EPSDT Behavioral Therapy Program

1. EPSDT Behavioral Therapy Program Virginia Department of Medical Assistance Services (DMAS) Provider Training April, 2012

2. Today’s Topics • EPSDT Overview • Behavioral Therapy Manual Review and Discussion • Provider Licensing and Staff Qualifications • Intensive In Home • Outpatient Programs with ABA Specialty • Provider Enrollment Requirements • EPSDT Member Eligibility Requirements

3. Today’s Topics • Covered Services and Limitations • Assessment and Service Authorization Information • Clinical Supervisor Requirements, • Behavioral Therapy Service Coordination

4. Today’s Topics • Medical Necessity Criteria, • Approvals, Denials, • Reconsideration and Appeals Process • Documentation Requirements • Medicaid Eligibility Verification Options and Direct Data Entry Billing Guidelines

5. Acronyms • QMHP: Qualified Mental Health Professional • LMHP: Licensed Mental Health Professional • BCBA: Board Certified Behavior Analyst • BCABA: Board Certified Associate Behavior Analyst • DBHDS: Department of Behavioral Health and Developmental Services • EPSDT: Early and Periodic Screening Diagnosis and Treatment • ESPN: ????

6. Early and Periodic Screening, Diagnosis and Treatment Benefits Well Child Visits (Screenings) Childhood Immunizations Dental, Vision, Hearing Benefits EPSDT Specialized Services

7. What is EPSDT? • Medicaid’s Early Periodic Screening Diagnosis and Treatment Program is the benefit plan for children under the age of 21 • Preventive care, traditional diagnostic and treatment services are the backbone of the program • There is no special application process for EPSDT. • Children are automatically eligible for EPSDT when enrolled in the Medicaid or FAMIS Fee-for-Service benefit plans

8. What is EPSDT? • The requirement to “correct and ameliorate” health conditions is a unique feature of the EPSDT program. This requirement of the program is included in many of the services that DMAS provides for children

9. Scope of Services • Individualized health care, diagnostic services, and “treatment” as listed in the Federal Medicaid statute, must be provided when medically necessary to correct and ameliorate (improve) physical and mental conditions discovered during screening services whether or not included in the Medicaid state plan • The program does not cover services that are experimental or investigational

10. Safety Net Function • EPSDT covers medically necessary treatments when: • Not available to certain disability groups • Not covered by Medicaid/FAMIS Plus • Including FAMIS FFS which get Medicaid benefit Examples: • Eating Disorders Treatment • Residential Substance Abuse Treatment • Behavioral Treatments

11. Specialized Services • The following Services are covered only under EPSDT and require service authorization: • Hearing Aids • Medicaid/FAMIS MCO member = Request through MCO • Assistive Technology • Medicaid MCO member = Request through MCO • Available through DME benefit for FAMIS MCO member = Request through MCO

12. Specialized Services • In Home Behavioral Therapy • Medicaid MCO member = Request services through EPSDT • FAMIS MCO = not covered service • Residential Behavioral Treatment • Medicaid MCO member = Request services through EPSDT • Not available for FAMIS MCO member (Level C) • Substance Abuse Residential Treatment • Medicaid MCO member = Request services through EPSDT • Not available for FAMIS MCO member

13. Specialized Services • Personal Care • Medicaid MCO member = Request services through EPSDT • FAMIS MCO member = Not available for FAMIS MCO member • Private Duty Nursing • Medicaid/FAMIS MCO member = Request through MCO • All EPSDT Specialized Services for FFS Medicaid/FAMIS Plus/FAMIS = request through EPSDT

14. What is Not Covered by EPSDT? • Services must be deemed as medically necessary • Ex: Personal care would be medically necessary if a child meets the EPSDT personal care criteria • Certain services are not covered by EPSDT due to Federal Regulations • Respite Care • Environmental Modifications • Vocational Services • Educational Services

15. Website Tipsdmasva.dmas.virginia.gov Information on many programs, Visit the Maternal and Child Health tab to find EPSDT Find Provider Manuals and Memos on the Virginia Medicaid Web Portal.

16. http://dmasva.dmas.virginia.gov/Content_pgs/mch-home.aspx Find EPSDT program information and forms here:

17. Behavioral Therapy Program

18. PROVIDER ENROLLMENT CRITERIA • Providers must be an agency • All providers of Behavioral Therapy must be licensed through the Department of Behavioral Health and Developmental Services (DBHDS). • The following licenses are allowed to provide Behavioral Therapy: • Intensive In-Home Services; • Outpatient Programs – Applied Behavioral Analysis

19. Agency Licensure Information • Information about agency licensure requirements and information about how to apply for a license is available through the DBHDS’ Office of Licensing. • Information may be found at the following website: • http://www.dbhds.virginia.gov/OL-default.htm

20. Intensive In Home Licensed Providers

21. Two Licenses, Two sets of Rules • There are two agency types that may provide EPSDT Behavioral Therapy. • Provider requirements will be discussed according to license type. • Both license types are expected to provide the majority of the Behavioral Therapy services in the home setting. • Clinic settings and alternative settings may be used for therapy sessions as needed based to address relevant clinical needs.

