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July 18, 2022, 11:45 EDT

Chapter 12: Peer Recovery Support Services Supplement

Updated: 6/28/2022

This supplement defines program requirements for Peer Recovery Support Services, which includes Peer Support Services and Family Support Partners.  The provision of Peer Support Services and Family Support Partners facilitates recovery from both serious mental health conditions and substance use disorders.  Recovery is a process in which people are able to live, work, learn and fully participate in their communities. Peer Recovery Support Services are delivered by registered peer recovery specialists who have been successful in the recovery process and can extend the reach of treatment beyond the clinical setting into a member’s community and natural environment to support and assist a member with staying engaged in the recovery process.  Peer recovery support services are an evidence-based model of care which consists of a qualified peer recovery specialist assisting members with their recovery. The experiences of peer recovery specialists, as participants of mental health and substance use services, can be an important component in the delivery of a comprehensive mental health and substance use service delivery system.

Effective July 1, 2017, the Department of Medical Assistance Services (DMAS) expanded the Medicaid benefit to allow for reimbursement of Peer Recovery Support Services to include Peer Support Services and Family Support Partners.  This was in response to a legislative mandate to implement peer recovery support services to eligible children and adults who have mental health conditions and/or substance use disorders.  Peer Support Services shall target members 21 years or older with mental health or substance use disorders or co-occurring mental health and substance use disorders.  Family Support Partners may be provided to eligible members under the age of 21 who have a mental health or substance use disorder or co-occurring mental health and substance use disorders which are the focus of the support with their families or caregivers.  Members 18-20 years-old who meet the medical necessity criteria, may choose to receive Peer Support Services or Family Support Partners. 

Peer Support Services and Family Support Partners are covered by the Fee-For-Service (FFS) Contractor for members enrolled in fee for service and the Managed Care Organization (MCO) for members enrolled in Medallion 4.0 and Commonwealth Coordinated Care (CCC) Plus.

Definitions (BH)

“Behavioral Health Service” means treatments and services for mental and/or substance use disorders.

“Certified substance abuse counselor” or “CSAC” means the same as defined in 18VAC115-30-10 and in accordance with 54.1-3507.1.

“Certified substance abuse counseling-assistant” or “CSAC-A” means the same as defined in 18VAC115-30-10 and in accordance with §54.1-3507.2.

“DBHDS” means the Department of Behavioral Health and Developmental Services.

"Credentialed addiction treatment professionals" or “CATP” means an individual licensed or registered with the appropriate Board in the following roles: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) physician extenders with experience in or training in addiction medicine (iii) a licensed psychiatrist; (iv) a licensed clinical psychologist; (v) a licensed clinical social worker; (vi) a licensed professional counselor; (vii) a registered psychiatric clinical nurse specialist; (viii) a licensed psychiatric nurse practitioner; (ix) a licensed marriage and family therapist; (x) a licensed substance abuse treatment practitioner; (xi) residents under supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and registered with the Virginia Board of Counseling; (xii) residents in psychology under supervision of a licensed clinical psychologist and registered with the Virginia Board of Psychology (18VAC125-20-10); or (xiii) supervisees in social work under the supervision of a licensed clinical social worker and registered with the Virginia Board of Social Work (18VAC140-20-10).

“Caregiver” means the family members, friends, or neighbors who provide unpaid assistance to a Medicaid member with a mental health or substance use disorder or co-occurring mental health and substance use disorder. “Caregiver” does not include individuals who are employed to care for the member.

“Direct Supervisor in ARTS” is the person who provides direct supervision to the Peer Recovery Specialist (PRS). The direct supervisor:  1) shall have two consecutive years of documented practical experience rendering peer support services or family support services, have certification as a PRS under a certifying body approved by DBHDS, and have completed the DBHDS PRS supervisor training; or 2) shall be a CATP or a CSAC who has documented completion of the DBHDS PRS supervisor training The CSAC shall be acting under the supervision or direction of a licensed substance use treatment practitioner or licensed mental health professional (LMHP). 

“Direct Supervisor in a Mental Health” setting is the person who provides direct supervision to the PRS. The direct supervisor:  1) shall have two consecutive years of documented practical experience rendering peer support services or family support services, have certification as a PRS under a certifying body approved by DBHDS, and have completed the DBHDS PRS supervisor training; or 2) shall be a qualified mental health professional (QMHP) as defined in 12VAC30-105-20 with at least two consecutive years of experience as a QMHP, and who has completed the DBHDS PRS supervisor training; or 3) shall be an LMHP, LMHP-resident (LMHP-R), LMHP-resident in psychology (LMHP-RP), or LMHP-supervisee in social work (LMHP-S) who has documented completion of the DBHDS PRS supervisor training who is acting within their scope of practice under state law. 

