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April 15, 2020

COVID-19 Response - DMAS Behavioral Health Providers & Stakeholders

Please use the Q & A Function to ask content/service specific questions. Use the Chat feature if you are having technology challenges.

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April 15, 2020

Items DMAS Lead Staff Time

Welcome and Introductions Dr. Alyssa Ward,Behavioral Health Division Director

11:00-11:05am

Purpose of today’s callReview of action items

Dr. Alyssa Ward,Behavioral Health Division Director

11:05-11:10am

Overlapping Services Guidance Dr. Cleopatra Lightfoot-Booker,Behavioral Health Senior Program Advisor

11:10-11:20am

Continuation: Review Frequently Asked Questions

Ashley Harrell, LCSWARTS Senior Program Advisor &Dr. Cleopatra Lightfoot-Booker,Behavioral Health Senior Program Advisor

11:20-11:45am

Provider Questions (Q&A Function, if time allows)

Ashley Harrell, LCSWARTS Senior Program Advisor &Dr. Cleopatra Lightfoot-Booker,Behavioral Health Senior Program Advisor

11:45-11:55am

Conclusion and Next Steps Dr. Alyssa Ward,Behavioral Health Division Director

11:55-12:00pm

DMAS Behavioral Health Provider / COVID-19 UpdatesMeeting Agenda

Please use the Q&A Function to ask specific questions about service delivery. You may use the CHAT function to ask basic questions related to the Webex technology. We will gather these questions and attempt to answer as many of these during the hour as we can.

Provider Call Recordings Uploaded to YouTube

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Resource Coming: Telehealth Decision Tree

• https://health.hawaii.gov/bhhsurg/covid19-guidance/

Mahalo to our colleagues in Hawaii

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National Council for Behavioral Health Site

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National Council

Resources

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National Council

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BH Provider Relief Opportunities Webinar

QualiFacts

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Participants Will Learn: How to Leverage CMS Relief

•Medicare Accelerated Payment Program•$100 Billion Public Health Fund •Other Relief Options Loan Programs

•SBA 7(a) Paycheck Protection Program•Provisions for Medium-Sized Companies Employment Issues and Opportunities

•SBA Obligations re: Employment Programs•Tax Credits and Deferrals for Furloughed Employees

https://www2.qualifacts.com/l/74532/2020-04-13/9mm2pq

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DMAS Behavioral Health COVID-19 Response: Overlapping Services Guidance

Overlapping Services GuidanceInitiating New CMHRS Services

• New Services may be initiated• Services must be deemed medically necessary as defined by

the CMHRS Provider Manual • There are NO restrictions on the initiation of the start of new

services when medically appropriate • Services can be offered in the manor and under the guidance

that the state has issued

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Overlapping Services GuidanceTDT & IIH Services

TDT• Target behaviors that need to be stabilized

typically during the school day “or to supplement the school day”

• Current COVID-19 provider flexibilities, specifies the allowance of services to be provided in other settings outside of the school or a clinic setting for the next 120 days.

• TDT Providers are not allowed to physically provide services in the home, if the member is receiving IIH services. However, TDT providers may provide the service via telehealth to target behaviors.

IIH• Improve family dynamics• Provide modeling • Includes clinically necessary interventions

that increase functional and therapeutic interpersonal relations between family members in the home

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If a member is receiving both IIH and TDT services, the goals and targets for each service shall be clearly distinct. If there is overlap, it should be clearly documented how the provider is coordinating care with other providers and how the services are targeting distinct behaviors with differentiating interventions.

Overlapping Services GuidanceAuthorizations

• A prior authorization request is required to verify medical necessity and appropriateness of the service delivery model.

• Providers shall document on the service authorization form (may be written in as there is currently no specific field) the model of service delivery.

• Providers shall maintain appropriate documentation if the plan to provide or continue care deviates from the normal protocol or plan of care

• The MCO/BHSA shall review the information submitted based on medical necessity, the state issued guidance, and the MCO/BHSA shall request additional information from the provider, if required, before making a determination.

