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

REGULATIONS

Vol. 27 Iss. 24 - August 01, 2011

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 50

Emergency 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).

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

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

Effective Dates: July 18, 2011, through July 17, 2012.

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].

Preamble:

The department is promulgating these replacement emergency regulations to comply with Chapter 890, Item 297 YY of the 2011 Acts of Assembly, which requires changes in the provision of intensive in-home services and community mental health services to ensure appropriate utilization, cost efficiency, and provider qualifications. The services involved are skilled nursing facility services, EPSDT, and family planning; services related to the EPSDT program; community mental health services for children and adults; and mental health services utilization.

Summary:

This action implements the results of a review of mental health services for children and adults, as well as changes the name of the Department of Mental Health, Mental Retardation, and Substance Abuse Services to the Department of Behavioral Health and Developmental Services. The amendments also set forth rules and penalties related to the marketing of Medicaid mental health services.

An amendment to 12VAC30-50-130 deletes the allowance for a week of service for intensive in-home services without prior authorization to eliminate claims processing issues that delayed payments to providers. Additionally, a statement that prior authorization is required for day treatment for children and adolescents is added to reflect the current procedures.

Amendments to 12VAC30-60-61 require that specific assessment elements be included as part of the initial assessment for children's mental health services. It requires that the initial assessment for intensive in-home services be conducted in the home and adopts caseload and supervision guidelines that were published by the Department of Behavioral Health and Developmental Services' Licensing Division. The action specifies staff ratios for day treatment for children and adolescents and requires coordination with providers of case management. The amendment to 12VAC30-50-226 establishes qualifications for qualified mental health professionals (QMHPs) and establishes the definitions of the paraprofessionals' experience levels. In 12VAC30-50-130 and 12VAC30-50-226, language is added to the definition of clinical experience to include that internships, practicums, and field experience must be supervised.

A new section, 12VAC30-130-2000, contains the agency's requirements and limits for providers' marketing plans and activities to limit the frequency and manner in which providers approach potential clients and seek to engage such clients in their services.

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.

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

"Adolescent or child" means the individual receiving the services set out herein.

"Certified pre-screener" means an employee of the local Community Services Board, or its designee, who is skilled in the assessment and treatment of mental illness and has completed a certification program approved by DBHDS.

"Clinical experience" means (for the purpose of these services: intensive in-home services, day treatment for children and adolescents, community-based residential services for children, and adolescents who are younger than 21 (Level A) and therapeutic behavioral services (Level B)) providing direct clinical 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.

"Human services field" means (for the purpose of these services: intensive in-home, day treatment for children and adolescents, community-based residential services for children and adolescents younger than 21 (Level A) and 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, art or music therapy, or health promotion.

"Independent clinical assessment" means as defined in 12VAC30-60-61.

"Individual service plan" or "ISP" means a comprehensive and regularly updated document 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 annually and as the needs and progress of the individual changes.

"Licensed mental health professional" or "LMHP" means a licensed physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, a registered psychiatric clinical nurse specialist, or a licensed psychiatric nurse practitioner. A person who has been approved by the applicable Virginia health regulatory board as a supervisee in clinical social work or a resident in clinical psychology, professional counseling, substance abuse treatment practice, or marriage and family therapy may perform the functions of the LMHP for purposes of Medicaid reimbursement provided such supervisee or resident is in continuous compliance with the applicable board's requirements for supervised practice. For purposes of Medicaid reimbursement, these persons shall use the title "Supervisee" or "Resident" in connection with the applicable profession after their signatures to indicate such status. An individual may not perform the functions of the LMHP or be considered a "Supervisee" or "Resident" until the supervision for specific clinical duties at a specific site is pre-approved in writing by the appropriate Virginia health regulatory board.

