12 Va. Admin. Code § 30-50-130
B. General provisions for early and periodic screening, diagnosis, and treatment (EPSDT) of individuals younger than 21 years of age, and treatment of conditions found.
C. Community mental health services provided through early and periodic screening diagnosis and treatment (EPSDT) for individuals younger than 21 years of age. These services in order to be covered (i) shall meet medical necessity criteria based upon diagnoses made by LMHPs, LMHP-Rs, LMHP-RPs, and LMHP-Ss who are practicing within the scope of their licenses and (ii) shall be reflected in provider records and on providers' claims for services by recognized diagnosis codes that support and are consistent with the requested professional services.
1. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:
"Care coordination" means the collaboration and sharing of information among health care providers involved with an individual's health care to improve the care.
"Caregiver" means the same as defined in 12VAC30-130-5160.
"Child" means an individual ages birth through 11 years.
"Comprehensive needs assessment" means the face-to-face interaction in which the provider obtains information from the youth and parent or other family member, as appropriate, about the youth's mental health status. Requirements for the comprehensive needs assessment are set out in 12VAC30-60-143.
"DBHDS" means the Department of Behavioral Health and Developmental Services.
"Direct supervisor" means the person who provides direct supervision to the peer recovery specialist. The direct supervisor (i) shall have two consecutive years of documented practical experience rendering peer support services or family support services, have certification training as a PRS under a certifying body approved by DBHDS, and have documented completion of the DBHDS PRS supervisor training; (ii) shall be a qualified mental health professional (QMHP-A, QMHP-C, or QMHP-E) as defined in 12VAC35-105-20 with at least two consecutive years of documented experience as a QMHP, and who has documented completion of the DBHDS PRS supervisor training; or (iii) shall be an LMHP, LMHP-R, LMHP-RP, or LMHP-S who has documented completion of the DBHDS PRS supervisor training who is acting within his scope of practice under state law.
"DMAS" means the Department of Medical Assistance Services and its contractors.
"EPSDT" means early and periodic screening, diagnosis, and treatment.
"Family support partners" means the same as defined in 12VAC30-130-5170.
"Individual service plan" or "ISP" means the same as the term is defined in 12VAC30-50-226.
"Licensed mental health professional" or "LMHP" means the same as defined in 12VAC35-105-20.
"LMHP-resident" or "LMHP-R" means the same as "resident" as defined in (i) 18VAC115-20-10 for licensed professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment practitioners. An LMHP-resident shall be in continuous compliance with the regulatory requirements of the applicable counseling profession for supervised practice and shall not perform the functions of the LMHP-R or be considered a "resident" until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Counseling.
"LMHP-resident in psychology" or "LMHP-RP" means the same as an individual in a residency, as that term is defined in 18VAC125-20-10, program for clinical psychologists. An LMHP-resident in psychology shall be in continuous compliance with the regulatory requirements for supervised experience as found in 18VAC125-20-65 and shall not perform the functions of the LMHP-RP or be considered a "resident" until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Psychology.
"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as "supervisee" as defined in 18VAC140-20-10 for licensed clinical social workers. An LMHP-supervisee in social work shall be in continuous compliance with the regulatory requirements for supervised practice as found in 18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered a "supervisee" until the supervision for specific clinical duties at a specific site is preapproved in writing by the Virginia Board of Social Work.
"Peer recovery specialist" or "PRS" means the same as defined in 12VAC30-130-5160.
"Peer recovery support services" means the same as defined in 12VAC35-250-10.
"Person centered" means the same as defined in 12VAC30-130-5160.
"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes. Individualized and member-specific progress notes are part of the minimum documentation requirements and shall convey the individual's status, staff interventions, and, as appropriate, the individual's progress, or lack of progress, toward goals and objectives in the ISP.
"Psychoeducation" means (i) a specific form of education aimed at helping youth who have mental illness and their family members or caregivers to access clear and concise information about mental illness and (ii) a way of accessing and learning strategies to deal with mental illness and its effects in order to design effective treatment plans and strategies.
"Qualified mental health professional-child" or "QMHP-C" means the same as the term is defined in § 54.1-3500 of the Code of Virginia.
"Qualified mental health professional-eligible" or "QMHP-E" means the same as "qualified mental health professional – trainee" as defined in § 54.1-3500 of the Code of Virginia.
"Recovery-oriented services" means the same as defined in 12VAC30-130-5160.
"Recovery, resiliency, and wellness plan" means the same as defined in 12VAC30-130-5160.
"Resiliency" means the same as defined in 12VAC30-130-5160.
