The name “BRAVO” stands for Behavioral health Redesign for Access, Value & Outcomes. It’s a state Medicaid initiative in Virginia to revamp how behavioral health care is provided to people on Medicaid. In practical terms: it involves adding new services, improving access to existing services, and shifting toward earlier, community-based care rather than waiting for full-blown crises. 

See this document for more information. 

Project BRAVO more broadly emphasizes a continuum of care (prevention, early intervention, less reliance on inpatient/hospital services) for Medicaid behavioral health. As a provider, this means the context in which you provide ABA services is part of a larger re-designed system. Because Project BRAVO is part of a broader shift toward earlier intervention and community-based care, there may be new opportunities, new service models or expanded coverage that you might want to explore (or adjust your practice to). This might affect your caseload, location of services (home/community), coordination with other behavioral health services, etc. 

DMAS has published bulletins specific to ABA under Project BRAVO. You can find those documents here: 

Medicaid Bulletin March 2021 

Medicaid Bulletin July 2022 

• Before DHP (Department of Health Professions) licensure (through the Board of Medicine), there was an Outpatient ABA license through DBHDS (Department of Behavioral Health and Developmental Services).
  • This service was difficult for in-home providers since it was geared toward a clinic (asking for temperature of water, number of fire extinguishers, etc.)
  • It became unnecessary in 2012 when DHP began licensing behavior analysts through the Board of Medicine
• In 2014, a couple of years after our license was affirmed, DMAS (Department of Medicaid Assistance Services) created a service called Behavioral Therapy that would allow LBAs and other LMHPs to practice under their state issued licenses rather than a separate license from DBHDS. This service was not specifically ABA and encompassed other professions in addition to behavior analysis.
• In January 2019, Category 1 codes went into effect for behavior analysts.  This was a behavior analyst-led initiative, and the codes are approved by the American Medical Association but put forth by a Coding Coalition made of behavior analysts.  For more information, see www.abacodes.org.
• The Center for Medicare & Medicaid Services (CMS) has issued a statement on correct coding and the necessity of using codes that correspond with the service one is providing.  For more information, see https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html.
• Project BRAVO (Behavioral Health Enhancement) was launched by the Virginia Legislature which directed DMAS to improve Behavioral Health Services in 2018.  For more information on that initiative, see https://www.dmas.virginia.gov/for-providers/behavioral-health/enhancements/ or this VABA post: https://virginiaaba.org/behavioral-health-redesign/.  One of the service enhancements is Multisystemic Therapy (MST) and the correct code for that service is H2033, the same code that is being used by Behavioral Therapy.
• In 2021, VABA submitted a budget amendment in partnership with DMAS to do a rate study to move ABA to its correct codes thus freeing up the H2033 code for MST.  The legislation indicated that the code changes should take place on 12/01/2021, which brings us to the situation where we are today.
• Note that DMAS held two trainings: one with Mercer on how the rates were established (held 10/21) and the other with Dr. Ward on the new ABA Manual (held 10/26).  Follow Virginia Medicaid on YouTube for these and other trainings.  The manual should be posted around the second week of November 2021, and the Q&A from the trainings should be posted close to 12/1/21 on https://dmas.virginia.gov/for-providers/behavioral-health/.

For information about using the MES (Medicaid Enterprise System), click here: Virginia Provider Portal User Guide

The MES website has a variety of resources, including a video explaining how to submit an application, access the provider portal and set up delegates for your staff who will use the portal.

You will also find Frequently Asked Questions about provider training opportunities, setting up your provider account, taxonomy codes and pharmacy topics.

Also, see the video on this page.

There are three entities that are involved in reimbursing providers for services to Medicaid Members:

1. The Department of Medical Assistance Services (DMAS)

2. The Behavioral Health Services Administrator (BHSA) – Magellan

3. The Managed Care Organizations (MCOs) –  Aetna Better Health, Anthem Healthkeepers, Humana Healthy Horizons, Sentara Health Plans, and United Healthcare Community Plan

To become a provider, you first register with the BHSA/DMAS through the Medicaid Enterprise System (MES) – Home | MES (virginia.gov).  Unfortunately, the Center for Medicaid and Medicare Services (CMS – a federal organization) has instituted a one-time fee for new providers of $631.  We are working on getting funding to cover that, but for now, providers will need to pay the fee to register.

Once registered through the MES, you need to have each LBA credentialed and contracted with each MCO for whom you are going to accept patients (you can choose one or all six).

Note that to bill for RBTs or LABAs, you must have an organizational NPI number.

Here is information provided by DMAS

The short answer is no.  The only services you can get paid for delivering in schools is consultative.  However, DMAS and the VDOE are in the process of working with CMS to allow school systems to bill for ABA,  Note that private providers would need to contract with the school system as only the LEA could bill, not the private providers.  When the information is available, it will be located here: School Based Services (virginia.gov)

Please see this page for information from DMAS.  The state plan amendment was approved in September 2023 and is retroactive to July 2022.