"Qualified mental health professional-child" or "QMHP-C" means, as defined in 12VAC35-105-20, a person in the human services who is trained and experienced in providing psychiatric or mental health services to children who have a mental illness. To qualify as a QMHP-C, the person must have the designated clinical experience and must either (i) be a physician licensed in Virginia; (ii) have a master's degree in psychology from an accredited college or university with at least one year of clinical experience with children and adolescents; (iii) have a social work bachelor's or master's degree from an accredited college or university with at least one year of documented clinical experience with children or adolescents; (iv) be a registered nurse with at least one year of clinical experience with children and adolescents; (v) have at least a bachelor's degree in a human services field or in special education from an accredited college with at least one year of clinical experience with children and adolescents; or (vi) be a licensed mental health professional.

"Qualified mental health professional-eligible" or "QMHP-E" means, as defined in 12VAC35-105-20, a person who has (i) at least a bachelor's degree in a human service field or special education from an accredited college without one year of clinical experience or (ii) at least a bachelor's degree in a nonrelated field and is enrolled in a master's or doctoral clinical program, taking the equivalent of at least three credit hours per semester and is employed by a provider that has a triennial license issued by DBHDS and has a DBHDS-approved and DMAS-approved supervision training program.

"Qualified paraprofessional in mental health" or "QPPMH" means, as defined in 12VAC35-105-20, a person who must, at a minimum, meet one of the following criteria: (i) be registered with the United State Psychiatric Association (USPRA) as an associate psychiatric rehabilitation provider (APRP); (ii) have an associate's degree in a related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, or human services counseling) and at least one year of experience providing direct services to persons with a diagnosis of mental illness; or (iii) have a minimum of 90 hours of classroom training 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 experience (including the 12 weeks of supervised experience).

"Service-specific provider assessment" means the face-to-face interaction in which the provider obtains information from the child, adolescent, and parent or other family member or members, as appropriate, about health status. It includes documented history of health care problems and issues and contains the presenting issue/reason for referral, mental health history/hospitalizations, previous interventions and timeframes, medical profile, developmental history, educational/vocational status, current living situation and family history and relationships, legal status, drug and alcohol profile, resources and strengths, mental status profile, diagnosis, professional assessment summary and clinical formulation, and recommended treatment goals.

a. 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 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. These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child and his parents to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); case management activities and coordination with other required services; and 24-hour emergency response.

(1) These services shall be limited annually to 26 weeks.

(2) After an initial period, prior Service authorization is shall be required for Medicaid reimbursement.

(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 (more than a year old) assessments and ISPs shall be denied reimbursement. Requirements for assessments and ISPs are set out in 12VAC30-60-61.

(4) These services may be rendered by a LMHP, LMHP Supervisee or Resident, QMHP-C, and QMHP-E as herein defined.

b. 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. Prior to the provision of services, an independent assessment shall be conducted by an individual who meets the licensed mental health professional definition found in this section who is employed or contracted by a community services board (CSB), a behavioral health authority (BHA), or the CSB/BHA subcontractor.

(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 (more than a year old) assessments and ISPs shall be denied reimbursement. Requirements for assessments and ISPs are located in 12VAC30-60-61.

(3) These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-C and QMHP-E as herein defined.

c. 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 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.

(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 LMHP or LMHP Supervisee or Resident.

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

(4) Authorization is shall be required for Medicaid reimbursement.

(5) Room and board costs are not reimbursed. Facilities that only provide independent living services are not reimbursed.

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

(7) 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.

(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 (more than a year old) assessments and ISPs shall be denied reimbursement. Requirements for assessments and ISPs are set out in 12VAC30-60-61.

(10) These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-C, QMHP-E and QPPMH as herein defined.

d. 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, 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.

(2) Authorization is required for Medicaid reimbursement.

(3) Room and board costs are not reimbursed. Facilities that only provide independent living services are not reimbursed.

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

(7) Individuals must 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 (more than a year old) assessments and ISPs shall be denied reimbursement. Requirements for assessments and ISPs are set out in 12VAC30-60-61.

(9) These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-C, QMHP-E, and QPPMH as defined.

(10) The facility/group home shall coordinate services with other providers.

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 the local community services board 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 mental health day treatment/partial hospitalization, intensive community treatment, psychosocial rehabilitation, mental health support, crisis stabilization, and crisis intervention services) practical experience in providing direct services to individuals with diagnoses of mental illness or mental retardation/intellectual disability or the provision of direct geriatric services or special education services. Experience may shall include supervised internships, supervised practicums, and supervised field experience. Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience.

