justice system due to inappropriate social behavior.

b. (2) The individual has a history (three months or more) of a need for intensive mental health treatment or treatment for co-occurring serious mental illness and substance use disorder and demonstrates a resistance to seek out and utilize appropriate treatment options.

(1) An b. A written, service-specific provider assessment, as defined at 12VAC30-50-130, that documents the individual's eligibility and the need for this service must be completed prior to the initiation of services. This assessment must be maintained in the individual's records.

(2) A service plan must c. An individual service plan shall be initiated at the time of admission and must be fully developed, as defined in 12VAC30-50-226, within 30 days of the initiation of services.

d. The annual unit limit shall be 130 units with a unit equaling one hour.

e. These services may only be rendered by an LMHP, QMHP-A, QMHP-C, and QPPMH.

5. Crisis stabilization services for nonhospitalized individuals shall provide direct mental health care to individuals experiencing an acute psychiatric crisis which may jeopardize their current community living situation. Authorization Services may be authorized for up to a 15-day period per crisis episode following a documented face-to-face service-specific provider assessment by a QMHP which QMHP-A or QMHP-C that is reviewed and approved by an LMHP within 72 hours of the assessment. The maximum limit on this service is up to eight hours (with a unit being one hour) per day up to 60 days annually. Only one unit of service shall be reimbursed for this assessment. The provision of this service to an individual shall be registered with either DMAS or the BHSA to avoid duplication of services and to ensure informed care coordination. This registration shall transmit to DMAS or its contractor: (i) the individual's name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code, begin date of the service, and the amount of the service that will be provided; and (iii) the provider's name and NPI, a provider contact name and phone number, and email address.

a. The goals of crisis stabilization programs shall be to avert hospitalization or rehospitalization, provide normative environments with a high assurance of safety and security for crisis intervention, stabilize individuals in psychiatric crisis, and mobilize the resources of the community support system and family members and others for on-going maintenance and rehabilitation. The services must be documented in the individual's records as having been provided consistent with the ISP in order to receive Medicaid reimbursement.

b. The crisis stabilization program shall provide to recipients individuals, as appropriate, psychiatric assessment including medication evaluation, treatment planning, symptom and behavior management, and individual and group counseling.

c. This service may be provided in any of the following settings, but shall not be limited to: (i) the home of a recipient an individual who lives with family or other primary caregiver; (ii) the home of a recipient an individual who lives independently; or (iii) community-based programs licensed by DBHDS to provide residential services but which are not institutions for mental disease (IMDs).

d. This service shall not be reimbursed for (i) recipients individuals with medical conditions that require hospital care; (ii) recipients individuals with primary diagnosis of substance abuse; or (iii) recipients individuals with psychiatric conditions that cannot be managed in the community (i.e., recipients individuals who are of imminent danger to themselves or others).

e. The maximum limit on this service is 60 days annually.

f. Services must be documented through daily notes and a daily log of times spent in the delivery of services. The service-specific provider assessment, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization. Individuals must meet at least two of the following criteria at the time of admission to the service:

a. (1) Experience difficulty in establishing and maintaining normal interpersonal relationships to such a degree that the individual is at risk of psychiatric hospitalization, homelessness, or isolation from social supports;

b. (2) Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized;

c. (3) Exhibit such inappropriate behavior that immediate interventions documented by the mental health, social services, or judicial system are or have been necessary; or

d. (4) Exhibit difficulty in cognitive ability such that the individual is unable to recognize personal danger or significantly inappropriate social behavior.

g. These services may only be rendered by an LMHP, QMHP-A, or QMHP-C and a certified pre-screener.

6. Mental health support services (MHSS) shall be defined as training and supports to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed. These services may be authorized for up to six consecutive months as long as the individual meets the coverage criteria for this service. The service-specific provider assessment, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. This program shall provide the following services in order to be reimbursed by Medicaid: training in or reinforcement of functional skills and appropriate behavior related to the individual's health and safety, activities of daily living, and use of community resources; assistance with medication management; and monitoring health, nutrition, and physical condition.

a. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals who without these services would be unable to remain in the community. The individual must have meet at least two of the following criteria on a continuing or intermittent basis:

(1) Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that the individual is at risk of psychiatric hospitalization or homelessness or isolation from social supports;

(2) Require help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized;

(3) Exhibit such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial system are or have been necessary; or

(4) Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

b. The individual must demonstrate functional impairments in major life activities. This may include individuals with a dual diagnosis of either mental illness and mental retardation, or mental illness and substance abuse disorder.

c. Service-specific provider assessments shall be required at the onset of services and Individual Service Plans (ISPs) shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider assessments or ISPs shall be denied reimbursement. Requirements for provider-specific assessments and ISPs are set out in 12VAC30-50-130.

c. d. The yearly limit for mental health support services is 372 units. One unit is one hour but less than three hours.

e. These services may only be rendered by an LMHP, QMHP-A, QMHP-C, or QPPMH.

12VAC30-60-5. Applicability of utilization review requirements.

A. These utilization requirements shall apply to all Medicaid covered services unless otherwise specified.

B. Some Medicaid covered services require an approved service authorization prior to service delivery in order for reimbursement to occur.

1. To obtain service authorization, all providers' information supplied to the Department of Medical Assistance Services (DMAS) or the service authorization contractor shall be fully substantiated throughout individuals' medical records.

2. Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in providers' care. 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 unless specified otherwise.

C. DMAS, or its designee, shall perform reviews of the utilization of all Medicaid covered services pursuant to 42 CFR 440.260 and 456.1 et seq.

D. DMAS shall recover expenditures made for covered services when providers' documentation does not comport with standards specified in all applicable regulations.

E. Providers who are determined not to be in compliance with DMAS' requirements shall be subject to 12VAC30-80-130 for the repayment of those overpayments to DMAS.

F. Utilization review requirements specific to community mental health services, as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be as follows:

1. To apply to be reimbursed as a Medicaid provider, the required Department of Behavioral Health and Developmental Services (DBHDS) license shall be either a full annual, triennial, or conditional license. Providers must be enrolled with DMAS to be reimbursed. Once a health care entity has been enrolled as a provider, it shall maintain, and update periodically as DMAS requires, a current Provider Enrollment Agreement for each Medicaid service that the provider offers.

2. Health care entities with provisional licenses shall not be reimbursed as Medicaid providers of community mental health services.

3. Payments shall not be permitted to health care entities who either hold provisional licenses or who fail to enter into a Medicaid Provider Enrollment Agreement for a service prior to rendering that service.