“Family Support Partners” means a peer recovery support service that is a person-centered strength-based and recovery oriented rehabilitative service provided to the caregiver of Medicaid-eligible member under age 21, with a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. The services provided to the caregiver must be directed exclusively toward the benefit of the Medicaid-eligible youth.

"Licensed mental health professional" or "LMHP" means, 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. For purposes of Medicaid reimbursement to their supervisors for services provided by such residents, they shall use the title "Resident" in connection with the applicable profession after their signatures to indicate such status.

"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. For purposes of Medicaid reimbursement by supervisors for services provided by such residents, they shall use the title "Resident in Psychology" after their signatures to indicate such status.

"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. For purposes of Medicaid reimbursement to their supervisors for services provided by supervisees, these persons shall use the title "Supervisee in Social Work" after their signatures to indicate such status.

PRS includes both Peer Support Services and Family Support Partners.  

“Peer recovery support services” means the same as defined in 12VAC35-250-10.  Collaborative, nonclinical, peer-to-peer services that engage, educate, and support an individual’s self-help efforts to improve his health, recovery, resiliency, and wellness to assist individuals in achieving sustained recovery from the effects of mental illness, addiction or both.

“Peer Support Services” means a peer recovery support service that is a person centered, strength-based, and recovery oriented rehabilitative service for members 21 years or older provided by a Peer Recovery Specialist (PRS) successful in the recovery process with lived experience with mental health, substance use disorders, or co-occurring mental health and substance use disorders who is trained to offer support and assistance in helping others in recovery to reduce the disabling effects of a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support.

“Person Centered” means a collaborative process where the member participates in the development of their treatment goals and make decisions on the services provided.

"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  Recovery, Resiliency, and Wellness Plan.

“Recovery-oriented services” means supports and assistance to members with mental health or substance use disorders or both so that the member (i) improves their health, recovery, resiliency and wellness; (ii) lives a self-directed life; and (iii) strives to reach the member’s full potential.

“Recovery, Resiliency, and Wellness Plan” means a written set of goals, strategies, and actions to guide the member and the healthcare team to move the member toward the maximum achievable independence and autonomy in the community. The comprehensive documented wellness plan shall be developed by the member, caregiver as applicable, the PRS, and the direct supervisor within 30 days of the initiation of services and shall describe how the plan for peer support services and activities will meet the member’s needs.  This document shall be updated as the needs and progress of the member changes and shall document the member’s or family’s, as applicable, request for any changes in peer support services.   The Recovery, Resiliency, and Wellness Plan is a component of the member’s overall plan of care and shall be maintained by the provider in the member’s medical record.

"Registered peer recovery specialist" or “PRS” means the same as the term is defined in § 54.1-2400.1 of the Code of Virginia.

“Resiliency” means the same as defined in 12VAC30-130-5160 and the ability to respond to stress, anxiety, trauma, crisis, or disaster.

“Strength-based” means to emphasize individual strengths, assets and resiliencies.

“Self-Advocacy” means the same as defined in 12VAC30-130-5160 and is an empowerment skill that allows the member to effectively communicate preferences and choice.

“Supervision” means the same as defined in 12VAC30-130-5160 and is the ongoing process performed by a direct supervisor who monitors the performance of the PRS and provides regular documented consultation and instruction with respect to the skills and competencies of the PRS. 

PROVIDER PARTICIPATION AND SETTING REQUIREMENTS

Providers must meet all Provider Participation Requirements contained in Chapter II of this manual including DMAS enrollment requirements and be credentialed with the member’s Medicaid MCO for members enrolled in Medicaid managed care.   Payments shall not be permitted to providers that fail to enter into an enrollment agreement with DMAS or its contractor (s). Providers should refer to the specific Managed Care Organization (MCO) policies for information on single case agreements.

Provider Enrollment (Peer Supplement)

ARTS Peer Support Services and Family Support Partners

Providers of ARTS Peer Support Services and Family Support Partners shall be enrolled with DMAS as one of the following:

 

  1. General Acute Care Hospital level 4.0 licensed by Virginia Department of Health (VDH) as defined in 12VAC30-130-5150.

 

  1. Freestanding Psychiatric Hospital or Inpatient Psychiatric Unit (Levels 3.7 and 3.5) licensed by DBHDS as defined in 12VAC30-130-5130 through 5140.

