DMAS Office of Behavioral Health Department of Medical Assistance Services Opioid Treatment (H0020) DMAS Office of Behavioral Health 2013 www.dmas.virginia.gov 1

Department of Medical Assistance Services Disclaimer These slides contain only highlights of the Virginia Medicaid Community Mental Health Rehabilitative Services Manual (CHMRS) and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations. *Please refer to the manual, available on the DMAS website portal, for in-depth information on Community Mental Health Rehabilitative Services criteria. Providers are responsible for adhering to related state and federal regulations. www.vita.virginia.gov www.dmas.virginia.gov 2

Training Objectives To define Opioid Treatment; Department of Medical Assistance Services Training Objectives To define Opioid Treatment; To identify staff qualifications; To identify required activities; To clarify eligibility criteria; To review limitations of the service; and To review service authorization requirements. www.vita.virginia.gov www.dmas.virginia.gov 3

Department of Medical Assistance Services Service Definition Opioid treatment is an intervention strategy that combines psychological and psycho-educational treatment with the administering or dispensing of Opioid agonist treatment medication. www.vita.virginia.gov www.dmas.virginia.gov 4

Licensing Department of Medical Assistance Services H0020 www.dmas.virginia.gov 5

Licensing Requirements Department of Medical Assistance Services Licensing Requirements The Opioid Treatment provider must be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) as a provider of Medication Assisted Treatment/Opioid Services. www.vita.virginia.gov www.dmas.virginia.gov 6

Staff Qualifications Department of Medical Assistance Services H0020 www.dmas.virginia.gov 7

Staff Qualifications Department of Medical Assistance Services Individual and group counseling, family therapy, and occupational and recreational therapy must be provided by at least a Qualified Substance Abuse Professional (QSAP.) A QSAP, or a paraprofessional under the supervision of a QSAP, may provide education about the effects of alcohol and other drugs on the physical, emotional and social functioning of the individual, relapse prevention, occupational and recreational activities. A QSAP must be onsite when a paraprofessional is providing services. The QSAP must supervise the paraprofessional at least twice a month. Supervision shall include documented face-to-face meetings between the supervisor and the paraprofessional providing the services. Supervision may occur individually or in a group. Documentation of supervision shall be in the individual’s clinical record and signed by the QSAP. Paraprofessionals who do not meet the experience requirement may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and supervised by a QSAP. Supervision must include on site observation of services, face-to-face consultation with the paraprofessional, a review of progress notes, the individual’s progress towards achieving ISP goals and objectives, and recommendations for change based on the individual’s status. Supervision must occur and be documented in the clinical record monthly. www.vita.virginia.gov www.dmas.virginia.gov 8

Required Activities Department of Medical Assistance Services H0020 www.dmas.virginia.gov 9

Required Activities Department of Medical Assistance Services Major substance abuse treatment and psychiatric, psychological and psycho-educational modalities to include: individual, group counseling and family therapy; education about the effects of alcohol and other drugs on the physical, emotional, and social functioning of the individual; relapse prevention; occupational and recreational therapy, or other therapies. Psycho-education refers to education on mental health and substance abuse topics to improve the individual’s behavioral, mental, or emotional condition. Psycho-education may include communication skills, problem solving skills, anger management, and interpersonal communication. Prior to initiation of services a QSAP must perform a face-to-face evaluation/diagnostic service specific provider assessment and authorize the services. The service provider must notify or document the attempts to notify the primary care provider of the individual’s receipt of community mental health rehabilitative services. An ISP must be completed by a QSAP within 30 days of service initiation. Services must be provided in accordance with the ISP. www.vita.virginia.gov www.dmas.virginia.gov 10

Department of Medical Assistance Services Required Activities Progress notes for Opioid Treatment Services must be completed when services are delivered. The documentation must include the date of the service, the service or activity provided, the units provided, the provider rendering the service, and a staff signature. A QSAP must perform a face-to-face evaluation and re-authorize services that are provided longer than 90 continuous days. If case management is being provided, there must be coordination with the case management agency. www.vita.virginia.gov www.dmas.virginia.gov 11

Eligibility Criteria H0020 Department of Medical Assistance Services www.dmas.virginia.gov 12

Department of Medical Assistance Services Eligibility In order for individuals to receive Medicaid-reimbursed Substance Abuse Opioid Treatment Services, individuals must demonstrate a clinical necessity for the service by meeting the Diagnostic Statistical Manual diagnostic criteria for an Axis I Substance Use Disorder, with the exception of nicotine or caffeine abuse or dependence. A diagnosis of nicotine or caffeine abuse or dependence alone shall not be sufficient for approval of these services. American Society of Addiction Medicine (ASAM) criteria will be used to determine the appropriate level of treatment. If an individual has co-occurring mental health and substance use disorders, integrated treatment for both disorders is allowed within Opioid Treatment. www.vita.virginia.gov www.dmas.virginia.gov 13

Limitations H0020 Department of Medical Assistance Services www.dmas.virginia.gov 14

Department of Medical Assistance Services Limitations Substance abuse day treatment and substance abuse intensive outpatient services may not be provided concurrently with Opioid treatment. Staff travel time is excluded www.vita.virginia.gov www.dmas.virginia.gov 15

Units and Reimbursement Department of Medical Assistance Services Units and Reimbursement H0020 www.dmas.virginia.gov 16

Department of Medical Assistance Services Reimbursement Rate One unit of service is 15 minutes. Reimbursement is based on the qualifications of the staff providing the service. A maximum of 600 hours is allowed per fiscal year with a fiscal year being July 1 to June 30. Providers may submit reimbursement claims for opioids which are administered to individuals receiving Opioid Treatment Services. Providers may enroll as a Pharmacy provider (please refer to the Pharmacy Manual) or submit the appropriate Healthcare Common Procedure Coding System (HCPCS) identifier for medication administration. Pharmacies bill as point of sale. If the drug is provided through a clinic, then the appropriate HCPCS, J-code or S-code would be billed. For example, S0109 indicates 5 mg. of oral methadone. The HCPCS code, J8499 (unclassified non-chemotherapeutic drug, oral administration) may also be used to bill for the opioid drug. www.vita.virginia.gov www.dmas.virginia.gov 17

Service Authorization (SA) Department of Medical Assistance Services Service Authorization (SA) www.dmas.virginia.gov 18

Service Authorization Department of Medical Assistance Services Service Authorization Service authorizations are not required for Opioid Treatment. www.vita.virginia.gov www.dmas.virginia.gov 19

Contacts Helpful Resources: Department of Medical Assistance Services 12VAC30-50-226 - Emergency Regulations for Community Mental Health Services Virginia Medicaid Web Portal link www.virginiamedicaid.dmas.virginia.gov DMAS Office of Behavioral Health: Email Address CMHRS@dmas.virginia.gov DMAS Helpline: 804-786-6273 Richmond Area 1-800-552-8627 All other www.vita.virginia.gov www.dmas.virginia.gov 20