12VAC30-60-61. Services related to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT); community mental health services for children.

A. Definitions. The following words and terms shall have the following meanings unless the context indicates otherwise:

"At risk" means one or more of the following: (i) within two weeks after completion of the assessment, the individual shall be screened by an LMHP for escalating behaviors that have put either the individual or others at immediate risk of physical injury; (ii) the parent/guardian is unable to manage the individual's mental, behavioral, or emotional problems in the home and is actively, within the past two to four weeks, seeking an out-of-home placement; (iii) a representative of either a juvenile justice agency, a department of social services (either the state agency or local agency), a community services board/behavioral health authority, the Department of Education, or an LMHP, as defined in 12VAC35-105-20, and who is neither an employee of or consultant to the IIH services or therapeutic day treatment (TDT) provider, has recommended an out-of-home placement absent an immediate change of behaviors and when unsuccessful mental health services are evident; (iv) the individual has a history of unsuccessful services (either crisis intervention, crisis stabilization, outpatient psychotherapy, outpatient substance abuse services, or mental health support) within the past 30 days; (v) the treatment team or family assessment planning team (FAPT) recommends IIH services or TDT for an individual currently who is either: (a) transitioning out of residential treatment facility Level C services, (b) transitioning out of a group home Level A or B services, (c) transitioning out of acute psychiatric hospitalization, or (d) transitioning between foster homes, mental health case management, crisis intervention, crisis stabilization, outpatient psychotherapy, or outpatient substance abuse services.

"Failed services" or "unsuccessful services" means, as measured by ongoing behavioral, mental, or physical distress, that the service or services did not treat or resolve the individual's mental health or behavioral issues.

"Individual" means the Medicaid-eligible person receiving these services and for the purpose of this section is understood to mean children or adolescents.

"New service" means a community mental health rehabilitation service for which the individual does not have a current service authorization in effect as of July 17, 2011.

"Out-of-home placement" means placement in one or more of the following: (i) either a Level A or Level B group home; (ii) regular foster home if the individual is currently residing with his biological family and, due to his behavior problems, is at risk of being placed in the custody of the local department of social services; (iii) treatment foster care if the individual is currently residing with his biological family or a regular foster care family and, due to the individual's behavioral problems, is at risk of removal to a higher level of care; (iv) Level C residential facility; (v) emergency shelter for the individual only due either to his mental health or behavior or both; (vi) psychiatric hospitalization; or (vii) juvenile justice system or incarceration.

"Service-specific provider assessment" means the evaluation that is conducted according to the Department of Medical Assistance Services (DMAS) assessment definition set out in 12VAC30-50-130.

B. These services shall be rendered consistent with the definitions, service limits, and requirements described in this section and in 12VAC30-50-130.

A. C. Intensive in-home services for children and adolescents.

1. The service definition for intensive in-home (IIH) services is contained in 12VAC30-50-130.

1. 2. Individuals qualifying for this service must shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis to be authorized for these services:

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

2. At 3. Prior to admission, an appropriate service-specific provider assessment is made, as defined in 12VAC30-50-130, shall be conducted by the LMHP or the QMHP and approved by the LMHP, licensed mental health professional (LMHP), as defined in 12VAC35-105-20, documenting that the individual's diagnosis and describing how service needs can best be met through intervention provided typically but not solely in the client's individual's residence. An Individual Service Plan (ISP) must be fully completed within 30 days of initiation of services. The service-specific provider assessment shall describe how the individual's clinical needs put the individual at risk of out-of-home placement and shall be conducted face-to-face in the individual's residence. Claims for services that are based upon service-specific provider assessments that are incomplete, outdated (more than 12 months old), or missing shall not be reimbursed.

4. An individual service plan (ISP) shall be fully completed, signed, and dated by a QMHP-C, as defined in 12VAC35-105-20, and the individual and individual's parent/guardian within 30 days of initiation of services. The ISP shall meet all of the requirements as defined in 12VAC30-50-226.

5. DMAS shall not reimburse for dates of services in which the progress notes are not individualized and child-specific. Duplicated progress notes shall not constitute the required child-specific individualized progress notes. Each progress note shall demonstrate unique differences particular to the individual's circumstances, treatment, and progress. Claim payments shall be retracted for services that are supported by documentation that does not demonstrate unique differences particular to the individual.

3. 6. Services must shall be directed toward the treatment of the eligible child individual and delivered primarily in the family's residence with the child individual present. In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community if supported by the needs assessment and ISP. The assessment may be performed and the services rendered in the community if there is documentation, on that date of service, of the necessity of providing services in the community. The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP. For services provided outside of the home, there shall be documentation reflecting therapeutic treatment as set forth in the ISP provided for that date of service in the appropriately signed and dated progress notes.

4. 7. These services shall be provided when the clinical needs of the child individual put the child him at risk for out-of-home placement, as these terms are defined in this section:

a. When services that are far more intensive than outpatient clinic care are required to stabilize the child individual in the family situation, or

b. When the child's individual's residence as the setting for services is more likely to be successful than a clinic.

The service-specific provider assessment shall describe how the individual meets either subdivision a or b of this subdivision.

5. Services may not be billed when provided to a family while the child is not residing in the home. 8. Services shall not be provided if the individual is no longer a resident of the home.

6. 9. Services shall also be used to facilitate the transition to home from an out-of-home placement when services more intensive than outpatient clinic care are required for the transition to be successful. The child individual and responsible parent/guardian must shall be available and in agreement to participate in the transition.

7. 10. At least one parent parent/guardian or responsible adult with whom the child individual is living must be willing to participate in the intensive in-home services with the goal of keeping the child individual with the family.

8. 11. The enrolled provider must shall be licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services Behavioral Health and Developmental Services (DBHDS) as a provider of intensive in-home services. The provider shall also have a Provider Enrollment Agreement with DMAS or its contractor in effect prior to the delivery of this service that indicates that the provider will offer intensive in-home services.

9. 12. Services must only be provided by an LMHP, or a, QMHP or QMHP-C as defined in 12VAC30-50-226 12VAC35-105-20. Reimbursement shall not be provided for such services when they have been rendered by a QPPMH as defined in 12VAC30-50-226 12VAC35-105-20.

