On this page it discusses the seclusion/restraint reporting requirements.  There is a statement that all serious incidents should be sent to Magellan within 1 business day.

Can the writing be specific that serious incidents involving restraint or seclusion are sent within one business day? 

This will alleviate confusion among providers and prevent Magellan from receiving an overflow of serious incidents not related to restraints.

In this section, it discusses the need for contract with service providers for "services provided under arrangement".  The need for a fully executed contract with other service providers has become a cumbersome process.  Is it possible for the referral itself to include information about sharing medical records and NPI information rather than attempting to obtain a full contract?  Many providers are not willing to sign a contract (or letter of agreement) or have long processes to obtain signatures on a contract which would impede the proper and needed care for youth. 

To Whom It May Concern,

I am writing in regards to DMAS’ proposed changes to provider qualifications as outlined in Chapter II, pages 15-16. I am deeply worried about the impact these changes will have on access to mental health counseling in the state of Virginia. These changes will lead to thousands of DMAS recipients not being able to access the mental health care that they need and those currently receiving services will have a disruption in service while finding another provider.

While the lack of health insurance is a significant barrier to care, another critical problem affects Virginia communities and Virginians — the significant and growing shortage of mental health care providers. Nearly half of Virginia communities, inner city areas and rural localities have too few providers to care for all of those in need.  In these underserved areas of Virginia, those who need behavioral health services must either travel a great distance to receive care or go without treatment. This is especially problematic for children and young adults. When we do not act early to support our children and young adults, we face consequences like significant increases in suicide, incarceration, homelessness, and school drop-out. These children and young adults end up needing even more extensive services well into adulthood. When we add up these losses of life and human potential, we see the incredibly high cost of not acting early. The statistics outlined above do not even include other bad outcomes, like losses in productivity, damage to relationships, and losses in life satisfaction as a whole. It is clear the increase in need for services for Virginians is a result of lack of qualified treatment providers for childrens’ mental health concerns. As such, increasing early intervention and the number of mental health providers is crucial to ensuring all who need services are provided them.

One form of early intervention is play therapy. The need for play therapy clinicians is in high demand across the state. Voices for Virginias’ Children found in September 2017 that 100 of the 133 localities in Virginia do not have enough mental health professionals to meet the need for childrens’ mental health services. The University of Virginia found in a study from February 2017 that more than 66,000 uninsured and Medicaid-insured Virginians with a mental illness are not receiving the services they need. Residents in Counseling and Supervisees in Social Work being able to see those with Medicaid for outpatient counseling is an important part of increasing the number of providers available. At my agency alone, we have over 50 children and 30 adults waiting for services. If Medicaid takes away resident in counseling and supervisee in social works’ abilities to see those with Medicaid insurance for outpatient counseling, these children and adults could wait years. With what we know about the need for early intervention, the timing of interventions’ impact on treatment outcomes, and the number of people waiting for services in Virginia, this is highly problematic.

It is clear that we have a crisis going on in the state of Virginia with regards to mental health. This is even with residents in counseling and supervisees in social work being able to see clients with Medicaid for outpatient counseling. I cannot imagine what said crisis will become should this ability be ended. I urge you to reconsider these changes and the impact they will have on mental health. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to stop the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings. The consequences are too dire.

Sincerely,

Sarah Harig, MS, Resident in Counseling

Counselor

Family Service of Roanoke Valley

360 Campbell Ave SW

Roanoke, VA 24016

Phone: 540-563-5316, ext. 3064

My concern over the proposed changes to the provider qualifications is not only that so many fewer clients will have access to needed mental health services but in the longer view, how many fewer avenues to licensure we are providing new professionals. The professional requirements of clinical supervision while providing services will not change but how will these services be provided? There are few opportunities for clinicians to see clients in an out-patient setting that will allow these clincians a full range of client issues and diagnoses. The obvious result of these changes is decreased access due to long wait lists which will multiply as fewer professionals are able to meet the requirements of licensure AND those who are will surely have little or no experience with the wide range of clients that are now seen through these services. Fewer services in the short term, fewer qualified counselors and fewer credentialed counselors in the long term will result in such a decrease in accessibility of these needed services that it will leave our most vulnerable populations more impaired for longer periods of time further impacting their opportunities for successful outcomes. While these changes may serve to decrease expenditures for mental health services by limiting access, the costs associated with these changes would seem obvious to any professional working in the field. You can expect higher rates of psychiatric in patient stays, higher number of calls for crisis services, higher utilization of licensed childrens services such as intensive in home and therapeutic day treatment, and higher rates of judicial involvement due to unmet mental health needs. These costs would seem to negate any savings created by lower expenditures in the communities for out patient counseling. Please reconsider these changes. 

Karen Pillis, MS

I am part of a small mental health agency in Roanoke, VA.  We serve children and families, including foster care, adoptive, and at-risk children.  Many of these children have Medicaid for their insurance.  We have a wonderful staff of both licensed and licensed-eligible providers.  We provide play therapy, attachment therapy, family therapy, parenting education, and counseling to children and families from age 2 -adult.  Many of our clients could not find readily-available services anywhere else.  