 

  1. Residential Placements (Levels 3.7, 3.5, 3.3, and 3.1) licensed by DBHDS as defined in 12VAC30-130-5110 through 12VAC30-130-5140.

 

  1. Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs) (Levels 2.5, 2.1) and licensed by DBHDS as defined in 12VAC30-130-5090 and 12VAC30-130-5100.

 

  1. Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC).

 

  1. Outpatient Services (Level 1) as defined in 12VAC30-130-5080.

 

  1. Opioid Treatment Program (OTP) as defined in 12VAC30-130-5050.

 

  1. Preferred Office Based Opioid Treatment (OBOT) as defined in 12VAC30-130-5060.

 

  1. Pharmacy Services licensed by VDH.

 

  1. Hospital Emergency Department licensed by VDH.

MH Peer Support Services and Family Support Partners

Providers of MH Peer Support Services and Family Support Partners shall be enrolled with DMAS as one of the following:

  1. General Acute Care  Hospitals and Hospital Emergency Departments licensed by VDH;  
  2. Freestanding Psychiatric Hospitals and Inpatient Psychiatric Units licensed by DBHDS;
  3. Psychiatric Residential Treatment Facilities (PRTFs) licensed by DBHDS;
  4. Therapeutic Group Homes (TGHs) licensed by DBHDS;
  5. Outpatient mental health clinics licensed by DBHDS;
  6. Outpatient psychiatric services providers;
  7. Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC); or
  8. Mental Health providers licensed by DBHDS as a provider of one of the following Mental Health services:
  1. Therapeutic Day Treatment (TDT);
  2. Intensive In-Home (IIH);
  3. Multisystemic Therapy (MST);
  4. Functional Family Therapy (FFT);
  5. Mental Health Intensive Outpatient (MH-IOP);
  6. Mental Health Partial Hospitalization Program (MH-PHP);
  7. Psychosocial Rehabilitation (PSR);
  8. Mental Health Skill-Building Services (MHSS);
  9. Assertive Community Treatment(ACT);
  10. Mobile Crisis Response;
  11. Community Stabilization;
  12. 23-Hour Crisis Stabilization;
  13. Residential Crisis Stabilization Unit (RCSU); or
  14. Mental Health Case Management

Registered Peer Recovery Specialists (PRS)

Peer Support Services and Family Support Partners shall be rendered by a PRS who:

  • Is sufficiently trained and certified to deliver services;
  • Meets the definition of a Peer Recovery Specialist “PRS” as defined in 12VAC35-250;
  • Has the qualifications, education and experience as established by DBHDS in 12VAC35-250-30;
  • Has a current certification by a certifying body approved by DBHDS;
  • Is registered with the Board of Counseling at the Department of Health Professions; and,
  • Is employed by or has a contractual relationship with a provider enrolled with DMAS.

The PRS shall perform services within the scope of their knowledge, lived experience, and education.  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.

Referral for Peer Support Services and Family Support Partners

Peer Support Services and Family Support Partners are incorporated in many levels of care and DMAS encourages engagement of members into services. There are no limits to who can refer members for Peer Support Services and Family Support Partners.

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 CATP acting within their scope of practice under state law and who is recommending PRS for the member.  A CSAC may also provide a documented assessment and recommendation for services if they are acting under the supervision or direction of a CATP. 

This practitioner shall be an enrolled and credentialed as a Medicaid provider or working in an agency or facility enrolled and credentialed as a provider.  The documented recommendation within the assessment shall verify how the member will benefit from the service.  The assessment recommending the service shall be valid for no longer than 30 calendar days.

The qualified practitioner for ARTS Peer Support Services and Family Support Partners shall provide clinical oversight of the services provided by the PRS and oversight of the member’s Recovery, Resiliency, and Wellness Plan. 

MH Peer Support Services and Family Support Partners

MH Peer Support Services and Family Support Partners shall be rendered following a documented assessment for service by a LMHP, LMHP-R, LMHP-RP or LMHP-S who is an enrolled provider or working in an agency or facility enrolled as a provider.  The documented assessment shall verify how the member shall benefit from the service.  The documented assessment shall be valid for no longer than 30 calendar days.