"Self-advocacy" means the same as defined in 12VAC30-130-5160.
"Strength-based" means the same as defined in 12VAC30-130-5160.
"Supervision" means the same as defined in 12VAC30-130-5160.
"Youth" means an individual younger than 21 years of age.
2. Intensive in-home services (IIH) to youth shall be time-limited interventions provided in the youth's residence and when clinically necessary in community settings. All interventions and the settings of the intervention shall be defined in the Individual Service Plan. All IIH services shall be designed to specifically improve family dynamics and provide modeling and the clinically necessary interventions that increase functional and therapeutic interpersonal relations between family members in the home. IIH services are designed to promote psychoeducational benefits in the home setting of a youth 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 youth. These services provide crisis treatment; individual and family counseling; communication skills (e.g., counseling to assist the youth and the youth's parents or guardians, as appropriate, to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); care coordination with other required services; and 24-hour emergency response.
3. Therapeutic day treatment (TDT) shall be provided two or more hours per day in order to provide therapeutic interventions (a unit is defined in 12VAC30-60-61 D 11). Day treatment programs 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 counseling.
D. Therapeutic group home services and psychiatric residential treatment facility (PRTF) services for early and periodic screening diagnosis and treatment (EPSDT) of youth.
1. Definitions. The following words and terms when used in this subsection shall have the following meanings:
"Active treatment" means implementation of an initial plan of care (IPOC) and comprehensive individual plan of care (CIPOC).
"Activities of daily living" or "ADL" means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.
"Activities of daily living restoration" or "ADL restoration" means a face-to-face interaction provided on an individual or group basis to assist youth in the restoration of lost ADL skills that are necessary to achieve the goals established in the youth's plan of care. Services address performance deficits related to a lack of physical, cognitive, or psychosocial skills which hinder the ability of the youth to complete ADLs. Services include (i) restoring acceptable habits, behaviors, and attitudes related to daily health activities and personal care or hygiene and (ii) assisting the youth restoring and regaining functional ADL skills and appropriate behavior related to health and safety.
"ADL supervisor" means a child care supervisor with a baccalaureate degree in social work or psychology and two years of professional experience working with children one year of which must have been in a residential facility for children; or a high school diploma or General Education Development Certificate (GED) and a minimum of five years professional experience working with children with at least two years in a residential facility for children.
"ADL technician" means a child care worker at least 21 years of age who has a baccalaureate degree in human services (as defined by the Department of Health Professions); has an associate's degree and three months experience working with children; or is a high school graduate or has a GED and has six months of experience working with children. A trainee with a high school diploma or a GED may count experience working directly alongside a staff member who is, at a minimum, an ADL technician with at least one year of professional experience with children if the trainee is within sight and sound of the supervising staff member and does not work alone. An individual can only be classified as an ADL technician if they are supervised by an ADL supervisor, QMHP-C, LMHP, LMHP-R, LMHP-RP, or LMHP-S.
"Assessment" means the face-to-face interaction by an LMHP, LMHP-R, LMHP-RP, or LMHP-S to obtain information from the youth and parent, guardian, or other family member, as appropriate, utilizing a tool or series of tools to provide a comprehensive evaluation and review of the youth's mental health status. The assessment shall include a documented history of the severity, intensity, and duration of mental health problems and behavioral and emotional issues.
"Certificate of need" or "CON" means a written statement by an independent certification team that services in a therapeutic group home or PRTF are or were needed.
"Comprehensive individual plan of care" or "CIPOC" means a person centered plan of care that meets all of the requirements of this subsection and is specific to the youth's unique treatment needs and acuity levels as identified in the clinical assessment and information gathered during the referral process.
"Crisis" means a deteriorating or unstable situation that produces an acute, heightened emotional, mental, physical, medical, or behavioral event.
"Crisis management" means immediately provided activities and interventions designed to rapidly manage a crisis. The activities and interventions include behavioral health care to provide immediate assistance to youth experiencing acute behavioral health problems that require immediate intervention to stabilize and prevent harm and higher level of acuity. Activities shall include assessment and short-term counseling designed to stabilize the youth. Youth are referred to long-term services once the crisis has been stabilized.
"Daily supervision" means the supervision provided in a PRTF through a resident-to-staff ratio approved by the Office of Licensure at the Department of Behavioral Health and Developmental Services with documented supervision checks every 15 minutes throughout a 24-hour period.
"Discharge planning" means family and locality-based care coordination that begins upon admission to a PRTF or therapeutic group home with the goal of transitioning the youth out of the PRTF or therapeutic group home to a less restrictive care setting with continued, clinically-appropriate services as soon as possible upon discharge. Discharge plans shall be recommended by the treating physician, psychiatrist, or treating LMHP responsible for the overall supervision of the plan of care and shall be approved by the DMAS contractor.