Our agency is an "incubator" agency, meaning we have produced licensed therapists through training, supervision, and shared resources.  I am a registered play therapist-Supervisor.  I directly supervise resident counselors and supervisees in social work who provide exceptional services to these underserved populations.  The way the provider qualifications are now is a win-win-win for the clients, the therapists and the community: 

1.    Therapists gain the experience they need to become licensed.  Direct, outpatient clinical experience is the best possible experience for a license-eligible clinician.

2.  We serve a population that wouldn't have ready-access to services.  The clients have more choice and shorter or no waitlists.

3.  The community benefits.  We produce licensed therapists with excellent clinical skills who will use their skills to give back to the community.

If you change these rules, it will have a negative impact on our community and the very people that need help the most.  Please do not change the rules regarding provider qualifications!  

Susan Owen, LCSW, RPT-S

Thriving Families Counseling

Roanoke, VA

 As an advanced practice nurse in geriatrics and a proud board member of the impressive Famiky Servicrs of the Roanoke Valley, I agree with their previous comments and especially express concerns for the potential reduction in future counselors and current efforts to decrease wage lists for services.  I agree with one of our counselors: Fewer services in the short term, fewer qualified counselors and fewer credentialed counselors in the long term will result in such a decrease in accessibility of these needed services that it will leave our most vulnerable populations more impaired for longer periods of time further impacting their opportunities for successful outcomes. While these changes may serve to decrease expenditures for mental health services by limiting access, the real life result will be more crisis interventions, more crisis in families, and increased costs to society for dysfunction and repercussions of untreated anxieties and grief, loss, and stress related struggles. 

Please reconsider these changes!

I am a mental health provider in Roanoke, VA serving children with Medicaid.  At times, I support rising counselors seeking supervision.  During this supervisory experience, counselors-in-training rely on providing services for clients inclusive of those with Medicaid.  In the Roanoke area, it is not uncommon for many of our clients to have difficulty locating services that are readily-available, especially with providers that accept Medicaid.  Direct supervision with future counselors providing services to these underserved clients will be negatively impacted if the proposed changes are implemented.  Current provider qualifications support mutual opportunity for both clients and counselors in training.  I respectfully ask that the proposed changes be reconsidered and the current provider qualifications be maintained. 

Angie Anderson MA NCC LPC

Roanoke, VA

I am writing in regards to DMAS’ proposed changes to provider qualifications as outlined in Chapter II, pages 15-16. I am deeply worried about the impact these changes will have on access to mental health counseling in the state of Virginia. These changes will lead to thousands of DMAS recipients not being able to access the mental health care that they need and those currently receiving services will have a disruption in service while finding another provider.  I respectuflly ask that these changes be reconsidered so that the children who need mental health services will have the opprotunity to get them.  

Sheri Mitschelen, LCSW, RPT-S,

Crossroads Family Counseling Center, LLC, Fairfax, VA 

The child mental health system is a precarious thing that has been pasted together over the last couple of decades, primarily with Medicaid reimbursement as its funding.  Any change to the way in which this is administered will destabilize the system.  Out of the 133 localities in VA, 100 of them already do not have enough mental health professionals to serve children and their families (Voices for VA's Children).We can't have knee-jerk decisions without understanding the full impact of them.  This proposed change to disallow residents in counseling to be able to bring in Medicaid reimbursement will reduce service availability to children and families significantly and will reduce the training arena for our burgeoning professionals.    Very badand foolish decision, if pursued.

I am writing to request that DMAS’ proposed changes to provider qualifications as outlined in Chapter II, pages 15-16 be rejected. Such changes will substantially decrease children's access to mental health counseling in the state of Virginia, counseling that is critical to children's well-being. I implore you to reconsider and to reject these changes. 

Page 62 - Admission - Intensity and Quality of Service - Section C1 states that 'at least once-a-week psychiatric reassessments' must be included in the treatment plan.

The majority of EPSDT TGH youth are referred based on severe intellectual and / or developmental disorders with major behavioral issues and often lack safety awareness.  Psychiatric symptoms are present, but are usually secondary to their intellectual and functional deficits.  While these individuals do require support from psychiatrists, weekly sessions are often not required or appropriate.  Providers should assess the needs of each individual served and schedule psychiatrist visits to meet the individual needs instead of based on a prescriptive regulatory requirement.

I believe this section was copied from the EPSDT Psychiatric Residential Treatment Facility section (where this would be appropriate) and not adjusted for the TGH setting.  We are requesting that you please remove this requirement from this section of the manual or adjust the language to allow for flexibility based on individual needs.

Under the prosed changes, for Therapeutic Behavioral Services an adverse impact will occur for children across the Commonwealth of Virginia. By allowing for fewer mental health services in the short term, and fewer qualified and credentialed counselors in the long term. The direct result will be a decrease in access to mental health services for populations served by DMAS. Today, children and families benefit enormously from quality, child-focused early intervention services to alleviate the life-long effects of adverse childhood events and/or early identification and treatment for mental illness. Removing access to these services will leave our most vulnerable populations more impaired for longer periods of time further impacting their opportunities for successful long-term outcomes. Please recondider Chapter II, Psychiatric Services page 15-16, DMAS requirements regarding provider qualifications for outpatient counseling.