Specifically, see this training document.  Here are some highlights:

• LEAs need to make their own decisions regarding what they will bill as well as a rollout timeline.  Some LEAs may decide not to do this.  The State Plan Amendment was approved in late September and will be retroactive to July 1, 2022. You can work with your school division for a rollout plan.
• Relevant chapters in the LEA Provider Manual were updated in January 2024 and include Chapters 2 (Provider Qualifications), 4 (Covered Services), & 6 (Utilization Reviews and Controls – i.e. Documentation Requirements)
  • Chapter 5 (Billing) includes procedure codes and if there are max units; CPT codes that can be billed include 97151, 97152, 97154, 97155, 97156, 97153, 97158
• SLPs, OTs, PTs already bill Medicaid for services in schools and BCBA, LBAs  and BCaBA, LABAs are in the process of being added.
• An LBA is treated as a Healthcare Professional who is providing services in an educational setting.
• LBAs do not need to change what they do to fit the LEA guidelines but just understand how the language applies to them.
• The LEA can seek reimbursement for Applied Behavioral Therapy, but LEAs and LBAs cannot bill Medicaid directly for ABA.
• RBTs are considered unlicensed providers because they are not able to refer students to receive services under Medicaid, however, their time can be billed as long as they are under the supervision of an LBA.  RBTs are the only unlicensed individual who can participate in the assessment portion of the process and claim reimbursement. Divisions can claim for other unlicensed professionals (teachers, IAs), for providing services (not assessment) but this will be at the discretion of the licensed individual.
• Be sure to be aware of supervision requirements
• Medicaid services are not specific to students with IEPs (anyone with Medicaid can qualify for services if there is a need)
• A Plan of Care is necessary – this differs from the BIP or other reports and should be separate; there are specific components needed
• ICD-10 codes are to be identified in order to bill.  You can see common ones here.
• Note, in order to bill, the BCBA must be licensed as an LBA (or LABA), must have an NPI number and register that NPI with Medicaid as a Referring Provider
• LBAs who are employees will need to take part in the Random Moment Time Study but contractors will not (see training presentation for more information)
• It’s important to coordinate with Medicaid Coordinators in your LEA

No.  They can be MORE lenient than the regulations, but not less.  For instance, they can’t require that you hire RBTs, they can’t insist you use specific assessments, they can’t pay you less than the DMAS approved rate, etc.

If you are having trouble with reimbursement from any of the six Medicaid MCOs  here is a form to use to alert DMAS.  The information should be sent to cccpluscmhrs@dmas.virginia.gov.

Ignore the Nursing Center language.  It was developed for them but can be used for behavioral therapy.

Insurance carriers have to reimburse brand new providers within 30 days of acceptance for any services provided while waiting for their application to be accepted as long as the application is complete.

Here is a link to the original bill and the final law.

Also see this memo from DMAS for more information with respect to Medicaid.

If you are going to accept insurance (including private/employer, Medicaid through the MCOs, TRICARE, etc.), you must be contracted and credentialed with each company.

Sometimes this can be a difficult thing to do as insurance companies may not accept you because they say they have enough providers, even if you are accepted, they may drop you in the culling period they go through each year.

In Virginia, BCBAs operate under their DHP licenses (as an LBA) instead of having their company licensed, as is the case for some other professions in Mental Health.  Once licensed, an LBA can then be credentialed with a number of insurance companies and often the payors will contract with ABA companies rather than just the individual LBA.

To become contracted and credentialed, you will need to contact each insurance company specifically.

A bill in 2020 (HB822 – Head ) was enacted to help providers get paid while in the process of becoming credentialed (so those who need it can get services faster).  Through this bill, payors are required to pay providers for work they have done after all of their paperwork is in and they are just waiting for final approval from the payor.  There are some other specifics outlined below:

B. A carrier that credentials the physicians, mental health professionals, or other providers in its network shall establish reasonable protocols and procedures for reimbursing new provider applicants, within 30 days of being credentialed by the carrier, for health care services or mental health services provided to covered persons during the period in which the applicant’s completed credentialing application is pending. At a minimum, the protocols and procedures shall:

1. Apply only if the new provider applicant’s credentialing application is approved by the carrier;

2. Permit reimbursement to a new provider applicant for services rendered from the date the new provider applicant’s completed credentialing application is received for consideration by the carrier;

3. Apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged; and

4. Require that any reimbursement be paid at the in-network rate that the new provider applicant would have received had he been, at the time the covered health care services were provided, a credentialed participating provider in the network for the applicable health benefit plan.