"DSM-5" means the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric Association.
"Emergency admissions" means admissions that are made when, pending a review for the certificate of need, it appears that the youth is in need of an immediate admission to a therapeutic group home or PRTF and likely does not meet the medical necessity criteria to receive crisis intervention, crisis stabilization, or acute psychiatric inpatient services.
"Family engagement" means a family-centered and strengths-based approach to partnering with families in making decisions, setting goals, achieving desired outcomes, and promoting safety, permanency, and well-being for youth and families. Family engagement requires ongoing opportunities for a youth to build and maintain meaningful relationships with family members, for example, frequent, unscheduled, and noncontingent telephone calls and visits between the youth and family members. Family engagement may also include enhancing or facilitating the development of the youth's relationship with other family members and supportive adults responsible for the youth's care and well-being upon discharge.
"Family engagement activity" means an intervention consisting of family psychoeducational training or coaching, transition planning with the family, family and independent living skills, and training on accessing community supports as identified in the plan of care. Family engagement activity does not include and is not the same as family therapy.
"Family therapy" means counseling services involving the youth's family and significant others to advance the treatment goals when (i) the counseling with the family member and significant others is for the direct benefit of the youth, (ii) the counseling is not aimed at addressing treatment needs of the youth's family or significant others, and (iii) the youth is present except when it is clinically appropriate for the youth to be absent in order to advance the youth's treatment goals. Family therapy shall be aligned with the goals of the youth's plan of care. All family therapy services furnished are for the direct benefit of the youth, in accordance with the youth's needs and treatment goals identified in the youth's plan of care, and for the purpose of assisting in the youth's recovery.
"FAPT" means the family assessment and planning team.
"ICD-10" means International Statistical Classification of Diseases and Related Health Problems, 10th Revision, published by the World Health Organization.
"Independent certification team" means a team that has competence in diagnosis and treatment of mental illness, preferably in child and adolescent psychiatry; has knowledge of the youth's situation; and is composed of at least one physician and one LMHP, LMHP-R, LMHP-RP, or LMHP-S. The independent certification team shall be a DMAS-authorized contractor with contractual or employment relationships with the required team members.
"Initial plan of care" or "IPOC" means a person centered plan of care established at admission that meets all of the requirements of this subsection and is specific to the youth's unique treatment needs and acuity levels as identified in the clinical assessment and information gathered during the referral process.
"Intervention" means scheduled therapeutic treatment included in the individualized plan of care to help the youth achieve the youth's plan of care goals and objectives. Interventions may include individual or group psychoeducation; skills restoration; ADL restoration; individual, group, and family therapy; structured behavior support and training activities; recreation, art, and music therapies; community integration activities that promote or assist in the youth's ability to acquire coping and functional or self-regulating behavior skills; therapeutic passes; and family engagement activities. Interventions shall not include medical or dental appointments, physician services, medication evaluation, or management provided by a licensed clinician or physician and shall not include school attendance. Interventions are provided in the therapeutic group home or PRTF and, when clinically necessary, may occur in a community setting or as part of a therapeutic pass if the setting is documented in the plan of care.
"Plan of care" means the initial plan of care (IPOC) and the comprehensive individual plan of care (CIPOC).
"Physician" means an individual licensed to practice medicine or osteopathic medicine in Virginia, as defined in § 54.1-2900 of the Code of Virginia.
"Psychiatric residential treatment facility" or "PRTF" means the same as defined in 42 CFR 483.352 and is a 24-hour, supervised, clinically and medically necessary, out-of-home active treatment program designed to provide necessary support and address mental health, behavioral, substance abuse, cognitive, and training needs of a youth in order to prevent or minimize the need for more intensive treatment.
"Psychotherapy" or "therapy" means the use of psychological methods in a professional relationship to assist a person to acquire great human effectiveness or to modify feelings, conditions, attitudes, and behaviors that are emotionally, intellectually, or socially ineffectual or maladaptive.
"Recertification" means a certification for each applicant or recipient for whom therapeutic group home or PRTF services are needed.
"Room and board" means a component of the total daily cost for placement in a licensed PRTF. Residential room and board costs are maintenance costs associated with placement in a licensed PRTF and include a semi-private room, three meals and two snacks per day, and personal care items. Room and board costs are reimbursed only for PRTF settings.
"Skills restoration" means a face-to-face service to assist youth in the restoration of lost skills that are necessary to achieve the goals established in the youth's plan of care. Services include assisting the youth in restoring self-management, interpersonal, communication, and problem solving skills through modeling, coaching, and cueing.