Outpatient Counseling centers like Family Service of Roanoke Valley are critical community resources in providing early identification and intervention for children impacted by behavioral health concerns. License-eligible counselors or social workers under clinical supervision of a licensed counselor or social worker providing outpatient counseling to children is a win-win. Children and families have greater access to services and know they are receiving the highest quality services. Agencies are able to add to the workforce pipeline of counselors and social workers by acting as a training ground. This training ground includes a genuine experience serving a vulnerable and high-risk population. Once trained and licensed, these future counselors and social workers are more likely to choose to work with the population served by DMAS and Medicaid due to the experience they gain during supervision. Mental illness can start as young as 7 years old but the average delay in receving treatment is 8 - 10 years. By eliminating the ability of license-eligible counselors or social workers under supervision to serve Medicaid clients—the workforce pipeline will be squeezed nearly shut in a field that is already in more demand than there is supply of people in the field and the delay in treatment will likely increase. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

Continued access to robust, community-based services covered by Medicaid in childhood directly reduces costs on other state and community resources. Without this access, the Commonwealth will experience increased costs of incarceration, hospitalization, in-patient services, low graduation rates, teen pregnancy rates, etc.—which are all negative outcomes associated with not receiving intervention for childhood trauma or early onset mental illness. Please keep access as open as it is now for children to receive outpatient mental health services. Even with license-eligible counselors and social workers able to serve Medicaid clients while under supervision, there is a greater demand for services to children than providers are able to meet. Further constraining access is tantamount to creating a community health crisis for families in the Commonwealth. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

I am imploring that the changes made to Chapter II, pages 15-16 be rejected. Mental health services are already severly restricted and difficult to access. There are currently not enough professionals to service those in need. Such changes will substantially decrease children's access to mental health counseling in the state of Virginia and have negative impacts on our future's society. Additonally, this will create an even larger shortage in therapists, as they will have difficulty gaining the hours necessary to practice as a fully licesnsed professional. I implore you to reconsider and reject these changes. 

Provider Qualifications now require a fully licensed provider or a Resident or Supervisee which would be someone that has applied for supervision through one of the licensing entities.  Previous language allowed someone with a certain degree and who was ‘working toward licensure’ to also qualify to provide mental health services.  This allowed providers to hire someone who was licensed in another state and use their talent upon hire while they worked through the licensing requirements.

 The two licensing bodies in Virginia can take some time to license someone and often ask someone who was licensed in another state and has practiced for years to take an additional course or two before granting licensure in Virginia.  This will create some barriers for providers to recruit and hire talent, especially providers located close to the border with other states.

 I would suggest you add language that allows for the time limited use of providers who hold licensure in other states.

Regarding CMHRS, Chapter II, under Mental Health Skill Building, Medical Necessity Criteria, #3: "The individual shall not be in a supervised setting as described in §63.2-905.1 of the Code of Virginia. If the individual is transitioning into an independent living situation, services shall only be authorized for up to six months prior to the date of transition"

We are reading 2 possible interpretations of this. Is it stating that an individual receiving those services is ineligible under all circumstances, AND that other individuals living with their parents, for example, can only receive services up to 6 months prior to moving out/going to college/etc? OR is it stating that individuals receiving services described in §63.2-905.1 can receive services up to 6 months prior to the end of those services and that there's no restrictions on anyone else ages 18-21?

The proposed changes to provider qualifications eliminating residents and license eligible clinicians will have far reaching effects on mental health services for generations.  Research shows clear correlations between poverty and childhood trauma.  Children living in poverty are more likely to experience brain trauma via the continuous release of stress hormones.  This biological trauma affects brain development and manifests itself through disruptive behaviors best treated by trained counselors and social workers.  Children experiencing poverty are also at an increased risk of trauma related to abuse and neglect.  The lack of capacity to adequately treat childhood trauma is evidenced by waiting lists for mental health services across our state.  The capacity to serve these children is insufficient with the availability of residents and license eligible therapists.  To eliminate the ability of these individuals to seek reimbursement will assuredly decrease the capacity of organizations to serve the most vulnerable.  This proposed change would also significantly impact the ability of highly educated counselors and social workers to obtain the licensing credentials required to serve individuals with private insurance, extending the impact to the working class.  Mental health services in our country are already insufficient to meet the need.  DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

Chapter II page 15-16, DMAS requirements regarding provider qualifications for outpatient counseling

The child mental health system has needed support, primarily with Medicaid reimbursement as its funding.  Changes like this will be derimental and dangerous for the children, families, and the school systems that are involved. Children, families, shools and adults of low SES need services, and there are not enough providers as of right now in VA who can provide it. There are waitlist everywhere. Out of the 133 localities in VA, 100 of them already do not have enough mental health professionals to serve children and their families (Voices for VA's Children). To change this regulation, will be severe and will impact ALL OF VIRGINIA, not just the unlicensed professionals, but the entire state of Virginia. With the state of mental health these days, mental health services are needed to stablize our cities, communities, schools, state and country!  This proposed change to disallow residents in counseling and unlicensed counselors to be able to bring in Medicaid reimbursement will reduce service availability to children, adults, and families significantly and will reduce the training arena for our burgeoning professionals.   DO NOT PASS THIS CHANGE IN THE REGULATIONS, it is dangerous and foolish to do so!