• For example, the service could be IIH, TDT, or both. This is also applicable to all the other CMHRS services. (Please note: Behavioral Therapy services shall not be reimbursed concurrently with CMHRS services or behavioral, psychological or psychiatric therapeutic consultation )

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Overlapping Service GuidanceMCO/BHSA

• Services shall not be denied solely on the fact that groups or in office activities are not occurring.

• Behavioral health services, including CMHRS, shall not be denied for the sole purpose of the model of delivery of the service is different.

• Due to COVID-19 provider flexibilities, most of the Behavioral Health services model of delivery will be different.

• MCO/BHSA shall ensure the reason for the denial is well documented and supported in the denial letter(s) and ensure a referral to a more appropriate service is made through care coordination

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Reminder: If the provider is only providing specified services through telephonic communications (audio only), the provider shall bill a maximum of 1 unit per member per day, regardless of the amount of time of the phone call.

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DMAS Mental Health Services COVID-19 Response: Frequently Asked Questions – Part 2

FAQs: Mental Health Services

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Question (1 out of 8)Regarding Behavioral Therapy/ABA Requirements, can the referral letter from the child’s primary care provider be good for two years? 

Answer: • Please see the below language from the Behavioral Therapy Program supplement to the CMHRS

Manual for information on communication with the youth’s primary care provider and when additional information from the primary care provider is required. Most primary care providers have updated their practice to include telehealth during this time and coordination and communication with the physician should continue.

• Page 17: “The provider must summarize the results of Behavioral Therapy including outcomes from the

care coordination activity and submit an update to the individual’s primary care provider. Documentation that the update was sent to the individual’s primary care provider must be included in the individual’s record. The BHSA/MCO may request an updated order or letter of recommendation from the child’s primary care provider or a physician, nurse practitioner or physician assistant familiar with the child’s current status if necessary to complete a continuation of service request.”

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Question (2 out of 8)For CMHRS services, if we have collateral calls/meetings, via telephonic only communication, related to the member, can we bill one unit for these calls and then bill one unit for a call to the member on the same day?

Answer: • No, If the provider is only providing services through telephonic (phone only, no video) communications,

the provider shall bill a maximum of 1 unit per member per day, regardless of the number of calls made or the amount of time of the phone call(s).  

FAQs: Mental Health Services

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Question (3 out of 8)For CMHRS services, are we limited to billing one unit for the day for telephonic (audio only) communication within Intensive In-Home Services if we have meetings with collaterals that are more than 1 hour?

Answer: • Yes, if the provider is only providing services through telephonic (no video) communications, the provider

shall bill a maximum of 1 unit per member per day, regardless of the amount of time of the phone call(s).

FAQs: Mental Health Services

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Question (4 out of 8)Can providers bill for care coordination on a temporary basis during the COVID-19 pandemic so long as Targeted Case Management is not also being provided? 

Answer: • Care coordination is a covered component in all CMHRS services. The definition of care coordination is

found in the CMHRS Manual (Chapter IV, page 4): "Care Coordination" means locating and coordinating services across multiple providers to include collaborating and sharing of information among health care providers, who are involved with the individual’s health care, to improve the restorative care and align service plans.

• Please note that this is not referring to case management. At this time, only Community Service Boards are able to bill for case management services.

FAQs: Mental Health Services

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Question (5 out of 8)What about documentation expectations for collateral contacts allowable through care coordination?  

Answer: • Document and bill for collateral contacts as you previously did, care coordination has always been an existing part

of CMHRS services. It is not necessary to document that these services were provided through telehealth or bill with a telehealth code if these activities were billable via telephone prior to the state of emergency.

FAQs: Mental Health Services

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Question (6 out of 8)When providing telehealth CMHRS services, is there a minimum duration to bill?

Answer: • There is no minimum duration to bill but a billable service must be provided. For example, attempts for

telehealth or telephonic contacts that were unsuccessful would not support a billable service.

• For traditional behavioral health (i.e. individual, family, and group therapy) services, please continue to bill the amount of time the service was delivered using the correct billing codes to demonstrate the amount or hours/minutes of the session.

FAQs: Mental Health Services

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Question (7 out of 8)May groups occur through telehealth or conference calls, with audio and visual capabilities, where participants are each in their home/individual locations?