10. 13. The billing unit for intensive in-home service is shall be one hour. Although the pattern of service delivery may vary, intensive in-home services is an intensive service provided to individuals for whom there is a plan of care ISP in effect which demonstrates the need for a minimum of three hours a week of intensive in-home service, and includes a plan for service provision of a minimum of three hours of service delivery per client/family individual/family per week in the initial phase of treatment. It is expected that the pattern of service provision may show more intensive services and more frequent contact with the client individual and family initially with a lessening or tapering off of intensity toward the latter weeks of service. Service plans must shall incorporate a an individualized discharge plan which identifies that describes transition from intensive in-home to less intensive or nonhome based services.

14. The ISP, as defined in 12VAC30-50-226, shall be updated as the individual's needs and progress changes and signed by either the parent or legal guardian and the individual. Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP. If there is a lapse in services that is greater than 31 consecutive calendar days, the provider shall discharge the individual. If the individual continues to need services, then a new assessment/admission shall be documented and a new service authorization shall be required.

11. 15. The provider must shall ensure that the maximum staff-to-caseload ratio fully meets the needs of the individual.

12. Since case management services are an integral and inseparable part of this service, case management services may not be billed separately for periods of time when intensive in-home services are being provided. 16. If an individual receiving services is also receiving case management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider shall contact the case manager and provide notification of the provision of services. In addition, the provider shall send monthly updates to the case manager on the individual's status. A discharge summary shall be sent to the case manager within 30 days of the service discontinuation date.

13. 17. Emergency assistance shall be available 24 hours per day, seven days a week.

18. Providers shall comply with DMAS marketing requirements at 12VAC30-130-2000. Providers that DMAS determines violate these marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

19. The provider shall determine who the primary care provider is and inform him of the individual's receipt of IIH services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

B. D. Therapeutic day treatment for children and adolescents.

1. The service definition for therapeutic day treatment (TDT) for children and adolescents is contained in 12VAC30-50-130.

1. 2. Therapeutic day treatment is appropriate for children and adolescents who meet one of the following:

a. Children and adolescents who require year-round treatment in order to sustain behavior or emotional gains.

b. Children and adolescents whose behavior and emotional problems are so severe they cannot be handled in self-contained or resource emotionally disturbed (ED) classrooms without:

(1) This programming during the school day; or

(2) This programming to supplement the school day or school year.

c. Children and adolescents who would otherwise be placed on homebound instruction because of severe emotional/behavior problems that interfere with learning.

d. Children and adolescents who (i) have deficits in social skills, peer relations or dealing with authority; (ii) are hyperactive; (iii) have poor impulse control; (iv) are extremely depressed or marginally connected with reality.

e. Children in preschool enrichment and early intervention programs when the children's emotional/behavioral problems are so severe that they cannot function in these programs without additional services.

3. The service-specific provider assessment shall document the individual's behavior and describe how the individual meets these specific service criteria in subdivision 2 of this subsection.

4. Prior to admission to this service, a service-specific provider assessment shall be conducted by the LMHP as defined in 12VAC35-105-20.

5. An ISP shall be fully completed, signed, and dated by a QMHP-C, as defined in 12VAC35-105-20, and by the individual or the parent/guardian within 30 days of initiation of services and shall meet all requirements of an ISP as defined in 12VAC30-50-226. Individual progress notes shall be required for each contact with the individual and shall meet all of the requirements as defined in 12VAC30-50-130.

2. 6. Such services must shall not duplicate those services provided by the school.

3. 7. Individuals qualifying for this service must shall demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals must shall meet at least two of the following criteria on a continuing or intermittent basis:

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services, or judicial system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

4. 8. The enrolled provider of therapeutic day treatment for child and adolescents adolescent services must shall be licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services DBHDS to provide day support services. The provider shall also have a provider enrollment agreement in effect with DMAS prior to the delivery of this service that indicates that the provider offers therapeutic day treatment services for children and adolescents.

5. 9. Services must shall be provided by an LMHP, a QMHP, or a QPPMH who is supervised by a QMHP or LMHP or QMHP-C as defined in 12VAC35-105-20.

6. 10. The minimum staff-to-youth staff-to-individual ratio as defined by DBHDS licensing requirements shall ensure that adequate staff is available to meet the needs of the youth individual identified on the ISP.

7. 11. The program must shall operate a minimum of two hours per day and may offer flexible program hours (i.e., before or after school or during the summer). One unit of service is shall be defined as a minimum of two hours but less than three hours in a given day. Two units of service shall be defined as a minimum of three but less than five hours in a given day. Three units of service shall be defined as five or more hours of service in a given day.

8. 12. Time required for academic instruction when no treatment activity is going on cannot shall not be included in the billing unit.

9. 13. Services shall be provided following a diagnostic service-specific provider assessment that is authorized conducted by an LMHP as defined in 12VAC35-105-20. Services must be provided in accordance with an ISP which must be fully completed within 30 days of initiation of the service. An LMHP shall make and document the diagnosis. The service-specific provider assessment shall include the elements specified in subsection A of this section.

14. If an individual receiving services is also receiving case management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider shall collaborate with the case manager and provide notification of the provision of services. In addition, the provider shall send monthly updates to the case manager on the individual's status. A discharge summary shall be sent to the case manager within 30 days of the service discontinuation date.

15. The provider shall determine who the primary care provider is and inform him of the child's receipt of community mental health rehabilitative services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

16. Providers shall comply with DMAS marketing requirements as set out in 12VAC30-130-2000. Providers that DMAS determines have violated these marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

17. If there is a lapse in services greater than 31 consecutive calendar days, the provider shall discharge the individual. If the individual continues to need services, a new assessment/admission documentation shall be prepared and a new service authorization shall be required.

C. E. Community-Based Services for Children and Adolescents under 21 (Level A)

1. The staff ratio must be at least 1 to 6 during the day and at least 1 to 10 while asleep between 11 p.m. and 7 a.m. The program director supervising the program/group home must be, at minimum, a qualified mental health professional QMHP-C, as defined in 12VAC35-105-20 with a bachelor's degree and have at least one year of direct work with mental health clients. The program director must be employed full time.

2. At In order for Medicaid reimbursement to be approved, at least 50% of the provider's direct care staff at the group home must meet DMAS DBHDS' paraprofessional staff criteria, defined in 12VAC30-50-226 12VAC35-105-20.

3. Authorization is required for Medicaid reimbursement. DMAS shall monitor the services rendered. All Community-Based Services for Children and Adolescents under 21 (Level A) must be authorized prior to reimbursement for these services. Services rendered without such authorization shall not be covered. All community-based services for children and adolescents under 21 (Level A) require authorization prior to reimbursement for these services. Reimbursement shall not be made for this service when other less intensive services may achieve stabilization.