I am a Supervisee in Social Work currently working at an outpatient counseling practice in Roanoke, VA. The overwhelming majority of my clients receive Medicaid funding, many of whom would not have access to a licensed Therapist due to the high need in our region. Being able to receive Supervision towards licensure, and getting experience in Outpatient Counseling over the past three years has been invaluable professional development for me, and provided a needed service in the. community. This proposed change would seriously damage our regions ability to service the public's mental health needs. I strongly encourage you not to pass this proposed provision. Furthermore, any proposed change should be rolled out over the course of 6-12 months to provide therapists with an appropriate amount of time to provide resources and referrals to their Clients. Anything less would be unethical and cause serious shortages in the availability of mental health services across the state of Virginia. 

My agency works in an underserved community.  About 90% of our clients are Medicaid recipients.  We are the only provider within 45 minutes of this community.  Our agency has several staff on board that are in residency that see clients that otherwise would not be able to access mental health services.  If DMAS makes this change we will run longer wait lists and not be able to serve the same client population.  In addition, we will not be able to continue to employ our clinicans who will have to look elsewhere for clinical experience.  I believe that this change in regulation is ill-conceived and the impact will be determental to the community in which I work. 

All types of health care in the US, with includes mental health care, has always been provided in supervised settings by residents. WHY would we change Mental Health Care to be different?  If teaching hospitals were unable to employ residents to give care to their many patients on Medicare, people would be dying in the emergency rooms, -waiting for a doctor to see  them.  Let's not make Mental Health Care more difficult to obtain. 

Please do not cut funds or people from our mental health system.  We have little enough help for people who are in need of assistance.  If anything we should add people and money to the system to assist more of our citizens.

As a CASA I have seen many children, young people and parents in need of help to move on to a productive and healthy life.  It breaks my heart to see children and young adults in need of a helping hand. Our communities need to provide more care and support to those in need. 

I am a therapist in private practice in Charlottesville, VA.  I accept Medicaid insurance but am often full, as are many of my colleagues who accept Medicaid.  What this means is that there are more people needing therapy than there are therapists to provide services to them.  The decision to not allow residents in counseling or supervisee’s in social work to provide outpatient services under the supervision of a licensed therapist seems illogical and definitely not in the best interest of the people.  It is clear to anyone who pays attention to the news that our communities and our country are in need of more available mental health services and support … not less!  I am baffled at how this decision was even considered. 

Part of my training in preparation for becoming a licensed clinical social worker was providing outpatient therapy under the supervision of a licensed therapist.  This experience was invaluable to me.  It is the BEST training one can get … AND … it benefits the people in need of services.  It’s a Win-Win.  Please reconsider this change in regulations.  Let's work on expanding services, not decreasing.

This would be detrimental to our patients. We live in a very rural area and it is very difficult to obtain qualified staff. We currently have approximately 60% of our clients who are on Medicaid. Over 50% of outpatient counseling staff are supervisees. We have caseloads that are extremely high and we need additional staff to meet the needs of those requiring this service. Should this take effect, it will be detrimental to those that are currently receiving services not to mention those who will need services in the future. I cannot imagine the crisis this would cause here on the Shore, let alone around the state. There is a shortage of licensed staff across the country and very few are choosing to enter this field, as it is. We would just be making it even more difficult to obtain licensing, thus discouraging those who are considering counseling careers.    

These proposed changes are sudden, unexpected, and will have an incredibly large effect on service providers throughout the state as well as those who benefit from outpatient counseling.  Without supervisees and residents on staff to provide outpatient services, it will be difficult to find staff who are interested in providing services in these, often lower paying, positions.  Additionally, this seems to directly contradict the movement of the Virginia Board of Counseling who continues to press for residents to get experience doing masters level work (as opposed to QMHP level work), and yet DMAS limits the possibility for us to do such work.  It is disappointing that these regulatory bodies do not appear to communicate needs and expectations with one another in a way that is beneficial to providers and those whom we are trying to serve in our community.  This will amount to a number of residents and supervisees losing jobs and an even larger number of outpatient recipients losing much needed outpatient therapists with whom they work well and trust.

By denying residents in counseling (like me), as well as supervisees in social work, to provide outpaitent counseling is an injustice to our community.  Our practice is located in an underserved community with the majority of client's using medicaid.  This change would be unfair to the individuals we already serve, as well as those still needing services.  Making this change would create an even larger shortage of available counselors, and create an abrupt and unethical stop in the care of many individuals and families. 

I am a Resident-in-Counseling with 8 years in the community mental health field. I have, as most all of my fellow residents-in-counseling have in CACREP-accredited counseling programs, been extensively trained in the assessment of mental health diagnoses and effective interventions from a wide-range of disciplines to treat such diagnoses. As such, the Board of Counseling has validated and asserted the resident's ability to provide outpatient therapy in the Commonwealth of Virginia. 