22. Staffing Requirements (IIH) “Direct” behavioral services/therapy may be provided by a qualified mental health professional (QMHP) or a LMHP. Services provided by a QMHP must be provided under the supervision of a LMHP. QMHP’s may not provide an assessment or provide clinical supervision. • Clinical services must be provided by a LMHP or licensed-eligible mental health professional.

23. Clinical Supervisor-IIH A licensed mental health professional (LMHP) or a license-eligible mental health professional may provide clinical supervision • The clinical supervisor must be available for consultation as needed. • A professional with a Virginia license as a psychologist, psychiatrist, professional counselor, clinical social worker, or psychiatric clinical nurse specialist (LMHP); • A licensed professional may provide all of the clinical supervision

24. Individual Provider Credentials LMHP and Residents (IIH licensed) • Licensed mental health professional (LMHP) refers to a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed marriage and family therapist, a psychiatric clinical nurse specialist or a psychiatric nurse practitioner.

25. Individual Provider Credentials LMHP and Residents (IIH licensed), cont’d. • A person who has been approved by the applicable Virginia health regulatory board as a supervisee in clinical social work or a resident in clinical psychology, professional counseling, substance abuse treatment practice, or marriage and family therapy may perform the functions of the LMHP for purposes of Medicaid reimbursement provided such supervisee or resident is in continuous compliance with the applicable board’s requirements for supervised practice.

26. Resident Roles IIH Licensed Providers • For purposes of Medicaid reimbursement, these persons shall use the title “Supervisee” or “Resident” in connection with the applicable profession after their signatures to indicate such status. • An individual may not perform the functions of the LMHP or be considered a “Supervisee” or “Resident” until the supervision for specific clinical duties at a specific site is pre-approved in writing by the appropriate Virginia health regulatory board.

27. QMHP Definition (IIH Licensed Providers) • Qualified Mental Health Professional (QMHP) refers to a clinician in the human services field who is trained and experienced in providing psychiatric or mental health services to individuals who have a psychiatric diagnosis. In the Commonwealth of Virginia, authorized professionals and minimal qualifications for a QMHP are as follows:

28. QMHP Qualifications To qualify as a QMHP to provide EPSDT Behavioral Therapy, the individual must have the designated clinical experience and must: i. be a physician; ii. have master’s degree in psychology from an accredited college or university with at least one year of clinical experience; or iii. have a social work bachelor’s or master’s degree from an accredited college or university with at least one year of clinical experience with children or adolescents; or

29. QMHP Qualifications, cont’d. iv. be a registered nurse with at least one year of clinical experience with children and adolescents; or v. have at least a bachelor’s degree in a human services field or in special education from an accredited college and with at least one year of clinical experience with children and adolescents.

30. QMHP Clinical Experience • Clinical Experience means providing direct behavioral health services to children and adolescents with mental illness. • It includes supervised internships, practicums, and field experience. • A human services field is defined as social work, psychology, sociology, or counseling. • A listing of other degrees that are deemed equivalent is located on the DMAS Website.

31. Outpatient Programs Licensed Providers

32. Clinical Supervisor (Outpatient Programs License) • ABA Services can only be provided by individuals who are LMHP’s, BCBA’s and Licensed-Eligible mental health professional’s • Providers must employ or contract with one of the following individuals as a clinical supervisor for each enrollee that is receiving direct treatment: • A professional with a Virginia license as a psychologist, psychiatrist, professional counselor, clinical social worker, or psychiatric clinical nurse specialist (LMHP); with expertise in Applied Behavioral Analysis • A Board Certified Behavior Analyst (BCBA)

33. Individual Provider Credentials (Outpatient Programs licensed) • The individual providing direct services, if not a qualified LMHP or BCBA, must have completed the following: • Forty (40) hours of classroom training in ABA therapy techniques. The 40 hours must be provided by an LMHP with expertise in ABA or a BCBA. The training must be documented. • Direct care staff/behavioral counselors must also have a Bachelor’s degree in a human services or educational field with one year experience with individuals with mental health or developmental disabilities.

34. Previous Experience (Outpatient Programs) • Experience means providing direct behavioral health, special education and developmental services to children and adolescents with mental illness and developmental disabilities. • It includes supervised internships, practicums, and field experience. • A human services field is defined as special education, social work, psychology, rehabilitation or counseling.