A LMHP, LMHP-R, LMHP-RP or LMHP-S for MH Support Services and Family Support Partners shall provide clinical oversight of the services provided by the PRS and oversight of the member’s Recovery, Resiliency, and Wellness Plan.                 

Supervision of Peer Recovery Specialists

Supervision of the PRS can be provided by the qualified practitioner who completes the assessment for services or by another provider within the same agency who meets the direct supervisor qualifications as defined in the definition section of this supplement.   

Direct supervision of the PRS shall be provided as needed based on the level of urgency and intensity of service being provided. Supervisors shall maintain documentation of all supervisory sessions.

  1. If the PRS has less than 12 months of experience delivering Peer Support Services or Family Support Partners, they shall receive face-to-face, one-to-one supervisory meetings of sufficient length to address identified challenges for a minimum of 30 minutes, two times a month.  A direct supervisor must be available at least by telephone while the PRS is on duty. If the primary direct supervisor is not available, another direct supervisor meeting the qualifications is acceptable.
  2. If the PRS has been delivering Peer Support Services or Family Support Partners over 12 months and fewer than 24 months, they must receive monthly face-to-face, one-to-one supervision of sufficient length to address identified challenges for a minimum of 30 minutes. A direct supervisor must be available by phone for consult within 24 hours of service delivery if needed for challenging situations.  If the primary direct supervisor is not available, another direct supervisor meeting the qualifications is acceptable.

Face-to-face supervision can occur either in-person or through the use of two-way, real time interactive electronic communication between the PRS and their supervisor. This electronic communication must include, at a minimum, the use of secure audio and video equipment.

The Direct Supervisor shall have an employment (or contract) relationship with the same provider entity that employs/contracts with the PRS.

Documentation of all supervision sessions shall be maintained by the enrolled and credentialed provider in a supervisor’s log or the PRS’ personnel file.

Service Definitions: ARTS and MH Peer Recovery Support Services

Peer Support Services and Family Support Partners are Peer Recovery Support Services and are non-clinical, peer to peer activities that engage, educate, and support an member’s, and as applicable the caregiver’s, self-help efforts to improve health, recovery, resiliency and wellness.  Supervision and care coordination are required components of Peer Recovery Support Services.     

Peer Support Services

Peer Support Services for adults are person centered, strength-based, and recovery oriented rehabilitative service for members 21 years or older provided by a PRS successful in the recovery process with lived experience with mental health, substance use disorders, or co-occurring mental health and substance use disorders who is trained to offer support and assistance in helping others in recovery to reduce the disabling effects of a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support.  Services assist the member develop and maintain a path to recovery, resiliency, and wellness.  Specific peer support service activities shall emphasize the acquisition, development, and enhancement of recovery, resiliency, and wellness.  Services are designed to promote empowerment, self-determination, understanding, and coping skills through mentoring and service coordination supports, as well as to assist members in achieving positive coping mechanisms for the stressors and barriers encountered when recovering from their illness or disorder. 

Family Support Partners

Family Support Partners is a strength-based individualized team-based Peer Recovery Support Service provided to the caregiver of Medicaid-eligible youth under age 21, with a mental health or substance use disorder or co-occurring mental health and substance use disorder that is the focus of support. The services provided to the caregiver must be directed exclusively toward the benefit of the Medicaid-eligible youth. Services are expected to improve outcomes for youth, especially those youth with complex needs who are involved with multiple systems, and increase the youth and family’s confidence and capacity to manage their own services and supports while promoting recovery and healthy relationships. These services are rendered by a PRS who is (i) a parent of a minor or adult child with a similar a mental health or substance use disorder or co-occurring mental health and substance use disorder, or (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.  The PRS shall perform the service within the scope of their knowledge, lived-experience, and education.

Service Delivery

Service delivery shall be based on the member's identified needs, established medical necessity criteria, consistent with the assessment of the practitioner who recommended services, and goals identified in the member Recovery, Resiliency, and Wellness Plan.  The level of services provided and total time billed by the enrolled and credentialed provider for the week shall not exceed the frequency established in the Recovery, Resiliency, and Wellness Plan.  As determined by the goal(s) identified in the Recovery, Resiliency and Wellness Plan, services may be rendered in the provider’s office or in the community, or both. Peer Support Services and Family Support Partners shall be rendered on an individual basis or in a group.    Services shall be delivered in compliance with the following minimum contact requirements:

