Citation

Policy Statement

COMMENTARY

PROPOSED SOLUTION

General Language

Common use of the male gender references throughout, for instance, “Member and his caregiver need…”

A non-binary term is preferred for creating trusting and collaborative relationship between all persons served and the treatment network/providers.  While it is understood that this language proposed here is in payer policy, this modeling of language is crucial for healthcare providers adopting this content into member-facing policy where health engagement and acceptance is crucial and aligned with principles of recovery.

Please use a non-binary pronoun of “their” instead of “his” or “his or her.” 

General Language

Variability in the use of “member,” “person,” and “individual”

In some cases, “individual” is struck to be “member” and sometimes the reverse.

Suggested consistent use of either “member” (if that is standard language in other DMAS policy) or use “individual” as the best “person-first” alternative.

Definitions, Family Support Partners

PROPOSED ADDITION: “Services are expected to improve outcomes for youth with complex needs who are involved with multiple systems and…”

This statement implies that the target population is narrowed to “youth with complex needs who are involved with multiple systems.” Given the expectations of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) access expectations, the youth population who can access this service would be significantly broader.  Even without the expectations set forth by EPSDT, it would be beneficial to youth who are experiencing an episodic, mild, or moderate behavioral health presentation to have this intervention early in the course of behavioral health treatment and support to promote the concepts of hope and recovery and family-driven self-management skills and understanding.  The previous version did not have detail on the narrow target population. 

Please remove this language to make Family Support Partner services more accessible to more youth and their families.  If this is a priority population, then this writer suggest “Services are expected to improve behavioral health outcomes for youth, especially those youth with complex needs…”

Definitions, Family Support Partners

PROPOSED ADDITION: “Services are expected to improve outcomes for youth with complex needs who are involved with multiple systems and…”

See above and note that the target population is narrowed further by indicating that youth with “complex needs” must also be involved with “multiple systems” which implies child welfare, juvenile justice, school individualized education plan services (IEP), etc.  Many youth may have complex clinical presentations and medical necessity for this service without having triggered multi-public agency response.  The previous version did not have this detail which now proposes to narrow the target population.

Please remove this language to make Family Support Partner services more accessible to more youth and their families.  If this is a priority population, then this writer suggests “Services are expected to improve behavioral health outcomes for youth, especially those youth with complex needs who may be involved with multiple systems…”

Definitions, Family Support Partners

PROPOSED ADDITION:  These services are rendered by a PRS who is…(ii) an adult with personal experience with a family member with a similar a mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services.

This commenter supports this addition as PRS family members (such as siblings) increase the workforce numbers who may qualify to deliver services in this time when workforce is thin and

play an observable role in Virginia families' seeking recovery pathways.

None recommended.

Provider Enrollment, ARTS

PROPOSED ADDITION:  Adds Rural Health Centers, Federally Qualified Health Centers, and Hospital Emergency Rooms as provider types who can enroll.

The addition of these provider types greatly expands access and this commenter applauds these additions. 

None recommended.

Provider Enrollment, MH Peer Support Services

PROPOSED ADDITION: Adds youth behavioral health provider-types and names additional behavioral health provider types

The addition of these provider types greatly expands access and this commenter applauds these additions. 

None recommended.

Peer Recovery Specialists (header)

NO PROPOSED CHANGE: “The caseload assignment of a full time PRS shall not exceed 15 members at any one time allowing for new case assignments as those on the existing caseload begin to self-manage with less support.  The caseload assignment of a part-time PRS shall not exceed 9 members at any one time.”

This proposed maximum member threshold is restrictive and does not give the workforce the opportunity to maximize service delivery in a time where there is an extreme behavioral health workforce crisis.  A provider/supervising agency should be able to set case assignment based on the case mix for a PRS.  Other state examples of one-to-one peer support include Georgia at a maximum 1:50, Nebraska 1:25, SC – max cap on groups only.

Recommend removing 1:1 maximum caseload altogether or at least raising to 25 members served to promote access.

Supervision of Peer Recovery Specialists , Items 1 and 2

NO PROPOSED CHANGE:  “face-to-face, one-to-one supervision” is defined in both items 1 and 2.

Given the emergence of telehealth during the PHE, might the Medicaid agency consider the allowance of telehealth supervision (audio/visual) to reduce the demand on supervisors, promoting the ability to see more PRS back-to-back, increasing the supervision productivity and access for that workforce.  