Answer: • Yes, groups can occur via telehealth. It is recommended that therapeutic groups are conducted

with both audio and video communications.

• Groups delivered by videoconference are feasible and potentially can improve the accessibility of group interventions. This may be particularly useful for those who live in rural areas, have limited mobility and are socially isolated/quarantined.

FAQs: Mental Health Services

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Question (8 out of 8)If running a virtual group or videoconference, is it still required to limit group size to no more than ten? We may need to combine a couple of groups.

Answer:

• DMAS has not changed the group size limit to be more than 10. However, prior to the State of Emergency, policy has supported special situations where there may be a few more attendees; the goal is to not turn members away from treatment. DMAS recommends scheduling multiple group sessions to meet the needs for larger patient populations. Please note that the DMAS March 27 memo states that providers of medication assisted treatment will not be penalized if the required counseling sessions are not able to be met during the State of Emergency. 

FAQs: Mental Health Services

FAQs: ARTS

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Question (1 out of 9)We have moved to telehealth and saw the guidance for some programs that a unit can be billed regardless of the length of time. Does this apply to ARTS services?

Answer: • The reference to billing one unit is if the visit is telephonic/audio only and applies to CMHRS

services as defined in the Memo. DMAS has allowed other flexibilities for IOP and PHP services as well as medication assisted treatment.

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Question (2 out of 9)PHP is supposed to be a minimum of 5 hours per day. Is that still the expectation through telehealth?

Answer: Substance use partial hospitalization services (ASAM Level 2.5) as defined in 12VAC30-130-5100, are structured programs of skilled treatment services for adults, children and adolescents delivering. The minimum number of service hours per week is 20 hours with at least five service hours per service day of skilled treatment services. Per Chapter IV of the ARTS Provider Manual, skilled treatment services include but are not limited to: Member and group psychotherapy; Medication management; Education groups; Occupational, recreational therapy, and/or other therapies.

The minimum hour requirement will remain with the option of utilizing telehealth to deliver the services.

If providers are unable to provide the minimum amount of services required for the reimbursement of PHP, providers may bill the most psychotherapy, assessment, and evaluation codes.

FAQs: ARTS

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Question (3 out of 9)We are losing buprenorphine waiver slots as we lose prescribers to illness. Has DMAS talked to SAMHSA regarding loosening the buprenorphine patient limits?

Answer: • Current legislation allows for emergency increases. Practitioners with a current buprenorphine waiver

to prescribe up to 100 patients and who are not otherwise eligible to treat up to 275 patients under 42 CFR §8.610 may request a temporary increase to treat up to 275 patients in order to address emergency situations as defined in 42 CFR §8.2 if the practitioner provides information and documentation as defined in this CFR section: https://www.ecfr.gov/cgi-bin/text-idx?SID=7658f71c09313fe66cdad5749bb0f20b&mc=true&node=se42.1.8_1655&rgn=div8

• DMAS has learned that the American Society of Addiction Medicine is advocating to raise the cap on patient limits; this change will require Health and Human Services Secretary action.

FAQs: ARTS

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Question (4 out of 9)What flexibilities do we have to allow for take-home doses of methadone?

Answer: DMAS reimburses Opioid Treatment Programs (OTPs) to dispense up to a 28 day supply of take-home methadone doses. As noted in the March 27, 2020 memo, DMAS also recognizes that members may not be able to pick up their medications from OTPs during this State of Emergency. Thus, DMAS will reimburse OTP providers for the delivery of methadone doses, provided they follow the DEA guidance dated March 16, 2020 https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-015)%20SAMHSA%20Exemption%20NTP%20Deliveries%20(CoronaVirus).pdf.

• For delivery of up to a two week supply of medications: Bill 5 units of H0020 at $8.00/unit (equates to $40.00 or 70 miles round trip applying the federal personal mileage rate of 57.5 cents per mile).

• For delivery of three weeks or greater supply of medications: Bill 10 units of H0020 at $8.00/unit (equates to $80.00 or 140 miles round trip).

FAQs: ARTS

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Question (5 out of 9)What if the patient needs to transition from an injectable form of medication to another formula?