Note that the reference to 30 days is how long the insurance company has to pay you after you are credentialed.  It does not refer to the amount of time it takes to be credentialed, or the amount of time for which they will pay you while waiting.

Contact admin@virginiaaba.org if you have any questions.

Q. I understand that I cannot bill for indirect work, like supervision without the client present, data analysis, and materials creation. How am I supposed to keep behavior technicians if they do not get paid for that anymore?

First, you should absolutely pay your behavior technicians for every hour they work, be it through an hourly wage or
salary.  Behavior technicians MUST NOT be contractors.  They have to be paid as employees for all work they perform.  See
the BACB November 2018 newsletter (https://www.bacb.com/newsletters/) and also guidance from the IRS on this (https://www.irs.gov/businesses/small-businesses-self-employed/independent-contractor-self-employed-or-employee).  Also make  sure that you are paying at least minimum wage (see https://virginiaaba.org/aba-businesses-and-minimum-wage/).

Indirect services such as supervision without the client present and data analysis are “in kind” services and thus included in the rate
you are contracted to bill.  It is incumbent upon business owners to determine how to run their businesses in order to pay their employees an adequate wage, and billing and salaries do not correspond one-to-one.

Update: It seems the Medicaid will allow LBAs to bill for “ongoing assessment, data analysis
and time spent adjusting the treatment plan” without the child present despite the fact that the 97155 code is not meant for those services.  DMAS used to limit that billing to the same day as when the youth was seen face-to-face, but that restriction is now gone.

This does not have simple answer and is still being explored by VABA with the help of APBA who provided the following information.

There is an exception to our licensure law that says: “The provisions of § 54.1-2957.16 shall not be construed as prohibiting any professional licensed, certified, or registered by a health regulatory board from acting within the scope of his practice.”

“Scope of practice” in this context refers to the definition of the practice of a profession in its licensure law — that is, the description range of activities in which licensed members of the profession may legally engage. Legislated scopes of practice are usually quite broad and general. The subset(s) of activities within a profession’s scope of practice in which each individual licensed professional can engage ethically depends on the specific education and training that individual has completed — that is, their scope of competence.  This is stated explicitly in the regulations for most LMHPs (including LPCs and LCSWs).

Neither scope of practice for LPC or LCSW includes behavior analysis according to the licensure laws in VA.  Both refer to the principles and methods of those respective professions, which differ substantially from the principles and methods of behavior analysis. The task lists resulting from recent job analysis studies for counseling and social work include little or nothing on behavior analysis. Therefore, the same is true of the coursework, experiential training, and licensure exams in those professions.

In short, the practice of behavior analysis is not in the scope of practice of either of those professions, so even if some individual LPCs or LCSWs in VA claim to have some training and experience in behavior analysis, they don’t meet the criterion in the “Exceptions” section of our behavior analyst licensure law.

For more information, it is important to note the definitions of the healthcare provider taxonomy codes for Behavior Analyst, Counselor, and Social Worker that have been issued by the AMA’s National Uniform Claims Committee: https://npidb.org/taxonomy/

No. Virginia does not require it and neither does DMAS. The LBA or LABA is ultimately responsible for the technician’s actions.

The answer is no.

Q. In Northern VA, we often use behavior technicians for parent training because of language barriers (in that the technician can speak the family’s language). How can we manage this if parent training isn’t reimbursable for the technician level?

1. See DMAS’s language and disability access plan for help with this: https://www.dmas.virginia.gov/media/3536/2021-dmas-language-and-disability-access-plan.pdf

Providers are required in their enrollment agreement to be responsible for translation.  Providers cannot bill for translation work or to have an extra person there to translate.  Any expansion of billing that is currently in place will require GA authority.

4.15 TRANSLATION & INTERPRETER SERVICES Translation services (including oral interpreter services and sign language interpreter services) shall be available to ensure effective communication regarding treatment, consent to treatment, medical history, or health education. [42 CFR § 438.10(c)(4)] Trained professionals, including qualified sign language interpreters, shall be used when needed where technical, medical, or treatment information is to be discussed with the Member, a family Member or a friend. The Contractor shall institute a mechanism for all Members who do not speak English to communicate effectively with their PCPs and with Contractor staff and subcontractors. If five hundred (500) or more of its Members are non-English speaking and speak a common language, the Contractor shall include, if feasible, in its network at least two (2) medically trained professionals who speak that language. In addition, the Contractor shall provide TTY/TDD services for the hearing impaired.

See the manual for information about eligibility.  The individual must have a DSM diagnosis, but it doesn’t have to be for autism spectrum disorder.  They will need to meet other criteria.

No, the service falls under EPSDT. Some individuals over 21 are able to access behavior analysts through Therapeutic Consultation.

CNA is short for the Comprehensive Needs Assessment.  You must submit this for all individuals that you serve, even though it doesn’t seem very behavior analytic.  There are 15 key areas.  You can find the necessary information in Chapter 4 of the manual.