35. REQUESTS FOR PARTICIPATION All providers must request a participation agreement by contacting the DMAS Provider Enrollment Unit: Virginia Medicaid -PEU PO Box 26803 Richmond, Virginia 23261-6803 Phone - 804-270-5105 or 888-829-5373 Fax – 804-270-7027

36. Provider Enrollment Agreement • Instructions for billing and specific details concerning the EPSDT Behavioral Therapy Program are discussed in this manual. Providers must comply with all sections of this manual to maintain continuous participation in DMAS programs.

37. ELIGIBILITY CRITERIA

38. EPSDT Member Eligibility • EPSDT services are available to Medicaid/FAMIS Plus members under 21years of age and • FAMIS fee for service members under the age of 19. • The individual must be enrolled in • Medicaid Fee For Service • Medicaid/FAMIS Plus (MCO) or • FAMIS Fee for Service.

39. EPSDT Eligible Medallion II/FAMIS Plus MCO-Enrolled Members • Many Medicaid members receive primary and acute care through Medicaid contracted managed care organizations (MCO), also known as the Medallion II Program. • Members of the Department of Medical Assistance Services (DMAS) contracted MCO’s are eligible to receive Behavioral Therapy but the Behavioral Therapy services are not reimbursed or preauthorized through the MCO

40. EPSDT Eligible Medallion II/FAMIS Plus MCO-Enrolled Members, cont’d. • Behavioral Therapy is carved-out of the MCO contract and covered through the DMAS fee-for-service (FFS) provider network in accordance with DMAS FFS established coverage criteria and guidelines.

41. Family Access to Medical Insurance Security Plan (FAMIS) • Behavioral Therapy services are not included in the FAMIS MCO contract and are not covered through the DMAS fee-for-service provider network. • FAMIS MCO enrolled members are not eligible to receive Behavioral Therapy. • Behavioral Therapy services are available to “FAMIS Fee for Service” members.

42. EPSDT Program Eligibility Criteria • Behavioral therapy may be provided to persons with developmental delays such as autism and intellectual disabilities. • Children must exhibit intensive behavioral challenges to be authorized for services. • Children who have attained behavioral control and who require services such as social skills enhancement are not appropriate for the service. • The individual must have a medical need for behavioral therapy. The need for behavioral therapy must be identified by the child’s physician through an Inter-periodic/problem focused visit or an EPSDT screening/well-child visit.

43. Referral to Other Programs • Children who meet the eligibility requirements to receive Community Mental Health Rehabilitation services are not eligible for EPSDT Behavioral Therapy. • The verbal abilities and receptivity to verbal based therapy modalities required to be determined eligible for services such as Intensive In Home and Therapeutic Day Treatment exclude members from the EPSDT program • Example: Children diagnosed with ADHD and without a Developmental Delay diagnosis are not eligible for EPSDT Behavioral Therapy • Children with questionable diagnoses should be referred through the VICAP process for service recommendations.

44. Service Authorization,The Treatment Plan and Clinical Supervisor Requirements

45. Service Authorization Request If the service request is approved, DMAS will provide a service authorization number to the provider for use in claims. If the request is denied, notification will be provided to the provider and the member. DMAS has 10 business days to process requests for services.

46. Where to Send Requests Requests for members may be faxed to: (804) 612-0043 or (804) 225-3961 Requests for services may be mailed to: EPSDT Prior Authorization Coordinator Maternal and Child Health Division 600 E. Broad St. Richmond VA, 23219

47. Approval Allowances • DMAS will authorize 6 months for the initial service authorizations • Continuation of services will generally be authorized in 3 month increments • Less time may be approved when DMAS must request specific clinical information to decide if continuation of treatment is effective or clinically necessary

48. Assessment Requirements • The assessment must be done by the LMHP or BCBA (Outpatient Programs only) • The assessment must be done face to face. • The diagnosis can be done by the LMHP in collaboration with a multidisciplinary team. • If the BCBA does the assessment there must be a previous diagnosis done by an LMHP during the previous six months.

49. Clinical Assessment Documentation and LMN • Clinical assessment documentation must be completed by the treatment provider to document the need for EPSDT Behavioral Therapy services. • The documentation from the treatment provider must include a letter of medical necessity from the child’s physician which supports the therapy modality being requested by the direct services provider.

50. Assessment Summary • The assessment of the child should discuss why the proposed services have therapeutic value and discuss the ameliorative function of the services. • Therapeutic interventions must be designed, monitored and adapted closely with the clinical supervisor, ancillary treatment team members and family members. • Describe the diagnosis-specific reason for the service design/structured programming requested, and discuss the impact of not having services provided in this manner.