4. Services must be provided in accordance with an Individual Service Plan (ISP) (plan of care), which must be fully completed within 30 days of authorization for Medicaid reimbursement.

5. Prior to admission, a service-specific provider assessment shall be conducted according to DMAS specifications described in 12VAC30-50-130.

6. Such service-specific provider assessments shall be performed by an LMHP as defined in 12VAC35-105-20.

7. If an individual receiving community-based services for children and adolescents under 21 (Level A) is also receiving case management services, the provider shall collaborate with the case manager by notifying the case manager of the provision of Level A services and shall send monthly updates on the individual's progress. When the individual is discharged from Level A services, a discharge summary shall be sent to the case manager within 30 days of the service discontinuation date.

D. F. Therapeutic Behavioral Services for Children and Adolescents under 21 (Level B).

1. The staff ratio must be at least 1 to 4 during the day and at least 1 to 8 while asleep between 11 p.m. and 7 a.m. The clinical director must be a licensed mental health professional. The caseload of the clinical director must not exceed 16 clients individuals including all sites for which the clinical director is responsible. The program director must be full time and be a qualified mental health professional with a bachelor's degree and at least one year's clinical experience.

2. The program director must be full time and be a qualified mental health professional with a bachelor's degree and at least one year's clinical experience.

2. At 3. For Medicaid reimbursement to be approved, at least 50% of the provider's direct care staff must at the group home shall meet DMAS paraprofessional staff criteria, as defined in 12VAC30-50-226 12VAC35-105-20. The program/group home must coordinate services with other providers.

3. 4. All Therapeutic Behavioral Services (Level B) must shall be authorized prior to reimbursement for these services. Services rendered without such prior authorization shall not be covered.

4. 5. Services must be provided in accordance with an ISP (plan of care), which must shall be fully completed within 30 days of authorization for Medicaid reimbursement.

6. Prior to admission, a service-specific provider assessment shall be performed using all elements specified by DMAS in 12VAC30-50-130.

7. Such service-specific provider assessments shall be performed by an LMHP as defined in 12VAC35-105-20.

8. If an individual receiving therapeutic behavioral services for children and adolescents under 21 (Level B) is also receiving case management services, the therapeutic behavioral services provider must collaborate with the care coordinator/case manager by notifying him of the provision of Level B services and the Level B services provider shall send monthly updates on the individual's treatment status. When the individual is discharged from Level B services, a discharge summary shall be sent to the care coordinator/case manager within 30 days of the discontinuation date.

9. The provider shall determine who the primary care provider is and inform him of the individual's receipt of these Level B services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

E. G. Utilization review. Utilization reviews for Community-Based Services for Children and Adolescents under 21 (Level A) and Therapeutic Behavioral Services for Children and Adolescents under 21 (Level B) shall include determinations whether providers meet all DMAS requirements, including compliance with DMAS marketing requirements. Providers that violate the DMAS marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

12VAC30-60-143. Mental health services utilization criteria; definitions.

A. This section sets out the utilization criteria and standards relative to the community mental health services set out in 12VAC30-50-226. This section also contains definitions for the following words and terms which shall have the following meanings unless the context indicates otherwise:

"Licensed Mental Health Professional" or "LMHP" means the same as defined in 12VAC35-105-20.

"Qualified mental health professional-adult" or "QMHP-A" means the same as defined in 12VAC35-105-20.

"Qualified mental health professional-child" or "QMHP-C" means the same as defined in 12VAC35-105-20.

A. B. Utilization reviews shall include determinations that providers meet the following requirements:

1. The provider shall meet the federal and state requirements for administrative and financial management capacity. The provider shall obtain, prior to the delivery of services, and shall maintain and update periodically as the Department of Medical Assistance Services (DMAS) or its contractor requires, a current Provider Enrollment Agreement for each Medicaid service that the provider offers. DMAS shall not reimburse providers who do not enter into a Provider Enrollment Agreement for a service prior to offering that service.

2. The provider shall document and maintain individual case records in accordance with state and federal requirements.

3. The provider shall ensure eligible recipients individuals have free choice of providers of mental health services and other medical care under the Individual Service Plan.

4. Providers shall comply with DMAS marketing requirements as set out in 12VAC30-130-2000. Providers that DMAS determines have violated these marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E. Providers whose contracts are terminated shall be afforded the right of appeal pursuant to the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).

5. If an individual receiving community mental health rehabilitative services is also receiving case management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider shall collaborate with the case manager by notifying the case manager of the provision of community mental health rehabilitative services and sending monthly updates on the individual's treatment status. A discharge summary shall be sent to the care coordinator/case manager within 30 calendar days of the discontinuation of services.

6. The provider shall determine who the primary care provider is and inform him of the individual's receipt of community mental health rehabilitative services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

7. The provider shall include the individual and the family/caregiver, as may be appropriate, in the development of the ISP. To the extent that the individual's condition requires assistance for participation, assistance shall be provided. The ISP shall be updated annually or as the needs and progress of the individual changes. An ISP that is not updated either annually or as the treatment interventions based on the needs and progress of the individual changes shall be considered outdated. An ISP that does not include all required elements specified in 12VAC30-50-226 shall be considered incomplete. All ISPs shall be completed, signed, and contemporaneously dated by the QMHP-A or QMHP-C, as defined in 12VAC35-105-20, preparing the ISP within a maximum of 30 days of the date of the completed assessment unless otherwise specified. The ISP shall also be signed by the parent/legal guardian and individual. Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP.

C. Direct clinical services provided on a part-time basis will be reviewed by DMAS or its contractor based on the number of hours provided and counted based upon how many full-time (40 hours) weeks of service were provided.

B. D. Day treatment/partial hospitalization services shall be provided following a diagnostic service-specific provider assessment and be authorized by the physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, or licensed clinical nurse specialist-psychiatric LMHP as defined in 12VAC35-105-20. An ISP, as defined in 12VAC30-50-226, shall be fully completed, signed, and dated by either the LMHP or the QMHP QMHP-A, as defined at 12VAC30-50-226 in 12VAC35-105-20, within 30 days of service initiation.

1. The enrolled provider of day treatment/partial hospitalization shall be licensed by DMHMRSAS DBHDS as providers of day treatment services.

2. Services shall only be provided by an LMHP, a QMHP QMHP-A, QMHP-C, or a qualified paraprofessional under the supervision of a QMHP QMHP-A, QMHP-C, or an LMHP as defined at 12VAC30-50-226 in 12VAC35-105-20.

