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DC’s Behavioral Health Transformation Demonstration Program Services: Provider Requirements, Billing Codes, and Beneficiary Eligibility Criteria


Tuesday, March 24, 2020

On November 6, 2019, the Centers for Medicare and Medicaid Services (CMS) approved the District’s Behavioral Health Transformation demonstration with an effective date of January 1, 2020. The demonstration allows the District’s Medicaid program to pay for services provided to adults with serious mental illness (SMI)/serious emotional disturbance (SED) or substance use disorder (SUD) residing in an institution for mental disease (IMD). Additionally, the demonstration will add new community-based services designed to improve behavioral health treatment capacity and strengthen transitions from emergency, inpatient and residential treatment. This chart is to provide as complete of a description as possible as to how services will be covered and reimbursed for providers and beneficiaries. Reimbursement for all services noted below are governed by Chapter 86 (Behavioral Health Transformation Demonstration Program) of Title 29 (Public Welfare) of the DCMR. Those who serve as a qualified provider (QP) within the Mental Health Rehabilitation Services (MHRS) and Adult Substance Abuse Rehabilitative Services (ASARS) providers in a behavioral health setting include the following: 1) A qualified physician; 2) A psychiatrist; 3) A psychologist; 4) A licensed independent clinical social worker (LICSW); 5) A licensed graduate social worker (LGSW); 6) A licensed marriage and family therapist (LMFT); 7) A physician’s assistant (PA); 8) An advance practice registered nurse (APRN); 9) A registered nurse (RN); 10) A licensed professional counselor (LPC); 11) An independent social worker (LISW); 12) A graduate professional counselor for services provided outside the Human Care Agreement with the District; and 12) A Certified Addiction Counselor (CAC). Those staff must operate within the scope of their license. Some additional providers may provide services within ASARS and MHRS when adequately supervised by a QP: 1) Volunteers/Interns/Residents; 2) Credentialed/Unlicensed staff; 3) Certified peer specialists; and 4) Licensed or certified individuals who require supervision pursuant to their license or certification.