  • Billing shall occur only for services provided with the member present. 
  • Face-to-face services may be provided through telemedicine. Coverage of services delivered by telemedicine are described in the “Telehealth Services Supplement”. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.
  • Telephone time is supplemental rather than replacement of face-to-face contact and is limited to 25% or less of total time per recipient per calendar year. Justification for services rendered with the member via telephone shall be documented.   Any telephone time rendered over the 25% limit will be subject to retraction.
  • Contact shall be made with the member receiving Peer Support Services or Family Support Partners a minimum of twice each month. At least one of these contacts must be face-to-face and the second may be either face-to-face or telephone contact, subject to the 25% limitation described above, depending on the member’s support needs and documented preferences.
  • In the absence of the required monthly face-to-face contact and if at least two unsuccessful attempts to make face-to-face contact have been tried and documented, the provider may bill for a maximum of two telephone contacts in that specified month, not to exceed two units.  After two consecutive months of unsuccessful attempts to make face-to-face contact, discharge shall occur.
  • Peer Support Services or Family Support Partners may operate in the same building as other day services; however, there must be a distinct separation between services in staffing, program description, and physical space. Services shall not be delivered at the same time and within the same space of another service. 
  • Peer Support Services shall be an ancillary service and shall not impede, interrupt, or interfere with the provision of the primary service setting.

Covered Services (BH)

Specific strategies and activities shall be rendered and fully align with the Recovery, Resiliency, and Wellness Plan.  Strategies and activities shall include at a minimum:

  1. Person centered, strength based planning to promote the development of self-advocacy skills;
  2. Empowering the member to take a proactive role in the development and updating of their Recovery, Resiliency, and Wellness Plan; 
  3. Crisis support; and
  4. Assisting in the use of positive self-management techniques, problem‐solving skills, coping mechanisms, symptom management, and communication strategies identified in the Recovery, Resiliency, and Wellness Plan so that the member:
    1. Remains in the least restrictive setting;
    2. Achieves their goals and objectives identified in the Recovery Resiliency and Wellness Plan;
    3. Self-advocates for quality physical and behavioral health services; and
    4. Has access to strength-based behavioral health services, social services, educational services and other supports and resources.

Medical Necessity (BH)

ARTS Peer Support Services

In order to receive Peer Support Services, members 21 years or older shall meet the following requirements:

  1. Require recovery oriented assistance and support for:
    1.  the acquisition of skills needed to engage in and maintain recovery; and
    2. for the development of self-advocacy skills to achieve a higher level of community tenure while decreasing dependency on formalized treatment systems; and
    3. and to increase responsibilities, wellness potential, and shared accountability for the member’s own recovery; and

2. Have a documented substance use disorder or co-occurring mental health and substance use disorder diagnoses.

3. Demonstrate moderate to severe functional impairment because of the diagnosis that interferes with or limits performance (relative to the person’s ethnic or cultural environment) in at least one of the following domains:

  • educational (e.g., obtaining a high school or college degree);
  • social (e.g., developing a social support system);
  • vocational (e.g., obtaining part-time or full-time employment);
  • self-maintenance (e.g., managing symptoms, understanding his or her illness, living more independently).

ARTS Family Support Partners

Caregivers of youth under age 21 who qualify for Family Support Partners (i) have a youth with a substance use disorder or co-occurring mental health and substance use disorder, who requires recovery assistance, and (ii) meets two or more of the following:

1. The member and their caregiver need peer-based recovery oriented services for the maintenance of wellness and acquisition of skills needed to support the youth;

2. The member and their caregiver need assistance to develop self-advocacy skills to assist the youth in achieving self-management of the youth’s health status;

3. The member and their caregiver need assistance and support to prepare the youth for a successful work/school experience; or

4. The member and their caregiver need assistance to help the youth and caregiver assume responsibility for recovery.

Members aged 18-20 may choose to receive ARTS Peer Support Services or ARTS Family Support Partners depending on their needs and medical necessity.

MH Peer Support Services

Members 21 years or older qualifying for MH Peer Support Services shall meet the following requirements:

  1. Have a documented mental health disorder diagnosis;
  2. Require recovery oriented services for:
    1. the acquisition of skills needed to engage in and maintain recovery; and
    1. the development of self-advocacy skills to achieve a decreasing dependency on formalized treatment systems; and,
    2. increasing responsibilities, wellness potential, and shared accountability for the member’s own recovery; and
  3. Demonstrate moderate to severe functional impairment because of the diagnosis that interferes with or limits performance (relative to the person’s ethnic or cultural environment) in at least one of the following domains:
  • educational (e.g., obtaining a high school or college degree);
  • social (e.g., developing a social support system);
  • vocational (e.g., obtaining part-time or full-time employment);
  • self-maintenance (e.g., managing symptoms, understanding his or her illness, living more independently).