3. The program shall operate a minimum of two continuous hours in a 24-hour period.

4. Individuals shall be discharged from this service when other less intensive services may achieve or maintain psychiatric stabilization.

C. E. Psychosocial rehabilitation services shall be provided to those individuals who have experienced long-term or repeated psychiatric hospitalization, or who experience difficulty in activities of daily living and interpersonal skills, or whose support system is limited or nonexistent, or who are unable to function in the community without intensive intervention or when long-term services are needed to maintain the individual in the community.

1. Psychosocial rehabilitation services shall be provided following an a service-specific provider assessment which clearly documents the need for services. The This assessment shall be completed by either an LMHP, or a QMHP, and QMHP-A, or QMHP-C. If the service-specific provider assessment is done by a QMHP-A or a QMHP-C, it shall be approved by a an LMHP within 30 calendar days of admission to services. An ISP shall be completed by either the LMHP or the QMHP QMHP-A within 30 calendar days of service initiation. Every At least every three months, the LMHP, or the QMHP QMHP-A, or the QMHP-C must review, modify as appropriate, and update the ISP.

2. Psychosocial rehabilitation services of any individual that continue more than six months must shall be reviewed by an LMHP who must shall document the continued need for the service. The ISP shall be rewritten at least annually.

3. The enrolled provider of psychosocial rehabilitation services shall be licensed by DMHMRSAS DBHDS as a provider of psychosocial rehabilitation or clubhouse services.

4. Psychosocial rehabilitation services may be provided by either an LMHP, a QMHP QMHP-A, or QMHP-C, or a qualified paraprofessional under the supervision of either a QMHP QMHP-A, a QMHP-C, or an LMHP.

5. The program shall operate a minimum of two continuous hours in a 24-hour period.

6. Time allocated for field trips may be used to calculate time and units if the goal is to provide training in an integrated setting, and to increase the client's individual's understanding or ability to access community resources.

D. Admission to crisis F. Crisis intervention services is shall be indicated following a marked reduction in the individual's psychiatric, adaptive or behavioral functioning or an extreme increase in personal distress.

1. The crisis intervention services provider shall be licensed as a provider of outpatient services by DMHMRSAS DBHDS.

2. Client-related activities provided in association with a face-to-face contact are reimbursable.

3. An Individual Service Plan (ISP) shall not be required for newly admitted individuals to receive this service. Inclusion of crisis intervention as a service on the ISP shall not be required for the service to be provided on an emergency basis.

4. For individuals receiving scheduled, short-term counseling as part of the crisis intervention service, an ISP must shall be developed or revised by the fourth face-to-face contact to reflect the short-term counseling goals by the fourth face-to-face contact.

5. Reimbursement shall be provided for short-term crisis counseling contacts occurring within a 30-day period from the time of the first face-to-face crisis contact. Other than the annual service limits, there are no restrictions (regarding number of contacts or a given time period to be covered) for reimbursement for unscheduled crisis contacts.

6. Crisis intervention services may be provided to eligible individuals outside of the clinic and billed, provided the provision of out-of-clinic services is clinically/programmatically appropriate. Travel by staff to provide out-of-clinic services is shall not be reimbursable. Crisis intervention may involve contacts with the family or significant others. If other clinic services are billed at the same time as crisis intervention, documentation must clearly support the separation of the services with distinct treatment goals.

7. An LMHP, a QMHP QMHP-A, QMHP-C, or a certified prescreener must shall conduct a face-to-face service-specific provider assessment. If the QMHP QMHP-A or QMHP-C performs the service-specific provider assessment, it must be reviewed and approved by an LMHP or a certified prescreener within 72 hours of the face-to-face service-specific provider assessment. The service-specific provider assessment shall document the need for and the anticipated duration of the crisis service. Crisis intervention will be provided by an LMHP, a certified prescreener, or a QMHP.

8. Crisis intervention shall be provided by either an LMHP, a certified prescreener, a QMHP-A, or a QMHP-C.

8. 9. Crisis intervention shall not require an ISP.

9. 10. For an admission to a freestanding inpatient psychiatric facility for individuals younger than age 21, federal regulations (42 CFR 441.152) require certification of the admission by an independent team. The independent team must include mental health professionals, including a physician. Preadmission These preadmission screenings cannot be billed unless the requirement for an independent team certification, with a physician's signature, is met.

10. 11. Services must shall be documented through daily notes and a daily log of time spent in the delivery of services.

E. G. Case management services (pursuant to 12VAC30-50-226) pursuant to 12VAC30-50-420 (seriously mentally ill adults and emotionally disturbed children) or 12VAC30-50-430 (youth at risk of serious emotional disturbance).

1. Reimbursement shall be provided only for "active" case management clients, as defined. An active client for case management shall mean an individual for whom there is a plan of care an ISP in effect which that requires regular direct or client-related contacts or activity or communication with the client individuals or families, significant others, service providers, and others including a minimum of one face-to-face client individual contact within a 90-day period. Billing can be submitted only for months in which direct or client-related contacts, activity, or communications occur.

2. The Medicaid eligible individual shall meet the DMHMRSAS DBHDS criteria of serious mental illness, serious emotional disturbance in children and adolescents, or youth at risk of serious emotional disturbance.

3. There shall be no maximum service limits for case management services. Case management shall not be billed for persons in institutions for mental disease.

4. The ISP must shall document the need for case management and be fully completed within 30 calendar days of initiation of the service, and the. The case manager shall review the ISP at least every three months. The review will be due by the last day of the third month following the month in which the last review was completed. A grace period will be granted up to the last day of the fourth month following the month of the last review. When the review was completed in a grace period, the next subsequent review shall be scheduled three months from the month the review was due and not the date of actual review.

5. The ISP shall also be updated at least annually.

6. The provider of case management services shall be licensed by DMHMRSAS DBHDS as a provider of case management services.

F. H. Intensive community treatment (ICT) for adults.

1. An A service-specific provider assessment which documents eligibility and the need for this service shall be completed by either the LMHP or the QMHP, QMHP-A, or the QMHP-C prior to the initiation of services. This assessment must shall be maintained in the individual's records. Proper completion of the service-specific provider assessment shall comport with the requirements of 12VAC30-50-130.

2. An individual service plan, based on the needs as determined by the service-specific provider assessment, must be initiated at the time of admission and must be fully developed by either the LMHP or the QMHP, QMHP-A, or QMHP-C and approved by the LMHP within 30 days of the initiation of services.

3. ICT may be billed if the client individual is brought to the facility by ICT staff to see the psychiatrist. Documentation must be present in the individual's record to support this intervention.

