Thank you for the opportunity to provide input on the proposed changes to CMHRS services and their impact on the behavioral health community we serve. With nearly two decades of experience delivering legacy CMHRS and other mental health services across Virginia, Compass has developed a deep understanding of the complexities of service delivery, billing, operational implementation, and regulatory compliance. From this perspective, we recognize and support the need to overhaul CMHRS legacy services to address existing gaps and inefficiencies. However, we strongly urge the Commonwealth to carefully consider the unique needs of the populations we serve. Overcomplicated processes or burdensome requirements risk disrupting service delivery and jeopardizing access to quality mental health care for those who need it most.

The proposed regulations lack sufficient detail to enable meaningful and constructive feedback. Critical aspects, such as medical necessity criteria, service delivery expectations, and operational requirements, are either vague or missing entirely. This leaves providers unable to assess the feasibility, sustainability, or potential impact of these regulations. Without more clarity and comprehensive guidance, it is challenging to offer informed commentary or evaluate how these changes will affect service delivery, client outcomes, and provider operations.

While the flexibility to serve clients in various settings is a positive and necessary step, the proposed regulations fail to address practical limitations adequately. For instance, school-based services currently require formal agreements, such as a MOU, between the school and the provider/agencies conducting these services. As written, the regulations assume universal access without considering how such permissions would be obtained or outlining the requirements for providing school-based services. 

Similarly, while tiered services tailored to individual needs are conceptually appealing, the operational realities of accessing workplaces or schools to deliver these services make implementation highly unrealistic. It is crucial to ensure clarity and feasibility in these regulations to avoid inadvertently creating barriers and confusion to care.

Concerns and Recommendations

DBHDS Involvement in Regulations

• Lack of Specificity: The proposal provides insufficient detail about DBHDS’s role in shaping or enforcing the regulations. This oversight creates ambiguity, particularly for providers who rely on DBHDS guidance to ensure compliance with Virginia-specific requirements.
  
  
• Inconsistencies and Duplication: Adding accreditation to DBHDS oversight results in redundant processes, creating confusion for providers. DBHDS already has robust regulatory mechanisms tailored to Virginia’s needs, and an external accreditation layer dilutes this expertise.

• Recommendation: Keep oversight strictly within DBHDS to maintain consistency with Virginia’s standards and avoid unnecessary financial and administrative burdens. Work with DBHDS to refine service definitions and regulations.

Accreditation vs. DBHDS Licensing

• Feasibility for Home-Based Services: Accreditation is ill-suited for home-based services due to their decentralized nature and lack of infrastructure for traditional accreditation standards.

• Cost Concerns: Accreditation imposes significant costs without clear benefits, disproportionately affecting smaller providers and reducing service availability in underserved areas.

• Recommendation: Eliminate the dual requirement of DBHDS licensing and accreditation. If accreditation is necessary, integrate it into DBHDS processes to avoid duplication and conflict.

CANS Assessments

• Chapter 4 Regulations and Shared CNA: Mental health service programs that adhere to Chapter 4 regulations can use a single 15-point Comprehensive Needs Assessment (CNA) across multiple services provided by the same organization. This flexibility has been essential for enhancing efficiency, improving access to services, reducing the administrative burden on providers, and minimizing redundant paperwork for clients and caregivers. In contrast, the CANS assessment may not be suitable for every program or client population, which could disrupt the streamlined processes that providers have established. Implementing CANS without allowing for alternative assessments could undermine the efficiency gains achieved under the current regulations.

• Recommendation: Retain the flexibility to use the same intake assessment, such as the CNA, across multiple programs under Chapter 4 regulations. Allow for alternatives to CANS in programs where it is not the best fit, ensuring assessments are person-centered to meet specific client needs and can be seamlessly shared between services. Preserve the existing structure that enables providers to coordinate services efficiently while minimizing duplication, reducing administrative strain, and lowering barriers to care.

Definition of LMHP

• Clarification Needed: The proposal does not clearly define whether LMHP-types, including residents (LMHP-R, LMHP-S, LMHP-RP), are eligible for supervisory roles.

• Recommendation: Provide a clear and inclusive definition of LMHPs, explicitly stating the eligibility of LMHP-types for specific responsibilities.

Caseload Limits

• Unnecessary Constraints: Imposing caseload limits is restrictive and fails to account for variations in provider capacity or client needs. This decision should be left to professional licensing boards that understand the nuances of clinical practice.

• Impact on Access: Mandating caseload limits could exacerbate workforce shortages by reducing the number of clients each provider can serve, further straining already limited resources.

• Recommendation: Remove caseload limits from the regulations and defer this decision to licensing boards, allowing flexibility based on agency needs and professional judgment.

Field Experience Requirement

• Restrictive for SMI/SED Cases: Requiring at least two years of field experience for cases involving Severe Mental Illness (SMI) or Serious Emotional Disturbance (SED) could limit workforce availability, particularly for newer providers or those serving underserved populations.

• Workforce Concerns: This requirement may disincentivize entry-level professionals from pursuing roles in CPST, reducing the overall talent pool and increasing recruitment challenges.

• Recommendation: Relax or phase in the two-year experience requirement to allow for a broader talent pool while ensuring adequate training and supervision for less experienced staff.

Training in EBPs

• Challenges of Implementation: While EBPs are crucial for quality care, their implementation is complicated by high staff turnover and training costs. Onboarding new staff represents a significant financial and administrative burden and maintaining fidelity to EBPs requires ongoing supervision and retraining, which further raises expenses.

• Impact of High Turnover: High turnover rates often diminish the benefits of training investments, as staff may leave before they can fully contribute. This not only undermines the effectiveness of training efforts but also creates a continuous cycle of resource expenditure on new hires.

• Recommendation: DMAS should explore options to mitigate these challenges, such as subsidized training programs, reimbursement adjustments, and retention incentives to offset training costs. Collaborative training initiatives and phased implementation timelines could assist providers in gradually building their EBP capacity while ensuring service continuity. These measures would support providers in integrating EBPs into the CPST model without compromising workforce stability or quality of care. DMAS should consider these challenges and explore options to support training costs, such as subsidized programs or reimbursement adjustments. 

Key Risks Without Revisions

• Some providers may exit the Medicaid system due to the combined financial and administrative burden of accreditation and other requirements. Which may lead to reduced access to care
• Workforce shortages, delays in assessments, and service interruptions due to unclear or restrictive regulations will harm clients needing timely care.
• General operational confusion due to inconsistent definitions and overlapping regulatory requirements will create administrative inefficiencies and compliance risks.