"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 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 mental health day treatment/partial hospitalization, intensive community treatment, psychosocial rehabilitation, mental health support, crisis stabilization, and crisis intervention services) social work, gerontology, psychology, psychiatric rehabilitation, special education, sociology, counseling, vocational rehabilitation, human development, behavioral sciences, marriage and family therapy, art or music therapy, health promotion, and human services counseling or other degrees deemed equivalent by DMAS.

"Individual" means the patient, client, or recipient of services set out herein.

"Individual service plan" or "ISP" means a comprehensive and regularly updated statement 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.

"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., as defined in 12VAC35-105-20, a licensed physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, or certified psychiatric clinical nurse specialist/practitioner. A person who has completed his graduate degree and is under the direct personal supervision of a person licensed under Virginia law, who is working towards licensure, and who is in compliance with the appropriate Virginia licensing board may perform the functions of the LMHP for purposes of Medicaid reimbursement. For purposes of Medicaid reimbursement, these persons shall use LMHP-E after their signatures to indicate this status.

"Qualified mental health professional-adult" or "QMHP" "QMHP-A" 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:, as defined in 12VAC35-105-20, a person who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness including (i) a doctor of medicine or osteopathy licensed in Virginia; (ii) a doctor of medicine or osteopathy, specializing in psychiatry and licensed in Virginia; (iii) an individual with a master's degree in psychology from an accredited college or university with at least one year of clinical experience; (iv) a social worker: an individual with at least a bachelor's degree in human services or related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling or other degree deemed equivalent to those described) from an accredited college and with at least one year of clinical experience providing direct services to persons with a diagnosis of mental illness; (v) an individual with at least a bachelor's degree from an accredited college in an unrelated field that includes at least 15 semester credits (or equivalent) in a human service field and who has at least three years of clinical experience; (vi) a certified psychiatric rehabilitation provider (CPRP) registered with the United States Psychiatric Rehabilitation Association (USPRA); (vii) a registered nurse licensed in Virginia with at least one year of clinical experience; or (viii) any other licensed mental health professional.

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-eligible" or "QMHP-E" means a person, as defined in 12VAC35-105-20, who has (i) at least a bachelor's degree in a human service field or special education from an accredited college without one year of clinical experience or (ii) at least a bachelor's degree in a nonrelated field and is enrolled in a master's or doctoral clinical program, taking the equivalent of at least three credit hours per semester and is employed by a provider that has a triennial license issued by the Department of Behavioral Health and Developmental Services (DBHDS) and a DBHDS-approved and DMAS-approved supervision training program.

"Qualified paraprofessional in mental health" or "QPPMH" means an individual who meets at least one of the following criteria:, as defined in 12VAC35-105-20, a person who must, at a minimum, meet one of the following criteria: (i) registered with the United States Psychiatric Association (USPRA) as an associate psychiatric rehabilitation provider (APRP); (ii) has an associate's degree in a related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human service counseling) and at least one year of experience providing direct services to persons with a diagnosis of mental illness; or (iii) has a minimum of 90 hours classroom training and 12 weeks of experience under the direct personal supervision of a QMHP-Adult providing services to persons with mental illness and at least one year of experience (including the 12 weeks of supervised experience).

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.

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.

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 behavior that requires repeated interventions or monitoring by the mental health, social services, or judicial system; 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 be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QMHP-E, and QPPMH as herein defined.

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.

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

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

e. These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QPPMH, and QMHP-E as herein defined.

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.

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 by mental health, social services, or the judicial system are 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 be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QMHP-C, QMHP-E, and a certified pre-screener, as herein defined.

4. Intensive community treatment (ICT), initially covered for a maximum of 26 weeks based on an initial 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 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. To qualify for ICT, the individual must meet at least one of the following criteria:

a. 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. 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 assessment that documents 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 be initiated at the time of admission and must be fully developed within 30 days of the initiation of services.

c. These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QMHP-E, and QPPMH as herein defined.