PROPOSED ADDITION to Items 1 and 2: The term face-to-face is inclusive of secure, confidential audio/visual telehealth modalities which allow the PRS and supervisor to freely yet confidentially engage in supervision.

Medical Necessity, ARTS Family Support Partners

PROPOSED CHANGE:  “Individuals aged 18-20 who meet the medical necessity criteria for ARTS Peer Support Services may choose to receive ARTS Peer Support Services or Family Support Partners depending on their needs.”

For an emerging adult age 18 through 20, can it be possible for the family members to receive Family Support Partners (providing peer support to the family members who are assisting the emerging adult member towards mastery of his Recovery Plan) and the member to also receive Peer Support Services directly from a PRS who identifies as a “peer?”  In this case, the two would be offered in a dyadic model with the family and the member receiving support, preparing the emerging young adult to embrace his own recovery management in the future.

Suggest removing the word “or” herein and replacing with “and/or:”

“Individuals aged 18-20 who meet the medical necessity criteria for ARTS Peer Support Services may choose to receive ARTS Peer Support Services or and/or Family Support Partners depending on their needs.”

Medical Necessity, MH Family Support Partners

NO PROPOSED CHANGE:  “Members 18-20 years old who meet the medical necessity criteria stated above for MH Peer Support Services, who would benefit from receiving peer supports directly, and who choose to receive MH Peer Support Services directly instead of through MH Family Support Partners shall be permitted to receive MH Peer Support Services by an appropriate PRS.”

For an emerging adult age 18 through 20, can it be possible for the family members to receive Family Support Partners (providing peer support to the family members who are assisting the emerging adult member towards mastery of his Recovery Plan) and the member to also receive Peer Support Services directly from a PRS who identifies as a “peer?”  In this case, the two would be offered in a dyadic model with the family and the member receiving support, preparing the emerging young adult to embrace his own recovery management in the future.

PROPOSED CHANGE (to mirror ARTS Family Support Partners statement in the row above):

“Individuals aged 18-20 who meet the medical necessity criteria for MH Peer Support Services may choose to receive MH Peer Support Services or and/or Family Support Partners depending on their needs.”

Language Confusion between the term “Referral” and “Recommendation”

See citations from several sections of the Proposed Supplement:

• Section titled Referral for Peer Support Services and Family Support Partners:  “There are no limits to who can refer members for Peer Support Services and Family Support Partners.”
• Section titled Assessment and Recommendation for Services and Clinical Oversight  ARTS Peer Support Services and Family Support Partners - ARTS Peer Support Services and Family Support Partners shall be rendered following a documented assessment from a referring provider. Referrals must be made by a practitioner who meets the definition of Credentialed Addiction Treatment Professional (CATP) acting within their scope of practice under state law and who is recommending PRS for the member.
• Section titled:  Assessment for Services  Any person involved in the member’s treatment, caregiver or community partner can make a referral for services. The member may also self-refer. Once a referral for services is received an assessment for Peer Support Services or Family Support Partners shall be completed and must include the dated signature of the LMHP,…”

While bullets 1 and 2 in column 2 seem clear about the expectation that referral can emanate from any source, the second bullet seems to blend the definition of “referral” with the function of a practitioner recommending a member for a service. 

PROPOSED CHANGE (strikethrough deletions and additions in bold/italics):  Assessment and Recommendation for Services and Clinical Oversight  - ARTS Peer Support Services and Family Support Partners - ARTS Peer Support Services and Family Support Partners shall be rendered following a documented assessment from a referring provider as defined below. Referrals Recommendations for the service must be based upon the assessment and made by a practitioner who meets the definition of Credentialed Addiction Treatment Professional (CATP) acting within their scope of practice under state law and who is recommending PRS for the member.

Recovery, Resiliency, and Wellness Plan

NO PROPOSED CHANGE:  Services with a length of stay fewer than 30 calendar days still require a Recovery, Resiliency, and Wellness Plan.  Members receiving Peer Support Services or Family Support Partners within a short-term program require a Recovery, Resiliency, and Wellness Plan as described above during the provision of services that focuses on the identified recovery goals.  Providers are to ensure the timely completion of the Recovery, Resiliency, and Wellness Plan while a member is receiving services of durations that are fewer than 30 calendar days.”