4. The enrolled ICT provider shall be licensed by the DMHMRSAS DBHDS as a provider of intensive community services or as a program of assertive community treatment, and must provide and make available emergency services 24-hours per day, seven days per week, 365 days per year, either directly or on call.

5. ICT services must be documented through a daily log of time spent in the delivery of services and a description of the activities/services provided. There must also be at least a weekly note documenting progress or lack of progress toward goals and objectives as outlined on the ISP.

G. I. Crisis stabilization services.

1. This service must shall be authorized following a face-to-face service-specific provider assessment by either an LMHP, a certified prescreener, or a QMHP QMHP-A, or QMHP-C. This assessment must be reviewed and approved by a licensed mental health professional within 72 hours of the assessment.

2. The service-specific provider assessment must document the need for crisis stabilization services and anticipated duration of need.

3. The Individual Service Plan (ISP) must be developed or revised within 10 business days of the approved assessment or reassessment 24 hours of admission to this service. The LMHP, certified prescreener, QHMP-A, or QMHP QHMP-C shall develop the ISP.

4. Room and board, custodial care, and general supervision are not components of this service.

5. Clinic option services are not billable at the same time crisis stabilization services are provided with the exception of clinic visits for medication management. Medication management visits may be billed at the same time that crisis stabilization services are provided but documentation must clearly support the separation of the services with distinct treatment goals.

6. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from a condition due to an acute crisis of a psychiatric nature which puts the individual at risk of psychiatric hospitalization.

7. Providers of crisis stabilization shall be licensed by DMHMRSAS DBHDS as providers of outpatient services.

H. J. Mental health support services. Refer to 12VAC30-50-226 for criteria, service authorization requirements, and service-specific provider assessments that shall apply for individuals in order to qualify for this service.

1. At Prior to admission, an appropriate face-to-face service-specific provider assessment must be made completed, signed, and dated, and documented by the LMHP or the QMHP indicating that service needs can best be met through mental health support services. The assessment must be performed by the LMHP or the QMHP and approved by the LMHP within 30 days of the date of admission. The LMHP or the QMHP will complete the ISP within 30 days of the admission to this service.

2. The ISP must, as defined in 12VAC30-50-226, shall be completed, signed, and dated by a QMHP-A or QMHP-C within 30 calendar days of service initiation, and shall indicate the specific supports and services to be provided and the goals and objectives to be accomplished. The LMHP or QMHP will QMHP-A shall supervise the care if delivered by the qualified paraprofessional.

2. 3. Every three months, the LMHP, or the QMHP must QMHP-A, or QMHP-C shall review, modify as appropriate, and update the ISP showing a new signature and date of each revision. The ISP must shall be rewritten, signed, and dated by either a QMHP-A, QMHP-C, or an LMHP at least annually.

3. 4. Only direct face-to-face contacts and services to individuals shall be reimbursable.

4. 5. Any services provided to the client individual that are strictly academic in nature shall not be billable. These include, but are not limited to, such basic educational programs as instruction in reading, science, mathematics, or the individual's work towards obtaining a GED.

5. 6. Any services provided to clients individuals that are strictly vocational in nature shall not be billable. However, support activities and activities directly related to assisting a client an individual to cope with a mental illness to the degree necessary to develop appropriate behaviors for operating in an overall work environment shall be billable.

6. 7. Room and board, custodial care, and general supervision are not components of this service.

7. 8. This service is not billable for individuals who reside in facilities where staff are expected to provide such services under facility licensure requirements.

8. 9. Provider qualifications. The enrolled provider of mental health support services must shall be licensed by DMHMRSAS DBHDS as a provider of supportive in-home services, intensive community treatment, or as a program of assertive community treatment. Individuals employed or contracted by the provider to provide mental health support services must shall have training in the characteristics of mental illness and appropriate interventions, training strategies, and support methods for persons with mental illness and functional limitations.

9. 10. Mental health support services, which continue for six consecutive months, must shall be reviewed and renewed at the end of the six-month period of authorization by an LMHP who must shall document the continued need for the services.

10. 11. Mental health support services must shall be documented through a daily log of time involved in the delivery of services and a minimum of a weekly summary note of services provided.

DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)

Virginia Medicaid Nursing Home Manual, Department of Medical Assistance Services.

Virginia Medicaid Rehabilitation Manual, Department of Medical Assistance Services.

Virginia Medicaid Hospice Manual, Department of Medical Assistance Services.

Virginia Medicaid School Division Manual, Department of Medical Assistance Services.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association.

Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001, American Society on Addiction Medicine, Inc.

Medicaid Special Memo, Subject: New Service Authorization Requirement for an Independent Clinical Assessment for Medicaid and FAMIS Children's Community Mental Health Rehabilitative Services, dated June 16, 2011, Department of Medical Assistance Services.

Medicaid Special Memo, Subject: Changes to Children Community Mental Health Rehabilitative Services - Children's Services, July 1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical Assistance Services.

Medicaid Special Memo, Subject: Changes to Community Mental Health Rehabilitative Services - Adult-Oriented Services, July 1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical Assistance Services.

Part XVII
Marketing of Provider Services

12VAC30-130-2000. Marketing requirements and restrictions.

A. Purpose. The purpose of these rules shall be to define how providers shall be permitted to market their services to potential Medicaid or FAMIS beneficiaries and individuals who may or may not be currently enrolled with the particular provider. This shall apply to providers of community mental health services (12VAC30-50-226) and Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) community mental health services (12VAC30-50-130) with the exception of Part C services.

B. Definitions.

"Beneficiaries" means individuals of any age and their families who are using or who may use community mental health rehabilitative services.

"DMAS" means the Department of Medical Assistance Services.

"FAMIS" means Family Access to Medical Insurance Security.

"Provider" means an individual or organizational entity that is appropriately licensed as required and enrolled as a DMAS provider of community mental health and substance abuse services.

C. Requirements.

1. Marketing and promotional activities (including provider promotional activities) shall comply with all relevant federal and state laws.

2. Providers shall provide clearly written materials that completely and accurately describe the Medicaid or FAMIS behavioral health service or services offered, the beneficiary eligibility requirements to receive the service or services, applicable fees and other charges, and all other information required for beneficiaries and their families to make fully informed decisions about enrollment into the service or services offered by the provider that is marketing its services.

3. Providers shall distribute their marketing materials only in the service locations approved within the license issued by the Licensing Division of the Department of Behavioral Health and Developmental Services.