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 may be for up to a 15-day period per crisis episode following a documented face-to-face assessment by a QMHP which is reviewed and approved by an LMHP within 72 hours. The maximum limit on this service is up to eight hours (with a unit being one hour) per day up to 60 days annually. 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. The crisis stabilization program shall provide to recipients, as appropriate, psychiatric assessment including medication evaluation, treatment planning, symptom and behavior management, and individual and group counseling. This service may be provided in any of the following settings, but shall not be limited to: (i) the home of a recipient who lives with family or other primary caregiver; (ii) the home of a recipient who lives independently; or (iii) community-based programs licensed by DBHDS to provide residential services but which are not institutions for mental disease (IMDs). This service shall not be reimbursed for (i) recipients with medical conditions that require hospital care; (ii) recipients with primary diagnosis of substance abuse; or (iii) recipients with psychiatric conditions that cannot be managed in the community (i.e., recipients who are of imminent danger to themselves or others). Services must be documented through daily notes and a daily log of times spent in the delivery of services. 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. 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. 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. Exhibit such inappropriate behavior that immediate interventions by the mental health, social services, or judicial system are necessary; or

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

e. These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QMHP-C, QMHP-E, and a certified pre-screener as herein defined.

6. Mental health support services 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. These services may be authorized for six consecutive months. 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 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 by the mental health, social services, or judicial system are 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. The yearly limit for mental health support services is 372 units. One unit is one hour but less than three hours.

d. These services may be rendered by LMHP, LMHP Supervisee or Resident, QMHP-A, QMHP-E, and QPPMH as herein defined.

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

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

"Independent assessor" means a professional who performs the independent clinical assessment.

"Independent clinical assessment" means the evaluation that is done by the CSB/BHA or its subcontractor prior to the initiation of intensive in-home services, therapeutic day treatment, Levels A and B residential treatment, and mental health support services (as defined in 12VAC30-50-226) for children under 21. The elements of the independent clinical assessment are specified in the agreements with the CSBs/BHAs.

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

"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.

"Service-specific provider assessment" means the evaluation that is conducted according to the DMAS assessment definition set out in 12VAC30-50-130.

A. Independent clinical assessment requirements.

1. Effective July 18, 2011, an independent clinical assessment shall be required as a part of the service authorization process, for new services beginning on or after this date for Medicaid and FAMIS intensive in-home (IIH), therapeutic day treatment (TDT), and mental health support services (MHSS) for individuals up to the age of 21. This independent clinical assessment shall be performed prior to the initiation of treatment for individuals who are not already receiving services. CSBs/BHAs shall conduct these independent clinical assessments on and after August 1, 2011, for service reauthorizations with dates of service continuing on and after September 1, 2011. The independent clinical assessment shall be completed prior to the service provider conducting an assessment or providing treatment.

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

b. For individuals who receive services on and after July 17, 2011, the independent clinical assessment shall be required as part of the first service reauthorization process.

c. For individuals who are already receiving IIH, TDT, or MHSS services, the requirement for a completed independent clinical assessment shall be effective for service reauthorizations for dates of services on after September 1, 2011.

d. Individuals who are being discharged from residential treatment (DMAS service Levels A, B, or C) do not need an independent clinical assessment prior to receiving community IIH, TDT, or MHSS. They shall be required, however, to have an independent clinical assessment as part of any subsequent service reauthorization.

2. An independent clinical assessment shall be conducted within 30 days prior to the expiration of the current service authorization. The independent clinical assessment shall be completed and submitted to the DMAS service authorization contractor by the independent assessor prior to the service provider submitting the service reauthorization request to the DMAS service authorization contractor, or the provider's service reauthorization request will be administratively rejected. A copy of the independent clinical assessment shall be in the service provider's individual's file.