There is an extroardinary amount of need for counseling and psychotherapy for children and disadvantaged individuals - mental illness knows no privilege, in fact we know that low-income individuals, those that require Medicaid assistance for their health needs, are particularly vulnerable to developing mental illness, or to have a preexisting mental health diagnosis. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most most vulnerable citizens of the Commonwealth. They should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

If enacted, the proposed changes for Therapeutic Behavioral Services will impact children across the Commonwealth by allowing for fewer mental health services in the short term, and fewer qualified and credentialed counselors in the long term. The direct result will be a decrease in access to mental health services for populations served by DMAS. Today, children and families benefit enormously from quality, child-focused early intervention services to alleviate the life-long effects of adverse childhood events and/or early identification and treatment for mental illness. Removing access to these services will leave our most vulnerable populations more impaired for longer periods of time further impacting their opportunities for successful long-term outcomes. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.this text and enter your comments here. You are limited to approximately 3000 words.

In the area where I live, hundreds of children and families  are provided services through residents in counseling and social work each week. Residents have completed a bachelors degree in human services, a master's degree in counseling or social work, and a hands-on practicum AND internship before filing for supervision, and it takes years of supervision to become fully licensed. Residents are highly qualified practitioners, just as medical residents are highly qualified to provide lifesaving work every day under the guidance of an attending physician. This change in the regulations would greatly reduce the treatment capacity for our locality and prevent many, many children and families from accessing services. Please DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

As a current Resident in Counseling working in an inpatient psychiatric hospital, I work with hundreds of patients in crisis everyday. When our patients get discharged, they are in need of accessible and high quality mental health care within the communtiy. Removing access to qualified providers with years of training who have already been accepted into residency for licensure would remove access to care for so many of our patients leaving the hospital. These patients would be more likely to relapse in their mental illness and would then readmit to the hospital or worse, bumping up health care costs and posting greater damages to our society.

Furthermore, this change would be a barrier to licensure and prevent residents from receiving some of the most relevant and educational training opportunities available for licensure. Such a loss would contribute to the critical gap in services so needed to meet the high demand for mental health care in our region.

DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

I am a Resident-in-Counseling with 6 years of experience in the community mental health field. I have, as most all of my fellow residents-in-counseling have in CACREP-accredited counseling programs, been extensively trained in the assessment of mental health diagnoses and effective interventions from a wide-range of disciplines to treat such diagnoses. As such, the Board of Counseling has validated and asserted the resident's ability to provide outpatient therapy in the Commonwealth of Virginia. 

There is an extroardinary amount of need for counseling and psychotherapy for children and disadvantaged individuals - mental illness knows no privilege, in fact we know that low-income individuals, those that require Medicaid assistance for their health needs, are particularly vulnerable to developing mental illness, or to have a preexisting mental health diagnosis. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most most vulnerable citizens of the Commonwealth. They should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

I am a Resident-in-Counseling with 3 years in the community mental health field. I have, as most all of my fellow residents-in-counseling have in CACREP-accredited counseling programs, been extensively trained in the assessment of mental health diagnoses and effective interventions from a wide-range of disciplines to treat such diagnoses. As such, the Board of Counseling has validated and asserted my ability to provide outpatient therapy in the Commonwealth of Virginia. 

As my colleague has eloquently stated, there is an extroardinary amount of need for counseling and psychotherapy for children and disadvantaged individuals - mental illness knows no privilege, in fact we know that low-income individuals, those that require Medicaid assistance for their health needs, are particularly vulnerable to developing mental illness, or to have a preexisting mental health diagnosis. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most vulnerable citizens of the Commonwealth. It should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

Personally, my brother with autism is currently seeing a supervisee in social work and would be forced to stop seeing him if this new rule is enforced. As you may know, it is difficult for those with autism to find people they connect with and my brother has found that. There is NO reason for that to be taken away. Additionally, I along with my colleagues and my brother's counselor, are completely capable of working with any individual with mental health needs. Medicaid or no Medicaid- it makes no difference. All this rule does is take away possible counselors for those out there who are using Medicaid thus further taking away needs and services that they desperately are searching for in order to succeed as healthy human beings. Please reconsider this idea, it only hurts those who are already hurting the most.

Our community fosters and supports a significant Medicaid population from areas around the world. Harrisonburg continues to be a relocation site for refugees from Middle Eastern countries, as well as home to over 60 different dialects. The individual need of each of these low-income families continues to be a need for wrap-around therapeutic services, including Outpatient services. In our area, there is a wait period of about eight (8) weeks before gaining access to a Medicaid Outpatient provider. Eliminating the option for LMHP-e or Residents in Counseling/Social Work to provide Outpatient services will directly impact families, children, and individuals from receiving the care they need.

Services currently being rendered by a Resident in Counseling/Social Work will need to be discharged if this change is approved without adequate transition of services to an alternate provider due to the lack of available clinicians mentioned above. The ACA Code of Ethics, 2014, states "Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arragements for the continuation of treatment..." (A.12.) Forceful discharge of clients receiving services from Residents in Counseling/Social Work will result in harm to the clients, a lapse in treatment for clients with clinical need, and abandonment of treatment. 