Q. Care coordination is something that is relied heavily upon with this service for Medicaid members, but is not as common with other payors and therefore probably won’t be accounted for in the rate study. Will there be a separate code for Case Coordination so that it can be billed directly?

1. Yes. When the manual was posted on 11/22, it listed 97155 as the code for care coordination, when the activities meet certain elements in the code description “non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.”

Here is additional billing guidance:

-Care coordination, data analysis and treatment plan preparation activities provided by the LBA, LMHP or LABA without the youth present may be billed under 97151 at the time of the initial assessment and reassessments.
-To bill for time spent by the QHP to review data, modify the treatment protocol and provide additional care coordination as part of ongoing assessments, the QHP must bill under 97155.

Care coordination is a larger system issue for DMAS (beyond just ABA), so there will most likely be changes in the future as Project BRAVO takes shape.

Q. Will Technicians be allowed to bill for Care Coordination?

1. No. 97151 is for LBAs and LABAs.

There used to be two separate types of Medicaid called CCC Plus and Medallion 4.0.  They combined to have one contract and are now called Cardinal Care.

Definitions:

CCC Plus – Commonwealth Coordinated Care Plus (CCC Plus) is a Medicaid managed long-term services and support program that serves over 260,000 individuals throughout the Commonwealth of Virginia. CCC Plus uses an integrated delivery model, across a comprehensive range of health services, to assist members with complex care needs. Enrollment in the program is required for qualifying individuals, who benefit from the person-centered care management program. CCC Plus strives to improve health care quality, access and efficiency for its members through contracted managed care organizations, also known as health plans. (https://www.dmas.virginia.gov/for-members/managed-care-programs/ccc-plus/)

Medallion 4.0 – The Medallion 4.0 is a statewide Medicaid program. The Medallion 4.0 program provides services to qualified members in the areas of maternity care, including early prenatal care, case management, and postpartum care; care for infants and children, including early intervention services, immunizations, screening, and preventive care; and wellness, behavioral health, community mental health services, behavioral therapy, family planning and chronic disease support for adults. (https://www.dmas.virginia.gov/for-members/managed-care-programs/medallion-40/)

Fee for Service (FFS) – People with Medicare or private health insurance, people receiving long-term care services, and children in foster care receive Medicaid coverage through a fee-for-service arrangement. The provider charges a fee for each service and receives payment from DMAS for each service. (https://www.dss.virginia.gov/files/division/bp/medical_assistance/intro_page/faq/about.pdf)

The transition to Cardinal Care happened around July 2022.  Phase I is the merging of the products and rebranding, which won’t really affect providers.  Phase II was implemented January 2023 and more changes took place.

Changes in service due to transition:

• When members transition between Medallion 4.0 and CCC plus, sometimes they are assigned FFS for about a month while the transition is going through.  This will not happen once the two are combined.
• A regional open enrollment will be instituted rather than the entire state having open enrollment at the same time.
• There will be unified contracts and accountability and oversight will be aligned
• A Responsive Model of Care will be instituted.  More information on page 13: https://www.dmas.virginia.gov/media/3910/medicaid-managed-care-advisory-commitee-march-29-2021-final.pdf.  Those who have CCC Plus do have care coordinators already and after the transition, there will be determination on how much care coordination and care management a member receives based on an analytical tool that differs by MCO.
• Providers may receive re-contracting information
• You may have already experienced the change in system to MES.  If you have questions about that, contact admin@virginiaaba.org

What stays the same:

• Access to care
• No disruption to members or providers
• Same 6 MCOs (Aetna, Anthem, Humana, Sentara, UnitedHeathcare)

Also, please note that the continuous coverage afforded to Medicaid recipients since March 2020 (due to the pandemic and under the Families First Coronavirus Response Act – FFCRA) will most likely expire in July 2022.  Continuous coverage means that people who were eligible for Medicaid in March of 2020 or later will remain on Medicaid  until the public health emergency (PHE) ends, even if they are no longer qualified for the service.  When the PHE ends, DMAS will redetermine eligibility for all Medicaid recipients and some may lose coverage.  It can take up to 12 months to complete the redetermination.  DMAS is working on “unwinding” in their anticipatory planning efforts. There are three phases of this unwinding – 1. Automation, 2. Staff Augmentation, 3. Outreach/Communication.

Virginia requires that Medicaid Providers (Therapeutic Consultation and ABA for Medicaid) verify each month that they are not in the exclusions database.  This database is of providers, not organizations, so if you have several providers, you’ll need to verify for all.  Here is the link: https://exclusions.oig.hhs.gov/

Enter the name and then print/save as pdf the verification.  If you have a similar name to someone with an issue, there is a SSN option.