3. Levels A and B residential services will follow these same requirements effective in November 2011.

4. Service provider requirements. If a service provider receives a request from parents or legal guardians to provide IIH, TDT, or MHSS for individuals who are younger than 21 years of age, the service provider shall refer the parent/legal guardian to the local CSB/BHA to obtain the independent clinical assessment prior to providing services. When individuals are already receiving these services, then the provider of services shall inform the parent/legal guardian in writing at least 30 days prior to the current service authorization expiration date that an independent clinical assessment is needed in order for the services to continue.

a. The service provider shall be required to conduct a service-specific provider assessment as defined in 12VAC30-50-130 B.

b. If the selected service provider concurs that the child meets criteria for the service recommended by the independent assessor, the selected service provider will submit a service authorization request to the DMAS service authorization contractor. A copy of the independent clinical assessment shall be retained in the service provider's individual's file. The service-specific provider's assessment for IIH, TDT, or MHSS service shall not occur prior to the independent clinical assessment.

c. If, within 30 days after the independent clinical assessment, a service provider identifies the need for services that were not included in the independent clinical assessment, 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 independent clinical assessment was conducted. If the independent assessment is greater than 30 days old, another independent clinical assessment must be obtained prior to the initiation of a new IIH, TDT, or MHSS service for individuals younger than 21 years of age. 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/legal guardian.

d. If the independent assessment does not recommend the requested service and the service provider agrees with the independent clinical assessment recommendation, no service authorization request will be submitted to the DMAS service authorization contractor. If the service provider documented a significant change in the child's life since the independent clinical assessment that may change the independent assessor's recommendation, the service provider must contact the independent assessor to discuss the recommendation. The CSB/BHA may modify the independent clinical assessment as deemed necessary.

e. If the independent assessor does not recommend the service and the parent/legal guardian disagrees with the recommendation, the parent/legal guardian may approach a service provider requesting the service. If, after conducting the service specific assessment, the service provider identifies additional documentation beyond the independent clinical assessment that demonstrates the service is clinically indicated, the service provider may submit a service authorization request to the DMAS service authorization contractor. The DMAS service authorization contractor will review the service authorization submission and the independent assessment, and make a determination. If the determination results in a service denial, the member 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 assessor shall refer the individual to the appropriate currently reimbursed Medicaid emergency services in accordance with 12VAC30-50-226 and may also contact the individual's MCO to alert the MCO.

6. Requirements for community services boards/behavioral health authorities.

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

b. The independent assessor shall conduct the independent clinical assessment with the individual and the parent or legal guardian using a standardized format and make a recommendation for the most appropriate, medically necessary services, if indicated. Only the parent or legal guardian and individual shall be permitted in the room during the independent clinical assessment.

c. The independent clinical assessment shall be effective for a 30-day period.

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

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

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

1. Individuals qualifying for this service must 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:

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 repeated interventions by the mental health, social services or judicial system are necessary.

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

2. At admission, an appropriate service-specific provider assessment is made shall be conducted by the LMHP or the QMHP and approved by the LMHP, Licensed Mental Health Professional (LMHP), as that term is defined in 12VAC30-50-130 or an individual who is a LMHP Supervisee or Resident, under the supervision of a LMHP, documenting that 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. If the LMHP Supervisee or Resident performs the assessment, it must be reviewed, within 24 hours, approved, and signed/dated by the LMHP in order for Medicaid reimbursement to occur. Either a LMHP or LMHP Supervisee or Resident person shall make and document the diagnosis. The assessment shall include all of the elements specified herein. All assessments shall contain:

a. The presenting issue or reason for the referral;

b. The individual's mental health history and related hospitalizations and previous interventions and timeframes;

c. The individual's medical profile, such as significant past and present medical problems, illnesses, injuries, known allergies, and current physical complaints as well as medications used to treat them;

d. The individual's developmental history;

e. The individual's educational or vocational status, or both;

f. The individual's current living situation and family history and relationships;

g. The individual's legal status;

h. The individual's drug and alcohol profile, including that of family members;

i. The individual's resources and strengths, including extracurricular activities and informal supports, church, and extended family (for example, anyone in the child's family or an important person who acts as a support to the child);

j. The individual's mental status profile;

k. The individual's diagnosis as set out in the Diagnostic and Statistical Manual 4th Edition (DSM-IV) (as may be amended from time to time) code and description;

l. The professional assessment summary and clinical formulation; and

m. The recommended treatment goals.