Thank you for your consideration of the needs of our community and their right to receive and continue receiving quality, supervised care from our Residents/LMHP-e staff.

I am currently a Resident in Counseling serving my hometown community in Virginia.  Not only do these proposed Medicaid changes affect the range of experiences that I can have as a Resident, but the changes greatly limit the amount of people that will be receiving services that are, at times, underpaid and tightly resourced (but absolutely necessary and important).  Not only are Residents more often able to take on lower-funded jobs in pursuit of licensure, but we are also ready to learn and experience this part of the counseling world, which involves insurance processes specifically.  

In graduating from a CACREP-accredited Masters Program, I feel well-prepared and competent in entering the world of outpatient counseling.  Learning about the processes of Medicaid-funded services has been a wonderful part of my Residency and has been a vital part in the preparation for my future as an LPC.  Without the opportunity for Residents in Counseling to participate in Medicaid-funded outpatient counseling, I wonder where Residents will be able to find experiential learning opportunities in this realm.  Therefore, LPC's that then enter their practices with no experience with Medicaid-funded outpatient counseling will be "starting from scratch" in learning the in's and out's of the Medicaid processes, which may make our LPC's less competent in dealing with Medicaid requirements, paperwork, treatment planning, etc.  Furthermore, what better time is there to learn about these processes than when one is in Residency, with constant supervision, support, and knowledge provided from supervisors and colleagues?

It would be an unfortunate change to the field if Residents were not permitted to participate in outpatient counseling with persons that have Medicaid.  The simple fact that one is on Medicaid benefits, points to the great need of intervention in many forms... outpatient counseling being a very important intervention that could affect many areas of life and well-being.  If Residents in Counseling are not permitted to participate in this, then how many people will lack adequate counseling services?  Enough people on Medicaid lack these services as-is because of a shortage of practitioners that take Medicaid.  These changes will keep many qualified persons from providing much-need and incredibly important care to our community, as well as many other communities in Virginia.

Please reconsider these changes by deeply listening to those who are actively serving in the field and building the future of Virginia's counseling force.  

I am revising the comments made by my colleuge, Jeff Lown, because he accurately summarizes my sentiments and im short on time. 

I am a Resident-in-Counseling with 4 years in the community mental health field. I have, as most all of my fellow residents-in-counseling have in CACREP-accredited counseling programs, been extensively trained in the assessment of mental health diagnoses and effective interventions from a wide-range of disciplines to treat such diagnoses. As such, the Board of Counseling has validated and asserted the resident's ability to provide outpatient therapy in the Commonwealth of Virginia.

There is an extroardinary amount of need for counseling and psychotherapy for children and disadvantaged individuals - mental illness knows no privilege, in fact we know that low-income individuals, those that require Medicaid assistance for their health needs, are particularly vulnerable to developing mental illness, or to have a preexisting mental health diagnosis. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most most vulnerable citizens of the Commonwealth. They should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

I am an LCSW who provides licensure supervision for supervisees in Social Work as well as residents in counseling en route to their independent licensure.

This regulation change would further harm pubic access to needed counseling services for mental health needs, by shrinking the pool of qualified providers.  Many licensure candidates struggle to find positions where they can build their expertise with qualified supervisors.  Making it so that candidates could not provide this service, while in their residencies under supervision of persons already holding the credential would not support the training routes for practitioners of the future. 

Most people are aware that medical doctors serve a residency under supervision of more experienced doctors.  Clinical social workers and counselors in training have an analogous route for their training as well.  And this serves a cost containment purpose for services overall.  If these regulations were passed, more expensive care from practitioners who are already licensed would be in demand; or the services just wouldnt be there.  Please dont be so short-sighted.  Mental health emergencies strike all socio-economic groups, when you or a loved one needs mental health care, you want a robust service system with a range of providers, to be there!

I am a Ph.D. candidate in Counselor Education and Supervision at James Madision University, an Instructor in Eastern Mennonite University's MA in Counseling program, and a Resident in Counseling in Virginia. I have participated in training counselors at EMU and JMU, both of which are CACREP accredited Clinical Mental Health Counseling programs. The students who graduate from these programs have provided a minumum of 700 hours of closely supervised clinical service to members of our communites, many of whom live in rural or medically underserved areas and would otherwise likey not recieve any behavioral health services. These students have also recieved high quality classroom experinces through our CACREP accredited programs. Upon graduation, these students are ready to carry out the work of professional counselors under the guidence of a supervisor. For that task, the majority of our students register to become Residents in Counseling, a period (3,400 hours over about 2 years) of closely supervised work. I strongly believe that Residents in Counseling are qualified to provide outpaitent clinical mental helath services and should qualify for reimbursment through Medicaid.

Further, there is an extroardinary amount of need for counseling and psychotherapy for our low-income neighbors and community members, many of whom live in rural and medically underserved communities. As you know well, our behavioral health provdiders are already overburdened by a large and growing need for counseling and psychotherapuetic services. Residents in Counseling assist a great deal in meeting that need. By preventing Residents and Counseling and Supervisees in Social Work from providing outpatitent services through Medicaid, you would drastically reduce the availability behavioral health services in our communities. Please do not do that. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most most vulnerable citizens of the Commonwealth. They should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services. The pool of qualified providers is already critically small. 