With the addition of Hospital Emergency Departments are provider enrollment types being added to the provider network, there should likely be added an accommodation to the Recovery, Resiliency, and Wellness Plan which is modified to reflect the nature of that brief intervention, understanding the stabilization nature of the ED.

PROPOSED CHANGE:  Add sentence, “Given the quick turn-around of a PRS-delivered intervention in a Hospital Emergency Department, an abridged Recovery, Resiliency, and Wellness Plan may be utilized, documenting 1-2 brief goals for immediate post-emergency recovery engagement.”

SERVICE AUTHORIZATION AND BILLING LIMITATIONS: ARTS and MH Peer Recovery Support Services  

PROPOSED CHANGE: “Providers must submit a registration to the member’s MCO or FFS contractor prior to starting services.”

Generally, Peer Support Services provided in Emergency Departments, in Crisis Stabilization Units, and via Mobile Crisis do not require a registration prior to the start of services.  Can DMAS consider this in what will become the final supplement (in accordance with other crisis authorization policy)?

PROPOSED CHANGE (additions in bold/italics):

“Providers must submit a registration to the member’s MCO or FFS contractor prior to starting services (except for Crisis Response services which include Emergency Department-based intervention, Crisis Stabilization Unit services, and Mobile Crisis Services).”

RATES

PROPOSED DELETION of Rates

While rates are being removed from this supplement and to be memorialized in on the DMAS or MCO website, it is important to denote the sub-par reimbursement for PRSs via this benefit.  This commenters fear is that service access will never increase if the reimbursement, and directly linked wages for the PRS are not competitive for employing providers.  For instance, $26/hour with a stellar productive billing time of 30/hours week only yields an agency $40,460/year.  Assuming an industry norm for billing time, CEU time, PTO, indirect costs such as EHRs access, Internet access, office space, travel reimbursement, etc. at 25-40%, a PRS would make $30K, a wage which is not competitive in current work markets.  Other state rates are provided here as a benchmark:  Georgia Medicaid - ~$81/hour, Ohio Medicaid - $62/hour, West Virginia Medicaid - $60/hour, Arizona - ~$68/hour.

If access to PRS-provided supports is to thrive, a livable wage must be supported by the reimbursement rate.  Please consider a cost-study for this service in the near term.

Provider Participation and Setting Requirements

PROPOSED CHANGE: “Providers must meet the criteria set forth in Chapter II of this provider manual in addition to the requirements below, etc.”

Non-clinical, peer-run Recovery Community Organization face significant barriers to accessing Medicaid reimbursement, yet they provide critical services to the Medicaid population. These organizations should be allowed to partner with clinical providers that bill Medicaid under their individual licenses and NPIs. Many free clinics and other nonprofit behavioral health providers bill Medicaid under the licenses and NPIs of individual providers. Specifying that billing can occur under a licensed individual’s NPI (as opposed to limiting billing to DBHDS licensed organizations) would foster partnerships among Recovery Community Organization and clinical partners to offer integrated services and access Medicaid reimbursement for peer support services. There also is no inherent loss of quality, oversight or capacity to allowing billing under individuals’ licenses compared with licensed organizations.

Specify that providers operating and billing under their individual NPIs and licenses through the Virginia Certification Board can bill for peer support services provided by Peer Recovery Specialists who are employed or contracted by the same entity.

Limitations: ARTS and MH Peer Recovery Support Services

NO CHANGE: “Non-covered activities include:…”

A key aspect of peer support services is that they meet people where they are. This includes conducting outreach to potential clients and providing transportation. These services should be billable because they significantly help individuals overcome barriers to behavioral health services.

To adhere to medical necessity requirements, outreach activities could be billed retroactively for individuals who are diagnosed and recommended for peer support. Transportation provided by Peer Recovery Specialists could be billed at its own rate or in a manner similar to Medicaid transportation benefits.

Service Delivery: limitation for billing of telephone time

NO CHANGES

This section addresses billing of telephone time as a supplement to face-to-face contact. Increasingly, all manner of behavioral health services are being offered via telehealth (video conference). Peer support provided entirely via telehealth should be included as a billable service in addition to face-to-face contact. This would allow for integrated clinical and peer support programs that are provided via telehealth, particularly to increase access in rural and underserved communities. It also would facilitate these types of services in the event of future public health emergencies that affect people’s ability to access in-person care.

Peer support services provided via telehealth (video conference) should be billable in addition to face-to-face contact. There should not be restrictions on the percentage of total peer support time provided via telehealth.