3. An individual service plan (ISP) must be fully completed within 30 days of initiation of services.

3. 4. Services must shall be directed toward the treatment of the eligible child and delivered primarily in the family's residence with the child present. The service-specific provider assessment shall be conducted face-to-face in the residence. In some circumstances, such as lack of privacy or unsafe conditions, the assessment and provision of services may be provided in the community if supported by the needs assessment and ISP the rationale is supported in the clinical record.

4. 5. These services shall be provided when the clinical needs of the child put the child him at risk for out-of-home placement:

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

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

5. 6. Services may not be billed when provided to a family while the child is not residing in the home.

6. 7. 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 and responsible parent/guardian must be available and in agreement to participate in the transition.

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

8. 9. 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.

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

10. 11. 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 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 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 child and family initially with a lessening or tapering off of intensity toward the latter weeks of service. Service plans must shall incorporate a discharge plan which identifies transition from intensive in-home to less intensive or nonhome based services. If there is a lapse in service for more than two weeks, the reason for the lapse and the rationale for the continued need for the service shall be documented. The ISP shall be reviewed and updated if there are changes, and signed by either the parent or legal guardian and if appropriate, the child. If the lapse is greater than 31 days, a new admission shall occur.

11. 12. The provider must shall ensure that the maximum staff-to-caseload ratio fully meets the needs of the individual. For full time staff, the staff-to-client ratio shall not exceed five cases per staff person. The ratio for half-time staff-to-clients shall be 1 to 3. Staff that work less than half-time shall be authorized by the licensing specialist for more than one case. A case load may be 1:6 staff to client ratio if the staff is transitioning one of the clients off of the case load for up to 30 days.

13. A full-time clinical supervisor shall not have more than 10 QMHPs to supervise. A half-time clinical supervisor shall not have more than five QMHPs to supervise.

12. 14. 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.

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

16. Providers shall comply with DMAS marketing requirements at 12VAC30-130-2000 et seq. Providers that DMAS determines to have violated the DMAS marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

17. If a child receiving services is also receiving case management services, as specified in 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 child's progress. A discharge summary shall be sent to the case manager within 30 days of the service discontinuation date.

18. The provider shall also inform the primary care provider of the child's receipt of community mental health rehabilitative services.

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

1. 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.

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

3. 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 repeated interventions by the mental health, social services or judicial system are necessary.

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

4. The enrolled provider of therapeutic day treatment for child and adolescents services must shall be licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services DBHDS to provide day support services.

5. Services must shall be provided by an a LMHP, LMHP Supervisee or Resident, a QMHP, or a QPPMH who is supervised by a QMHP or LMHP QMHP-C, or QMHP-E.

6. The minimum staff-to-youth staff-to-individual ratio shall ensure that adequate staff is available to meet the needs of the youth individual identified on the ISP. The staff-to-individual ratio shall not exceed one clinical staff to six clients.

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

9. Services shall be provided following a diagnostic service-specific provider assessment that is authorized conducted by an LMHP or LMHP Supervisee or Resident. A LMHP or LMHP Supervisee or Resident person shall make the diagnosis. Services must shall be provided in accordance with an ISP individual service plan (ISP) which must shall be fully completed within 30 days of initiation of the service. The assessment shall include the elements specified in 12VAC30-60-61 A 2.

10. 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 progress. A discharge summary shall be sent to the case manager within 30 days of the service discontinuation date.

11. The provider shall also inform the primary care provider of the child's receipt of community mental health rehabilitative services.

12. Providers shall comply with DMAS marketing requirements as set out in 12VAC30-130-2000 et seq. Providers that violate the DMAS marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

13. If there is a lapse in service for more than two weeks, the reason for the lapse and the rationale for the continued need for the service shall be documented. The ISP shall be reviewed, updated to determine if there are changes, and signed by either the parent or legal guardian and if appropriate, the child. If the lapse is greater than 31 days, a new admission shall occur.

C. D. 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. The program director supervising the program/group home must be, at minimum, a qualified mental health professional (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 least 50% of the direct care staff must meet DMAS paraprofessional staff criteria, defined in 12VAC30-50-226.