Thank you for your careful consideration of this vital topic.   

I serve as a Grants and Practice Manager for the Collins Center in Harrisonburg, Virginia.  Prior to serving The Collins Center, I worked at a non-profit in Miami, Florida that served 3,000 individuals.  I have seen first-hand the vital need for mental health counseling and psychotherapy for children and disadvantaged individuals.  I firmly believe that if you are able to address the underlying issues related to trauma, PTSD, sexual assault, domestic violence, etc., you save money down the road required for financial and medical stability for families and individuals.  Besides being the compassionate and morally-correct response to people in desperate need of mental and emotional assistance, it just makes good financial sense to provide the means for people to obtain help to acheive stability as soon as possible and thereby potentially prevent life-long distress and need for assistance due to unresolved trauma and pain.  Any proposed changes should be ammended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

Sincerely,

Anita Lunsford

I am surprised by the proposition of such a change in the regulations, as individuals who are on Medicaid have been well-served through MANY programs, practices, and offices by residents in counseling and supervisees in social work.  I wonder if Medicaid makes a similar distinction between medical residents and licensed physicians?  I wonder what the benefit is in limiting providers?

As many professionals and residents have stated in other comments, providing mental health services while under supervision is part of the training process and development of therapists and social workers.  This is the case in the health care world as well.  In my present position and in past positions, I have overseen the training and supervision of trainees in social work, counseling, and psychology.  I would say that individuals who receive services from a resident in training likely are getting even better care than normal, as they have the benefit of at least two mental health professionals considering the circumstances of their case,  and the supervisor wants adequate care given since it's their license on the line.  Also, residents under supervision can also get group supervision with classmates, a professor, or their coworkers.  These individuals have already completed an internship or two by this time and are competent to provide services with oversight.  Competence or quality of care should not be the concern.

The reality of reimbursement rate, the high rates of no shows, and the inability to charge a no show fee make it untenable for most solo or group providers to have more than a small percentage of Medicaid slots.  Until those realities change, again, it is ill-advised to restrict residents/supervisees from providing care to this population.

The need to great, and the amount of available providers is not commensurate.  This change would negatively impact the lower income communities in Virginia, the mental health professionals, and the students who are attempting to gain their licensure.  It also will over burden existing safety nets.  Any concerns that DMAS has identified should be problem solved in another way.

Amanda N. Trent, Psy.D.

Licensed Clinical Psychologist

Clinical Director, SARA

Charlottesville, VA

1)      RE: Chapter II, Psychiatric Services page 15-16, DMAS requirements regarding provider qualifications for outpatient counseling

If enacted, the proposed changes for Therapeutic Behavioral Services will impact children across the Commonwealth by allowing for fewer mental health services in the short term, and fewer qualified and credentialed counselors in the long term. The direct result will be a decrease in access to mental health services for populations served by DMAS. Today, children and families benefit enormously from quality, child-focused early intervention services to alleviate the life-long effects of adverse childhood events and/or early identification and treatment for mental illness. Removing access to these services will leave our most vulnerable populations more impaired for longer periods of time further impacting their opportunities for successful long-term outcomes. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

2)      RE: Chapter II, Psychiatric Services, page 15-16, DMAS requirements regarding provider qualifications for outpatient counseling

Outpatient Counseling centers are a critical community resource to provide early identification and intervention for children impacted by behavioral health concerns. License-eligible counselors or social workers under clinical supervision of a licensed counselor or social worker providing outpatient counseling to children is a win-win. Children and families have greater access to services and know they are receiving the highest quality services. Agencies are able to add to the workforce pipeline of counselors and social workers by acting as a training ground. This training ground includes a genuine experience serving a vulnerable and high-risk population. Once trained and licensed, these future counselors and social workers are more likely to choose to work with the population served by DMAS and Medicaid due to the experience they gain during supervision. By eliminating the ability of license-eligible counselors or social workers under supervision to serve Medicaid clients—the workforce pipeline will be squeezed nearly shut in a field that is already in more demand than there is supply of people in the field. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

3)      RE: Chapter II, Psychiatric Services, page 15-16, DMAS requirements regarding provider qualifications for outpatient counseling

Continued access to robust, community-based services covered by Medicaid in childhood directly reduces costs on other state and community resources. Without this access, the Commonwealth will experience increased costs of incarceration, hospitalization, in-patient services, low graduation rates, teen pregnancy rates, etc.—which are all negative outcomes associated with not receiving intervention for childhood trauma or early onset mental illness. Please keep access as open as it is now for children to receive outpatient mental health services. Even with license-eligible counselors and social workers able to serve Medicaid clients while under supervision, there is a greater demand for services to children than providers are able to meet. Further constraining access is tantamount to creating a community health crisis for families in the Commonwealth. DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

DO NOT approve the proposed changes to provider qualifications for psychiatric services as outlined in Chapter II, pages 15-16 to eliminate the ability of residents in counseling and supervisees in social work to see clients in outpatient counseling settings.