4. Providers shall receive DMAS' approval of all marketing materials and all changes to prior-approved marketing materials prior to their use or dissemination. Providers shall receive DMAS' marketing plan approval before engaging in any marketing activity.

a. Within 30 calendar days of receipt of providers' submissions, DMAS shall review submitted individual marketing materials and services and either approve them or deny their use or direct that specified modifications be made.

b. Providers failing to implement DMAS' required changes, or those which use disapproved materials, shall be subject to termination of the provider agreement pursuant to 12VAC30-130-2000 E.

D. Limits and prohibitions.

1. Providers shall not offer cash or other noncash incentives to their enrolled or prospective members for the purposes of marketing, retaining beneficiaries within the providers' services, or rewarding behavior changes in compliance with goals and objectives stated in beneficiaries' individual service plans.

2. While engaging in marketing activities, providers shall not:

a. Engage in any marketing activities that could misrepresent the service or DMAS;

b. Assert or state that the beneficiary must enroll with the provider in order to prevent the loss of Medicaid or FAMIS benefits;

c. Conduct door-to-door, telephone, unsolicited school presentations, or other 'cold call' marketing directed at potential or current beneficiaries;

d. Conduct any marketing activities or use marketing materials that are not specifically approved by DMAS;

e. Make home visits for direct or indirect marketing or enrollment activities except when specifically requested by the beneficiary or family;

f. Collect or use Medicaid or FAMIS confidential information or Medicaid or FAMIS protected health information (PHI), as that term is defined in Health Insurance Portability and Accountability Act of 1996 (HIPPA), that may be either provided by another entity or obtained by marketing provider, to identify and market services to prospective beneficiaries;

g. Violate the confidential information or confidentiality of PHI by sharing or selling or sharing lists of information about beneficiaries for any purposes other than the performance of the provider's obligations relative to its DMAS provider agreement;

h. Contact, after the effective date of disenrollment, beneficiaries who choose to disenroll from the provider except as may be specifically required by DMAS;

i. Conduct service assessment or enrollment activities at any marketing or community event; or

j. Assert or state (either orally or in writing) that the provider is endorsed either by the Centers for Medicare and Medicaid Services, DMAS, or any other federal or state governmental entities.

E. Termination. Providers who conduct any marketing activity, that is not specifically approved by DMAS or who violate any of the above prohibitions or requirements shall be subject to termination of their provider agreements for the services affected by the marketing plan/activity.

Part XVIII
Behavioral Health Services

12VAC30-130-3000. Behavioral health services.

A. Behavioral health services that shall be covered only for individuals from birth through 21 years of age are set out in 12VAC30-50-130 B 5 and include: (i) intensive in-home services (IIH), (ii) therapeutic day treatment (TDT), (iii) community based services for children and adolescents (Level A), and (iv) therapeutic behavioral services (Level B).

B. Behavioral health services that shall be covered for individuals regardless of age are set out in 12VAC30-50-226 and include: (i) day treatment/partial hospitalization, (ii) psychosocial rehabilitation, (iii) crisis intervention, (iv) case management as set out in 12VAC30-50-420 and 12VAC30-50-430, (v) intensive community treatment (ICT), (vi) crisis stabilization services, and (vii) mental health support services (MHSS).

12VAC30-130-3010. Definitions.

The following words and terms when used in these regulations shall have the following meanings unless the context clearly indicates otherwise:

"Behavioral health authority" or "BHA" means the local agency that administers services set out in § 37.2-601 of the Code of Virginia.

"Community services board" or "CSB" means the local agency that administers services set out in § 37.2-500 of the Code of Virginia.

"Behavioral health services administrator" or "BHSA" means an entity that manages or directs a behavioral health benefits program under contract with DMAS.

"DMAS" means the Department of Medical Assistance Services.

"Independent assessor" means a professional who performs the independent clinical assessment who may be employed by either the behavioral health services administrator, community services boards/behavioral health authorities (CSBs/BHAs) or their subcontractors.

"Independent clinical assessment" or "ICA" means the assessment that is performed under contract with DMAS either by the behavioral health services administrator or the CSB/BHA, or its subcontractor, prior to the initiation of (i) intensive in-home (IIH) services or therapeutic day treatment (TDT) as set out in 12VAC30-50-130 and (ii) mental health support services (MHSS) for children and adolescents (MHSS) as set out in 12VAC30-50-226.

"VICAP" means the form entitled Virginia Independent Clinical Assessment Program that is required to record an individual's independent clinical assessment information.

12VAC30-130-3020. Independent clinical assessment requirements.

A. The independent clinical assessment (ICA), as set forth in the Virginia Independent Assessment Program (VICAP-001) form, shall contain the Medicaid individual-specific elements of information and data that shall be required for an individual younger than the age of 21 to be approved for intensive in-home (IIH) services, therapeutic day treatment (TDT), or mental health support services (MHSS) or any combination thereof.

1. The required elements in the ICA shall be specified in the VICAP form with either the BHSA or CSBs/BHAs and DMAS.

2. Service recommendations set out in the ICA shall not be subject to appeal.

B. Independent clinical assessment requirements.

1. Effective July 18, 2011, an ICA shall be required as a part of the service authorization process for Medicaid and Family Access to Medical Insurance Security (FAMIS) intensive in-home (IIH) services, therapeutic day treatment (TDT), or mental health support services (MHSS) for individuals up to the age of 21. This ICA shall be performed prior to the request for service authorization and initiation of treatment for individuals who are not currently receiving or authorized for services. The ICA shall be completed prior to the service provider conducting an assessment or providing treatment.

a. Each individual shall have at least one ICA prior to the initiation of either IIH or TDT, or MHSS for individuals up to the age of 21.

b. For individuals who are already receiving IIH services or TDT, or MHSS, as of July 18, 2011, the requirement for a completed ICA shall be effective for service reauthorizations for dates of services on and after September 1, 2011.

c. Individuals who are being discharged from residential treatment (DMAS service Levels A, B, or C) or inpatient psychiatric hospitalization do not need an ICA prior to receiving community IIH services or TDT, or MHSS. They shall be required, however, to have an ICA as part of the first subsequent service reauthorization for IIH services, TDT, MHSS, or any combination thereof.

2. The ICA shall be completed and submitted to DMAS or its service authorization contractor by the independent assessor prior to the service provider submitting the service authorization or reauthorization request to the DMAS service authorization contractor. Failure to meet these requirements shall result in the provider's service authorization or reauthorization request being returned to the provider.