3. Authorization is required for Medicaid reimbursement. All community-based services for children and adolescents under 21 (Level A) shall be authorized prior to reimbursement for these services. 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. 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 12VAC30-60-61 A 2.

6. Such service-specific provider assessments shall be performed by a LMHP or LMHP Supervisee or Resident. If the LMHP Supervisee or Resident performs the assessment, then it must be reviewed, within 24 hours, approved and signed/dated in order for Medicaid reimbursement to occur.

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. A discharge summary shall be sent to the case manager when the service is discontinued.

D. E. 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. The clinical director must be a licensed mental health professional. The caseload of the clinical director must not exceed 16 clients 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. At In order for Medicaid reimbursement to be approved, at least 50% of the direct care staff must meet DMAS paraprofessional staff criteria, as defined in 12VAC30-50-226. The program/group home must coordinate services with other providers.

3. 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. 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.

5. Prior to admission, a service-specific provider assessment shall be performed using elements specified by DMAS in the agency guidance documents.

6. Such service-specific provider assessments shall be performed by a LMHP or LMHP Supervisee or Resident. If the LMHP Supervisee or Resident performs the assessment then it must be reviewed, within 24 hours, approved and signed/dated in order for Medicaid reimbursement to occur.

7. If an individual receiving day therapeutic behavioral services for children and adolescents under 21 (Level B) is also receiving case management services the provider must collaborate with the case manager by notifying the case manager of provision of Level B services and send monthly updates on the individual's progress. A discharge summary shall be sent to the case manager when the services are discontinued.

8. The provider shall also inform the primary care provider of the child's receipt of community mental health rehabilitative services.

E. F. 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.

A. 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.

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 et seq. Providers that violate the DMAS marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

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 must collaborate with the case manager by notifying the case manager of the provisions of community mental health rehabilitative services and send monthly updates on the individual's progress. The provider must also inform the primary care provider of the child's receipt of community mental health rehabilitative services. A discharge summary shall be sent when the services are discontinued.

B. 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. An ISP shall be fully completed by either the LMHP or the QMHP as defined at 12VAC30-50-226 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 be provided by an LMHP, LMHP Supervisee or Resident, a QMHP QMHP-A or QMHP-E, or a qualified paraprofessional under the supervision of a QMHP QMHP-A or an LMHP or LMHP Supervisee or Resident as defined at 12VAC30-50-226.

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. 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 service-specific provider assessment shall be completed by an LMHP, LMHP Supervisee or Resident or a QMHP, and QMHP-A or QMHP-E. If the service-specific provider assessment is done by a QMHP-A or QMHP-E, it shall be approved by a LMHP, LMHP Supervisee or Resident within 30 days of admission to services. An ISP shall be completed by the LMHP, or LMHP Supervisee or Resident or the QMHP QMHP-A or QMHP-E within 30 days of service initiation. Every three months, the LMHP, LMHP Supervisee or Resident or the QMHP QMHP-A or QMHP-E must review, modify as appropriate, and update the ISP.

2. Psychosocial rehabilitation services of any individual that continue more than six months must be reviewed by an LMHP, or LMHP Supervisee or Resident who must 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, LMHP Supervisee or Resident, a QMHP QMHP-A, QMHP-E or a qualified paraprofessional under the supervision of either a QMHP QMHP-A, QMHP-E, or an LMHP, or LMHP Supervisee or Resident.

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 intervention services is 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 Individual-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 be developed or revised 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 not 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, LMHP Supervisee or Resident, a QMHP QMHP-A, QMHP-C, or QMHP-E, or a certified prescreener must conduct a face-to-face service-specific provider assessment. If the QMHP QMHP-A, QMHP-C, or QMHP-E performs the service-specific provider assessment, it must be reviewed and approved by an LMHP, LMHP Supervisee or Resident 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, LMHP Supervisee or Resident, a certified prescreener, or a QMHP QMHP-A, QMHP-C, or QMHP-E.

8. Crisis intervention shall not require an ISP.

9. 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 screenings cannot be billed unless the requirement for an independent team, with a physician's signature, is met.