"Therapeutic group home" means a congregate residential service providing 24-hour supervision in a community-based home having eight or fewer residents.
"Therapeutic pass" means time at home or time with family consisting of partial or entire days of time away from the therapeutic group home or psychiatric residential treatment facility as clinically indicated in the plan of care and as paired with facility-based and community-based interventions to promote discharge planning, community integration, and family engagement activities. Therapeutic passes are not recreational but are a therapeutic component of the plan of care and are designed for the direct benefit of the youth.
"Therapeutic services" means the structured therapeutic program designed to restore appropriate skills necessary to promote prosocial behavior and healthy living to include: the restoration of coping skills; family living and health awareness; interpersonal skills; communication skills; and stress management skills. Therapeutic services also engage families and reflect family-driven practices that correlate to sustained positive outcomes post-discharge for youth and their family members. Therapeutic services include assessment, individualized treatment planning, and interventions.
"Treatment planning" means development, implementing, monitoring, and updating of a person centered plan of care that is specific to the individual's unique treatment needs and acuity levels.
"Youth" means an individual younger than 21 years of age.
2. Therapeutic group home services pursuant to 42 CFR 440.130(d).
c. Medical necessity criteria for admission to a therapeutic group home. The following requirements for severity of need and intensity and quality of service shall be met to satisfy the medical necessity criteria for admission.
(1) Severity of need required for admission. All of the following criteria shall be met to satisfy the criteria for severity of need:
(2) Intensity and quality of service necessary for admission. All of the following criteria shall be met to satisfy the criteria for intensity and quality of service:
(3) Continued stay criteria. The following criteria shall be met in order to satisfy the criteria for continued stay:
d. The following clinical activities shall be required for each therapeutic group home resident:
(4) An IPOC that is specific to the youth's unique treatment needs and acuity levels. The IPOC shall be completed on the day of admission by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be signed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the youth and a family member or legally authorized representative. The IPOC shall include all of the following:
(5) A CIPOC shall be completed no later than 14 calendar days after admission. The CIPOC shall meet all of the following criteria:
(6) The CIPOC shall be reviewed, signed, and dated every 30 calendar days by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the youth or a family member or primary caregiver. Updates shall be signed and dated by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the youth or a family member or legally authorized representative. The review shall include all of the following:
(14) Therapeutic passes shall be provided as clinically indicated in the plan of care and as paired with facility-based and community-based interventions to promote discharge planning, community integration, and family engagement activities.
e. Service exclusions include the following:
3. PRTF services are a 24-hour, supervised, clinically and medically necessary out-of-home program designed to provide necessary support and address mental health, behavioral, substance use, cognitive, or other treatment needs of a youth in order to prevent or minimize the need for more intensive inpatient treatment. Active treatment and comprehensive discharge planning shall begin prior to admission. In order to be covered for youth, these services shall (i) meet DMAS-approved psychiatric medical necessity criteria or be approved as an EPSDT service based upon a diagnosis made by an LMHP, LMHP-R, LMHP-RP, or LMHP-S who is practicing within the scope of his license and (ii) be reflected in provider records and on the provider's claims for services by recognized diagnosis codes that support and are consistent with the requested professional services.
f. Medical necessity criteria for admission to a PRTF. The following requirements for severity of need and intensity and quality of service shall be met to satisfy the medical necessity criteria for admission:
(1) Severity of need required for admission. The following criteria shall be met to satisfy the criteria for severity of need:
(2) Intensity and quality of service necessary for admission. The following criteria shall be met to satisfy the criteria for intensity and quality of service:
(3) Criteria for continued stay. The following criteria shall be met to satisfy the criteria for continued stay:
g. The following clinical activities shall be required for each PRTF resident:
(3) The initial plan of care (IPOC) shall be completed within 24 hours of admission by the treatment team. The IPOC shall include:
(4) The CIPOC shall be completed and signed no later than 14 calendar days after admission by the treatment team. This information shall be used when considering changes and updating the CIPOC. The CIPOC shall meet all of the following criteria:
h. The team developing the CIPOC shall meet the following requirements:
(2) The team shall include one of the following:
4. Requirements for independent certification teams applicable to both therapeutic group homes and PRTFs:
5. Service authorization requirements applicable to both therapeutic group homes and PRTFs:
d. Information that is required to obtain authorization for these services shall include:
(2) A certificate of need completed by an independent certification team specifying all of the following:
6. Continued stay criteria requirements applicable to both therapeutic group homes and PRTFs. For a continued stay authorization or a reauthorization to occur, the youth shall meet the medical necessity criteria as defined in this subsection to satisfy the criteria for continuing care. The length of the authorized stay shall be determined by DMAS or its contractor. A current plan of care and a current (within 30 calendar days) summary of progress related to the goals and objectives of the plan of care shall be submitted to DMAS or its contractor for continuation of the service. The service provider shall also submit:
8. Inpatient psychiatric services shall be covered for youth for medically necessary stays in inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the purpose of diagnosis and treatment of mental health and behavioral disorders identified under EPSDT when such services meet the requirements set forth in subdivision 7 of this subsection.