MH Family Support Partners

Caregivers of youth under age 21 who qualify to receive MH Family Support Partners shall (i) have a youth with a mental health disorder, who requires recovery oriented services, and (ii) meets two or more of the following:

1. The member and their caregiver need peer-based recovery oriented services for the maintenance of wellness and the acquisition of skills needed to support the youth;

2. The member and their caregiver need assistance to develop self-advocacy skills to assist the youth in achieving self-management of the youth’s health status;

3. The member and their caregiver need assistance and support to prepare the youth for a successful work/school experience;

4. The member and their caregiver need assistance to help the youth and caregiver assume responsibility for recovery.

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

Continued Stay Criteria

To qualify for continued services for Peer Support Services and Family Support Partners for both MH and ARTS, medical necessity service criteria shall continue to be met, progress notes shall document the status of progress relative to the goals identified in the Recovery, Resiliency, and Wellness Plan, and the member continues to require the monthly minimum contact requirements.

Discharge Criteria

Discharge criteria for both MH and ARTS Peers Support Services and Family Support Partners shall occur when one or more of the following is met:

  1. Goals of the Recovery, Resiliency, and Wellness Plan have been substantially met; or
  2. The member or as applicable for youth under 21, the caregiver, request discharge; or
  3. The member or as applicable for youth under 21, the caregiver, fail to make the monthly minimum contact requirements or the member or caregiver, as applicable, discontinues participation in services. 

Documentation of Required Activities (BH)

For both MH and ARTS Peer Support Services the provider shall have oversight of the member’s record and maintain member records in accordance with state and federal requirements.  The provider shall ensure documentation of all activities and shall ensure documentation of all relevant information about the Medicaid member receiving services. Such documentation shall fully disclose the extent of services provided in order to support providers' claims for reimbursement for services rendered. Documentation shall support the medical necessity criteria and how the members needs for the service match the level of care criteria. This documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered.

Documentation of required activities shall include:

  • Assessment for services
  • Recovery, Resiliency, and Wellness Plan;
  • Review of Recovery, Resilience, and Wellness Plan;
  • Progress Notes;
  • Supervision; and
  • Collaboration of services.

Additional information related to the utilization review of these services is located in Chapter VI of this manual.

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, LMHP-R, LMHP-RP, or LMHP-S or practitioner making the recommendation and their credentials.  The assessment for services shall be included as part of the Recovery, Resiliency, and Wellness Plan and medical record and may serve as verification that the member meets the medical necessity criteria for Peer Support Services or Family Support Partners. 

Recovery, Resiliency, and Wellness Plan

Under the clinical oversight of a qualified practitioner making the recommendation for Peer Support Services or Family Support Partners, PRS in consultation with their direct supervisor shall develop a Recovery, Resiliency, and Wellness Plan. The plan shall be based on the member’s, and as applicable the caregiver’s perceived recovery needs and any clinical assessment within 30 calendar days of the initiation of service.  Development of the Recovery, Resiliency, and Wellness Plan shall include collaboration with the member and, as applicable, the caregiver.  Individualized goals and strategies shall be focused on the member’s identified needs for self-advocacy and recovery. 

The Recovery, Resiliency, and Wellness Plan shall also include documentation of how many days per week and how many hours per week are required to carry out the services in order to meet the goals of the Plan. The Recovery, Resiliency, and Wellness plan shall be completed, signed, and dated by the qualified practitioner making the recommendation, the PRS, the direct supervisor, the member, and as applicable the caregiver involved in the member’s recovery within 30 calendar days of the initiation of service. The PRS shall act as an advocate for the member, encouraging the member and as applicable the caregiver to take a proactive role in developing and updating goals and objectives in the recovery planning. The PRS shall be empowered to convene multidisciplinary team meetings regarding a participating member’s needs and desires, and the PRS shall participate as an equal practitioner partner with all staff in multidisciplinary team meetings. 

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. 