It is already difficult to find therapists to provide outpatient mental health counseling. Do NOT make this change that would prohibit people moving towards licensure from being reimbursed. We need to provide training and work opportunities so that we can build a workforce to meet the growing need.

The proposed regulations would demonstrably increase barriers to access mental health services for children of low-income.  While the regulatory goal of increased quality of care is laudable, the proposed regulations will simply axe programs without licensed professionals with no regard for the quality of services, whether licensed or unlicensed.  

For social workers and other allied professions who provide mental health services to children, this regulation would prevent anyone seeking licensure from developing the necessary experience in child mental health to attain licensure.  Education, licensing, and supervision costs are already high in Virginia.  If we want to have enough social workers to meet the needs of our children, we need to make sure we can nurture a sustainable workforce.  These regulations would do a great deal of damage in that effort.  

We serve children who have alleged child abuse. Each of the 400 or so children we see each year is referred to mental health intervention. We relly on our community partners for these services, some of which use license eligible counselors. We currenly have limited availablity for our kids. Please reconsider sweeping changes to the services covered by Medicaid, so children in the Commonwealth can continue receiving counseling, residential and other behavioral health services. Do not further reduce access by disallowing license-eligible counselors from providing billable service, or dramatically changing the residential care system. If you do, then child abuse victime will reap the consequences of untreated childhood trauma. Children need to know they can get help, when and where they need it, no matter what! 

I am a student at James Madison University in the Clinical Mental Health Counseling program. This is a second career for me. I am also a lawyer and served as a public defender in Virginia for 5 years. In that role I represented many indigent clients who suffered from mental illness and/or substance abuse. I witnessed the lack of services available to them and the taxpayer dollars wasted on detaining, jailing and imprisoning these adults and children who would have been much better and inexpensively served through outpatient psychiatric services. Many of those adults and children might have become contributing members of society rather than a constant drain on our budget.

Part of the challenge in providing services for low income families and individuals is access. The proposed changes to "Psychiatric Services" Chapter II eliminates the Medicaid reimbursement of Counselors-In-Residency providing ?supervised ?services to those in need. In my CACREP-accredited counseling program at JMU we receive 3 full years of training and education including 1 year of internship before we become Residents. As a Resident, I will spend 4000 hours counseling under supervision before I can take my exam to become an LPC. Our training is rigorous and comprehensive, as are all CACREP-accredited programs. Perhaps instead of eliminating all Residents, a recommendation would be to include that all Residents must be from CACREP-accredited programs.

If all Residents are eliminated it will sever on-going counseling relationships, reduce the number of people served, and inevitably cost all of us more through the court and prison system. I am capable and I am driven to serve this population. I made this career change precisely for that reason. As a public defender and court-appointed attorney, I realized a better and cheaper way to provide long-lasting help for this population was through treatment. Please do not hinder our ability to serve in this way. We may all disagree about policy matters surrounding low income populations, but we can all agree that jail and prison are expensive. Preventative treatment, counseling, and substance abuse treatment work. These changes would further frustrate access to effective services. Please reconsider.  

Mental health services are needed now more than ever. Getting children the help they need as expediently as possible should be a priority if we hope to see them grow into healthy adults. 

We have very few licensed mental health providers in our community who accept Medicaid. Therefore, the proposed changes would limit access to much needed mental health services for many children. Limiting access will have long-term consequences for individuals and the Medicaid system alike.

As a staff member for an organization that works with children who have been abused, I implore you to not limit access for children needing the servies these changes could affect. As a mother of a child who was severely neglected within her birth family and a grandmother to a child who has developmental delays and whose mother has been in and out of his life for his entire life - I beg you to think about my daughter and grandson. They both attend therapy weekly, my daughter has been working through her childhood trauma for almost six years, without the guidance of her therapist, she would not be where she is today. My grandson has not yet learned what grief is and he will need the continued work through his therapist to help him work through it - they both did not ask for their past circumstances, they are now in a loving home being given the opportunity to heal, please do not take that opportunity from them.

To echo my colleagues and borrow from their language. I, too, am writing to request that DMAS’ proposed changes to provider qualifications as outlined in Chapter II, pages 15-16 be rejected. Such changes will substantially decrease children's access to mental health counseling in the state of Virginia, counseling that is critical to children's well-being.

I am a Counselor Educator and as such am aware that residents have been extensively trained in the assessment of mental health diagnoses and effective interventions from a wide-range of disciplines to treat such diagnoses. As such, the Board of Counseling has validated and asserted the resident's ability to provide outpatient therapy in the Commonwealth of Virginia.

There is an extroardinary amount of need for counseling and psychotherapy for children and disadvantaged individuals - mental illness knows no privilege, in fact we know that low-income individuals, those that require Medicaid assistance for their health needs, are particularly vulnerable to developing mental illness, or to have a preexisting mental health diagnosis. The proposed changed regulations would needlessly and severely limit access to robust mental health care to the most most vulnerable citizens of the Commonwealth. They should be amended to allow that residents-in-counseling and supervisees in social work can provide outpatient psychiatric services, as the pool of qualified providers is already critically small.

Please reconsider promoting and implementing a policy that will surely result in a detrimental outcome for those in critical need of mental health services.