E. Mental health family support partners.
5. Caregivers of youth who qualify to receive mental health family support partners shall (i) care for a youth with a mental health disorder who requires recovery assistance and (ii) meet two or more of the following:
12. The PRS shall be employed by or have a contractual relationship with the enrolled provider licensed for one of the following:
I. Behavioral therapy services shall be covered for individuals younger than 21 years of age.
1. Definitions. The following words and terms when used in this subsection shall have the following meanings unless the context clearly indicates otherwise:
"Behavioral therapy" means systematic interventions provided by licensed practitioners acting within the scope of practice defined under a Virginia Department of Health Professions regulatory board and covered as remedial care under 42 CFR 440.130(d) to youth. Behavioral therapy includes applied behavioral analysis. Family training related to the implementation of the behavioral therapy shall be included as part of the behavioral therapy service. Behavioral therapy services shall be subject to clinical reviews and determined as medically necessary. Behavioral therapy may be provided in the youth's home and community settings as deemed by DMAS or its contractor as medically necessary treatment.
"Counseling" means a professional mental health service that can only be provided by a person holding a license issued by a health regulatory board at the Department of Health Professions, which includes conducting assessments, making diagnoses of mental disorders and conditions, establishing treatment plans, and determining treatment interventions.
"Primary care provider" means a licensed medical practitioner who provides preventive and primary health care and is responsible for providing routine EPSDT screening and referral and coordination of other medical services needed by the individual.
"Youth" means an individual younger than 21 years of age who is receiving behavioral therapy services.
3. Behavioral therapy services shall be covered when recommended by the youth's primary care provider or other licensed physician, licensed physician assistant, or licensed nurse practitioner and determined by DMAS or its contractor to be medically necessary to correct or ameliorate significant impairments in major life activities that have resulted from either developmental, behavioral, or mental disabilities. Criteria for medical necessity are set out in 12VAC30-60-61 F. A behavioral therapy assessment shall be required prior to these services in order to receive authorization for reimbursement. Individual service plans (ISPs) shall be required throughout the entire duration of services. The services shall be provided in accordance with the individual service plan and clinical assessment summary. These services shall be provided in settings that are natural or normal for a youth without a disability, such as the youth's home, unless there is justification in the ISP, which has been authorized for reimbursement, to include service settings that promote a generalization of behaviors across different settings to maintain the targeted functioning outside of the treatment setting in the youth's home and the larger community within which the youth resides. Covered behavioral therapy services shall include:
J. School health services.
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.
3. 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.
4. Covered services include:
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.
K. Family planning services and supplies for individuals of child-bearing age.
§ 32.1-325 of the Code of Virginia, 42 USC § 1396 et seq.
Derived from VR460-03-3.1100 § 4, eff. April 1, 1993; amended, eff. June 30, 1993; Virginia Register Volume 10, Issue 22, eff. September 1, 1994; Volume 14, Issue 7, eff. January 22, 1998; Volume 17, Issue 5, eff. January 1, 2001; Volume 20, Issue 7, eff. February 1, 2004; Volume 22, Issue 8, eff. January 25, 2006; Volume 23, Issue 21, eff. January 1, 2008; Volume 25, Issue 5, eff. December 10, 2008; Volume 26, Issue 11, eff. March 3, 2010; Volume 31, Issue 9, eff. January 30, 2015; Volume 33, Issue 11, eff. February 22, 2017; Volume 33, Issue 12, eff. March 8, 2017; Volume 33, Issue 12, eff. April 1, 2017; Volume 34, Issue 3, eff. November 16, 2017; Volume 35, Issue 2, eff. October 27, 2018; Volume 35, Issue 6, eff. December 12, 2018; Volume 35, Issue 10, eff. February 21, 2019; Volume 35, Issue 24, eff. August 22, 2019; Volume 37, Issue 14, eff. April 14, 2021; Volume 37, Issue 24, eff. August 18, 2021; Volume 38, Issue 12, eff. March 17, 2022.