Answer: • If a member is receiving subcutaneous buprenorphine (Sublocade) and cannot attend a clinic,

providers can transition the member to sublingual buprenorphine (Suboxone) without additional in-person examinations. Similarly, members receiving intramuscular naltrexone (Vivitrol) may be transitioned to oral naltrexone without an additional examination.

FAQs: ARTS

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Question (6 out of 9)Are there any flexibilities for IPOC/ISP signature requirements? Will the 45 day extension to obtain member physical signature be extended?

Answer: • The provider shall make all reasonable attempts to obtain written signatures within 45 days

after the end of the emergency, and shall document those attempts and reason if the signatures are not able to be obtained (e.g. client is lost to follow up, client has died, client or family remains critically ill or hospitalized and unable to sign forms within the given time). To be clear, verbal consent is acceptable during the state of emergency. We encourage providers to begin as soon as possible within initial verbal or video contact to make reasonable attempts to send forms that require signatures either through electronic methods (e.g. patient portals, secure email) or postal mail a signature.

FAQs: ARTS

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Question (7 out of 9)Are there any flexibilities for waiving credentialing or provider enrollment processes?

Answer: • DMAS is not waiving credentialing or provider enrollment processes during the State of

Emergency.

FAQs: ARTS

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Question (8 out of 9)Is Medicaid reimbursing OBOT telephonic follow up medical visits for prescribing buprenorphine?

Answer: • Yes. Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug

Enforcement Agency (DEA), under the nationwide public health emergency, is allowing practitioners to prescribe buprenorphine to new and existing patients with opioid use disorder via telehealth and audio-only/telephone by otherwise authorized practitioners without requiring such practitioners to first conduct an examination of the patient in person or via telehealth or audio/visual means. This exemption does not apply to new OTP patients treated with methadone. https://www.samhsa.gov/sites/default/files/dea-samhsa-buprenorphine-telemedicine.pdf

FAQs: ARTS

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Question (9 out of 9)Are pharmacies stocking enough buprenorphine to meet the capacity of 90 day scripts?

Answer: Drug inventories in pharmacies are determined by previous trends and utilization. Some pharmacies may not have sufficient buprenorphine inventory to fill prescriptions written for 90 days. If providers experience their local pharmacies having a shortage of buprenorphine, prescribers should evaluate writing a 30 day supply with up to 2 refills to minimize the impact on pharmacies' inventories. Many pharmacies are now offering curb-side pickup or delivery during the State of Emergency.

FAQs: ARTS

Technical Assistance Opportunities

• Weekly Question and Answer Sessions on Providing Substance Use Disorder Treatment Via Telehealth▪ Fridays, 11 am – 12 pm, starting April 10th:

https://covaconf.webex.com/covaconf/j.php?MTID=mab0aec6846e298682399d24402952dad

▪ Session Leads: • Dr. Mishka Terplan, Addiction Medicine Specialist • Paul Brasler, Behavioral Health Addiction Specialist

• Upcoming Webinars: Presented by Paul Brasler ▪ Client Engagement

• 04.14, 1:00 – 2:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=e77c8c0c586ae3c522852ab6e5f6f058d

• 04.23, 2:00 - 3:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=efd94553eb1e87b6487d397eaddb51ab7

▪ Suicide:• 04.16, 2:00 - 3:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=e16af81eefc30dcfdcf99c39341b6053e

• 04.27, 1:00 – 2:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=e141f45d97f5661266cbc96cbfded32a6

▪ Crisis & De-escalation:• 04.20, 1:00 – 2:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=e35faf500def46a50cc03a9889bfbe6b9

• 04.24, 2:00 - 3:00 pm: https://covaconf.webex.com/covaconf/onstage/g.php?MTID=efb3b9012824404881905b173a44e37e7

▪ Questions about the webinars? Contact Paul.brasler@dmas.virginia.gov

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Advanced registration not required: use links below when webinars begin

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Provider Questions

Please Use Q & A Function

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Thank you for your partnership, support and participation.

Additional Questions?

Mental Health Services Questions: enhancedbh@dmas.virginia.govARTS Questions: SUD@dmas.virginia.gov