3. A copy of the ICA shall be retained in the service provider's individual's file.

4. If a service provider receives a request from parents or legal guardians to provide IIH services, TDT, or MHSS for individuals who are younger than 21 years of age, the service provider shall refer the parent or legal guardian to the BHSA or the local CSB/BHA to obtain the ICA prior to providing services.

a. In order to provide services, the service provider shall be required to conduct a service-specific provider assessment as defined in 12VAC30-50-130.

b. If the selected service provider concurs that the child meets criteria for the service recommended by the independent assessor, the selected service provider shall submit a service authorization request to DMAS service authorization contractor. The service-specific provider's assessment for IIH services, TDT, or MHSS shall not occur prior to the completion of the ICA by the BHSA or CSB/BHA, or its subcontractor.

c. If within 30 days after the ICA a service provider identifies the need for services that were not recommended by the ICA, the service provider shall contact the independent assessor and request a modification. The request for a modification shall be based on a significant change in the individual's life that occurred after the ICA was conducted. Examples of a significant change may include, but shall not be limited to, hospitalization; school suspension or expulsion; death of a significant other; or hospitalization or incarceration of a parent or legal guardian.

d. If the independent assessment is greater than 30 days old, a new ICA must be obtained prior to the initiation of IIH services, TDT, or MHSS for individuals younger than 21 years of age.

e. If the parent or legal guardian disagrees with the ICA recommendation, the parent or legal guardian may request that a service provider perform his own evaluation. If after conducting a service-specific provider assessment the service provider identifies additional documentation previously not submitted for the ICA that demonstrates the service is medically necessary and clinically indicated, the service provider may submit the supplemental information with a service authorization request to the DMAS service authorization contractor. The DMAS service authorization contractor will review the service authorization submission and the ICA and make a determination. If the determination results in a service denial, the individual, parent or legal guardian, and service provider will be notified of the decision and the appeals process.

5. If the individual is in immediate need of treatment, the independent clinical assessor shall refer the individual to the appropriate enrolled Medicaid emergency services providers in accordance with 12VAC30-50-226 and shall also alert the individual's managed care organization.

C. Requirements for behavioral health services administrator and community services boards/behavioral health authorities.

1. When the BHSA, CSB, or BHA has been contacted by the parent or legal guardian, the ICA appointment shall be offered within five business days of a request for IIH services and within 10 business days for a request for TDT or MHSS, or both. The appointment may be scheduled beyond the respective time frame at the documented request of the parent or legal guardian.

2. The independent assessor shall conduct the ICA with the individual and the parent or legal guardian using the VICAP-001 form and make a recommendation for the most appropriate medically necessary services, if indicated. Referring or treating providers shall not be present during the assessment but may submit supporting clinical documentation to the assessor.

3. The ICA shall be effective for a 30-day period.

4. The independent assessor shall enter the findings of the ICA into the DMAS service authorization contractor's web portal within one business day of conducting the assessment. The independent clinical assessment form (VICAP-001) shall be completed by the independent assessor within three business days of completing the ICA.

D. The individual or his parent or legal guardian shall have the right to freedom of choice of service providers.

12VAC30-130-3030. Application to services.

A. Intensive in-home (IIH) services.

1. Prior to the provision of IIH services, an independent clinical assessment shall be conducted by a person who meets the licensed mental health professional definition found at 12VAC35-105-20 and who is either employed by or contracted with a behavioral health services administrator (BHSA), community services board (CSB), behavioral health authority (BHA), or a subcontractor to the BHSA, CSB, or BHA in accordance with DMAS approval.

2. IIH services that are rendered in the absence of the required prior independent clinical assessment shall not be reimbursed.

B. Therapeutic day treatment (TDT).

1. Prior to the provision of TDT services, an independent clinical assessment shall be conducted by a person who meets the licensed mental health professional definition found at 12VAC35-105-20 and who is employed by or contracted with a BHSA, CSB, BHA, or the subcontractor of the BHSA, CSB, or BHA in accordance with DMAS approval.

2. TDT services that are rendered in the absence of the required prior independent clinical assessment shall not be reimbursed.

C. Mental health support services (MHSS).

1. Prior to the provision of MHSS, an independent clinical assessment, as defined in 12VAC30-130-3010, shall be conducted by a person who meets the licensed mental health professional definition found at 12VAC35-105-20 and who is employed by or contracted with a BHSA, CSB or BHA, or a subcontractor of a BHSA, CSB, or BHA in accordance with DMAS approval.

2. MHSS rendered in the absence of the required prior independent clinical assessment shall not be reimbursed.

NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access the form. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (12VAC30-130)

Forms accompanying Part II of this chapter:

Virginia Uniform Assessment Instrument.

Forms accompanying Part III of this chapter:

MI/MR Supplement Level I (form and instructions).

MI/MR Supplement Level II.

Forms accompanying Part VII of this chapter:

Request for Hospice Benefits DMAS-420, Revised 5/91.

Forms accompanying Part VIII of this chapter:

Inventory for Client and Agency Planning (ICAP) Response Booklet, D9200/D9210, 1986.

Forms accompanying Part IX of this chapter:

Patient Information form.

Instructions for Completion DMAS-122 form.

Forms accompanying Part XII of this chapter:

Health Insurance Premium Payment (HIPP) Program Insurance Information Request Form.

Health Insurance Premium Payment (HIPP) Program Medical History Form (HIPP Form-7, Rev. 11/92).

Health Insurance Premium Payment (HIPP) Program Employers Insurance Verification Form (HIPP Form-2, Rev. 11/92).

Health Insurance Premium Payment (HIPP) Program Employer Agreement (HIPP Form-3, Rev. 11/92).

Health Insurance Premium Payment (HIPP) Program Notice of HIPP Determination (HIPP Form-4, Rev. 11/92).

Health Insurance Premium Payment (HIPP) Program Notice of HIPP Approval.

Health Insurance Premium Payment (HIPP) Program Notice of HIPP Status (HIPP Form-6, Rev. 11/92).

Inventory for Client and Agency Planning (ICAP) Response Booklet, D9200/D9210, 1986.

Forms accompanying Part XIV of this chapter:

Residential Psychiatric Treatment for Children and Adolescents, FH/REV (eff. 10/20/99).

Forms accompanying Part XV of this chapter:

Treatment Foster Care Case Management Agreement, TFC CM Provider Agreement DMAS-345, FH/REV (eff. 10/20/99).

Forms accompanying Part XVIII of this chapter:

Virginia Independent Clinical Assessment Program (VICAP) (eff. 06/11).

VA.R. Doc. No. R11-2790; Filed January 14, 2013, 2:26 p.m.