Upon discharge from a short-term program, if the member chooses to continue receiving Peer Recovery Support Services and still meets the medical necessity criteria for Peer Support Services or Family Support Partners, the provider shall be allowed to continue services as long as all of the reimbursement criteria outlined in this Peer Recovery Support Services Supplement are met.  The Recovery, Resiliency, and Wellness Plan that was developed prior to discharge from the short-term program shall remain in effect and services shall continue to be delivered in accordance with the member’s goals and objectives as identified in the Recovery, Resiliency, and Wellness Plan.

Services shall be delivered in accordance with the member’s goals and objectives as identified in the Recovery, Resiliency, and Wellness Plan. As determined by the goal(s) identified in the Recovery, Resiliency, and Wellness Plan, services may be rendered in the provider’s office or in the community, or both. The level of services provided and total time billed for the week shall not exceed the frequency or intensity established in the Recovery, Resiliency, and Wellness Plan.

Review of Recovery, Resiliency, and Wellness Plan

Under the clinical oversight of the qualified practitioner making the recommendation for service, the PRS in consultation with their direct supervisor shall conduct and document a Review of the Recovery, Resiliency, and Wellness Plan every 90 calendar days with the member and caregiver as applicable.  The review shall be signed by the PRS and the member, and as applicable the identified caregiver. Review of the Recovery Resiliency and Wellness Plan means the PRS evaluates and updates the member's progress every 90 calendar days toward meeting the Recovery, Resiliency, and Wellness Plan’s goals and documents the outcome of this review in the member’s medical record. For DMAS to determine that these reviews are complete, the reviews shall (i) update the goals and strategies as needed to reflect any change in the member's recovery as well as any newly identified needs; (ii) be conducted in a manner that enables the member or caregiver as applicable to actively participate in the process; and (iii) be documented by the PRS in the member's medical record no later than 15 calendar days from the date of the review.

Progress Notes

Progress notes  shall be required and shall record the date, time, place of service, participants, face-to-face or telephone contact and circumstance of contact, regardless of whether or not a billable service was provided, and shall summarize the purpose and content of the Peer Support Services or Family Support Partner session along with the specific strategies and activities utilized as related to the goals in the Recovery, Resiliency, and Wellness Plan. Documentation of the specific strategies and activities rendered shall fully disclose the details of services rendered and align with the Recovery, Resiliency, and Wellness Plan.  

Progress notes shall reflect collaboration between the PRS and the member or caregiver as applicable in the development of the progress note. If contact with the member cannot be made, the service is not billable. However, the progress note shall reflect attempts to contact the member.  Progress notes shall contain the dated signature of the PRS who provided the service.

Supervision Documentation

The provider shall ensure that documentation of all supervision sessions be maintained in a supervisor’s log or in the PRS’ personnel file.

Care Coordination Documentation

Collaboration shall be required with all behavioral health service providers and shall include the PRS, the member, or caregiver as applicable and shall involve discussion regarding initiation of services and updates on the member’s status. Documentation of all collaboration shall be maintained in the member’s record. Plans for collaboration shall be included in the Recovery, Resiliency, and Wellness Plan and shall not be performed without properly signed release(s) of information. Collaboration rendered with other service providers without the member present shall not be billable.

The provider may integrate a member’s Peer Support Services or Family Support Partners record with the member’s other records maintained within the same provider agency or facility, provided the Peer Support Services or Family Support Partners record is clearly identified with logs and progress notes documenting the provision of Peer Support Services or Family Support Partners to corroborate billed services.

Service Authorization and Billing Instructions (BH)

Providers must submit a registration to the member’s MCO or FFS contractor prior to starting services. Information supplied by the provider to DMAS or its contractor shall be fully substantiated throughout the member’s record. Enrolled providers must contact the MCO for managed care enrolled members or the FFS contractor for fee-for-service members for information regarding service authorization and claims processing instructions.  

A unit of service shall be defined as 15 minutes. Peer Support Services and Family Support Partners shall be limited to four hours per day (up to 16 units per calendar day) and nine hundred (900) hours per calendar year.  Service delivery limits may be exceeded based upon documented medical necessity and service authorization approval. Providers should review the MCO contract requirements for specific requirements for registration or authorization.

 

Peer Support Services &

Family Support

Partners

Unit

Value

Procedure

Code

 

DAILY Limits

ANNUAL LIMITS

ARTS Individual

1 unit = 15 minutes

T1012

 

4 hours or 16 units per calendar day

 

 

Up to 900 hours or 3600 units per calendar year

ARTS Group

S9445

 

Mental Health Individual

H0024

 

Up to 900 hours or 3600 units per calendar year

Mental Health Group

H0025

 

 

Rates for ARTS and Mental Health Services are available on the DMAS website at https://www.dmas.virginia.gov/for-providers/rate-setting/ and on the Magellan of Virginia website at https://www.magellanofvirginia.com/for-providers/provider-tools/getting-paid/.