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

E. Case management services (pursuant to 12VAC30-50-226) (pursuant to 12VAC30-50-420 (seriously mental 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 in effect which requires regular direct or client-related contacts or activity or communication with the client or families, significant others, service providers, and others including a minimum of one face-to-face client 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 document the need for case management and be fully completed within 30 days of initiation of the service, and the case manager shall review the ISP 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 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. Intensive community treatment (ICT) for adults.

1. An A service-specific provider assessment which documents eligibility and need for this service shall be completed by the LMHP, LMHP Supervisee or Resident or the QMHP QMHP-A or QMHP-E prior to the initiation of services. This assessment must be maintained in the individual's records.

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 the LMHP, LMHP Supervisee or Resident or the QMHP QMHP-A or QMHP-E and approved by the LMHP or LMHP Supervisee or Resident within 30 days of the initiation of services.

3. ICT may be billed if the client is brought to the facility by ICT staff to see the psychiatrist. Documentation must be present 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. Crisis stabilization services.

1. This service must be authorized following a face-to-face service-specific provider assessment by an LMHP, LMHP Supervisee or Resident, a certified prescreener, or a QMHP QMHP-A, QMHP-C, or QMHP-E. 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 service-specific provider assessment or reassessment. The LMHP, certified prescreener, or QMHP 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. Mental health support services.

1. At admission, an appropriate face-to-face service-specific provider assessment must be made, within 30 days, and documented by the LMHP or the QMHP the LMHP Supervisee or Resident 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 service-specific provider assessment must be performed in order for Medicaid reimbursement to occur. The LMHP, LMHP Supervisee or Resident, or the QMHP will shall complete the ISP within 30 days of the admission to this service.

2. The ISP, as defined in 12VAC30-50-226, must shall indicate the specific supports and services to be provided and the goals and objectives to be accomplished. The LMHP, LMHP Supervisee or Resident or QMHP, QMHP-A, or QMHP-E will supervise the care if delivered by the qualified paraprofessional.

2. 3. Every three months, the LMHP, LMHP Supervisee or Resident, or the QMHP must QMHP-A, or QMHP-E shall review, modify as appropriate, and update the ISP. If the QMHP-A or QMHP-E reviews the ISP, it shall be discussed face to face with the LMHP or LMHP Supervisee or Resident. Such review shall be documented in the client's record. The ISP must shall be rewritten 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 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 GED.

5. 6. Any services provided to clients that are strictly vocational in nature shall not be billable. However, support activities and activities directly related to assisting a client 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 or LMHP Supervisee or Resident who must shall document the continued need for the services. The LMHP or LMHP Supervisee or Resident shall see the client face to face to conduct the six-month review.

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 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

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

A. Purpose. The purpose of these rules shall be to control how providers shall be permitted to market their services to potential Medicaid/FAMIS Plus beneficiaries and clients who may or may not be currently enrolled with the particular provider.

B. Definitions.

"Beneficiaries" means those individuals and their families who are using community mental health rehabilitative services.

"DMAS" means the Department of Medical Assistance Services.

"Provider" means an individual or organizational entity which is appropriately licensed as required by the Code of Virginia and enrolled as a DMAS provider.

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 mental health services offered, the beneficiary eligibility requirements to receive the service, applicable fees and other charges and all other information required for beneficiaries and their families to make informed decisions about enrollment into the service.

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. Prior to the initiation of or a change to a provider's marketing plan, the provider must submit its marketing plan and receive approval by DMAS 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 may be subject to termination of the provider contract pursuant to 12VAC30-130-2000 E.

D. Limits and prohibitions.

1. Providers shall not offer cash or noncash incentives to their enrolled 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 Plus benefits;

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

d. Conduct any marketing activities 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 confidential information or Medicaid protected health information (PHI), as that term is defined in Health Insurance Portability and Accountability Act of 1996 (HIPPA), that may be provided by another entity, to identify and market its 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 by either 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.

VA.R. Doc. No. R11-2790; Filed July 18, 2011, 4:53 p.m.