All Peer Recovery Support Services claims should be submitted on a CMS-1500.  Peer Recovery Support Services are billed separately from the facility per diem rate or Diagnostic Related Group (DRG) case rate for services provided in ARTS Substance Use Disorder Residential Placements (ASAM 3.1 – 3.7), Hospital Emergency Departments, Acute Care General Hospitals, Freestanding Psychiatric Hospitals, Inpatient Psychiatric Units, Psychiatric Residential Treatment Facilities and Therapeutic Group Home.

Limitations: ARTS and MH Peer Recovery Support Services

If an assessment is completed for MH Peer Support Services or MH Family Support Partners in addition to a completed assessment for ARTS Peer Support Services or ARTS Family Support Partners, no more than a total of four hours (up to 16 units) of services shall be rendered per calendar day.  

An enrolled provider cannot bill DMAS separately for:  i) MH Peer Recovery Support Services (MH Peer Support Services or MH Family Support Partners) and ii) ARTS Peer Recovery Support Services (ARTS Peer Support Services or ARTS Family Support Partners) rendered on the same calendar day unless the MH Peer Services and ARTS Peer Services are rendered at different times.  The enrolled provider must coordinate services to ensure the four hour daily service limit is not exceeded.  No more than a total of four hours of one type of service, or a total of four hours of a combination of service types (up to 16 units of total service) shall be provided per calendar day.    

Members may receive up to 900 hours of MH Peer Recovery Support Services (MH Peer Support Services and/or MH Family Support Partners)  and up to 900 hours of ARTS Peer Recovery Support Services (ARTS Peer Support Services and/or ARTS Family Support Partners).  

Service shall be initiated within 30 calendar days of the completed assessment and shall be valid for no longer, than 30 calendar days.  If the time has exceeded 30 calendar days without service initiation, another assessment for services shall be required.

Peer Support Services and Family Support Partners rendered in a group setting shall have a ratio of no more than 10 members to one PRS and progress notes shall be included in each Medicaid member’s record to support billing.

General support groups which are made available to the public to promote education and global advocacy do not qualify as Peer Support Services or Family Support Partners.

Non-covered activities include:

  • Transportation;
  • Record keeping or documentation activities (including but not limited to progress notes, tracking hours and billing and other administrative paperwork);
  • Services performed by volunteers;
  • Household tasks such as chores and grocery shopping;
  • On the job training;
  • Case management;
  • Meals and breaks:
  • Outreach to potential clients; and
  • Room and board.

The PRS shall document each 15-minute unit in which the member was actively engaged in Peer Support Services or Family Support Partners. Non-covered activities listed in this section shall not be included in the reporting of units of service delivered. Should a member receive other services during the range of documented time in/time out for Peer Recovery Support Service hours, the absence of services or interrupted services must be documented.

Family Support Partners is allowable only when the service is directed exclusively toward the benefit of the youth. The applicability to the targeted youth must be documented.

Family Support Partners shall not be billed for youth who resides in a congregate setting in which there are staff compensated for the care of the youth. An exception to this exclusion is for caregivers and  youth who are preparing for the transition of the youth to the caregiver’s home when  the service is directed to supporting the unification/reunification of the youth and his/her caregiver.  The circumstances surrounding the exception shall be documented.

Members with the following conditions are excluded from Peer Support Services and Family Support Partners unless there is clearly documented evidence and diagnosis of a substance use disorder or mental health disorder overlaying the diagnosis: developmental disability including intellectual disabilities, organic mental disorder including dementia or Alzheimer’s, or traumatic brain injury.  There must be documented evidence that the member is able to participate in the service and benefit from Peer Support Services or Family Support Partners.

Claims that are not adequately supported by appropriate up to date documentation may be subject to recovery of expenditures. Progress notes shall disclose the extent of services provided and corroborate the units billed. Claims not supported by corroborating progress notes shall be subject to recovery of expenditures.

The provider shall be subject to utilization reviews conducted by DMAS or its designated contractor.  Reimbursement shall be subject to retraction for any billed service that is determined to not be in compliance with DMAS requirements.