Caliber Virginia appreciates the opportunity to provide feedback on the proposed Coordinated Specialty Care (CSC) service as part of the Commonwealth’s Right Help, Right Now behavioral health redesign initiative. We support the expansion of evidence-based practices and recognize the importance of early intervention for individuals experiencing first-episode psychosis.

However, we have several concerns regarding the operational, workforce, and access-to-care implications of the proposed CSC model.

First, the staffing structure and caseload requirements present potential challenges for provider sustainability. The requirement for a multidisciplinary team, including a full-time Licensed Mental Health Professional (LMHP) Team Leader, combined with a 1:20 staffing ratio, may create barriers for many community-based providers. Recruitment and retention of licensed professionals remains a significant challenge across Virginia, and these requirements may limit the number of providers able to offer CSC services.

Second, the proposed model introduces substantial administrative and documentation requirements. These include standardized assessments such as the CANS-Lifetime tool, structured treatment planning timelines, mandatory weekly multidisciplinary team meetings, and detailed crisis planning and documentation requirements. While these elements support quality and accountability, they also significantly increase non-billable administrative responsibilities. Without corresponding reimbursement adjustments, providers may experience financial strain and reduced capacity for direct service delivery.

Third, we have concerns regarding service intensity and flexibility. The CSC model includes structured service authorization periods, unit limitations, and standardized service expectations. While consistency is important, these limitations may not adequately reflect the varying levels of acuity among individuals served. Providers must retain the ability to adjust intensity based on clinical need, particularly for individuals at higher risk of decompensation or hospitalization.

Additionally, the model places a strong emphasis on individual and family engagement. While this is a best practice, it is important to recognize that not all individuals have consistent or available natural supports. In underserved communities, barriers such as work schedules, transportation, and historical distrust of systems may limit family participation. The model should allow flexibility to ensure that individuals are not negatively impacted due to factors outside of their control.

Finally, we encourage consideration of the broader system impact. As currently structured, CSC may require significant investment in staffing, training, and compliance infrastructure. Smaller and community-based providers may face challenges meeting these requirements, which could reduce provider participation and limit access to care across certain regions.

Recommendations:

Caliber Virginia respectfully recommends the following:

• Allow flexibility in staffing models and consider alternatives to strict ratio requirements
• Align reimbursement with increased administrative and documentation expectations
• Provide flexibility in service intensity to reflect individual clinical need rather than standardized limits
• Offer phased implementation timelines to allow providers to build required teams and infrastructure
• Ensure the model accounts for variability in family and natural support engagement

Caliber Virginia remains committed to working collaboratively with DMAS to ensure that the implementation of Coordinated Specialty Care strengthens access to high-quality behavioral health services while remaining operationally sustainable for providers across the Commonwealth.

CSC Appendix

#1         #3.2 - Pick a name for the “CANS” and use it consistently

#2         Add “if appropriate” at the end of #2 & #7.a. & #8 (following “natural supports”

#3         Are reviews “every 90 days” or “quarterly” (pick one)

#4         How does any ISP “assure individual/family/caregiver involvement? [#8.a.iii]

#5         Is “psychotherapy” the only approach?  Is it required?

#6         #3.8.2.a. implies that there is a “team” sitting on a bench waiting for a call – the wording needs to reflect something less than that and if the preferred method is for the individual to use 988, then how will 988 connect with the appropriate staff?

#7         #3.8.#7 appears to contradict the second paragraph under 3.8

#8         #4.1 in paragraph #2 – “CSC teams shall operate from a single office location” – define exactly what that means – considering that some services can be provided via telehealth, and some in person where the individual lives/works; what tasks are to be done in a specific office?

#9         #4.1.1 -- “and attend at least 3 out of 4 weekly” a caveat needs to be added about being on “approved leave” – particularly in light of HB5/SB199 in the 2026 Session!

#10       #4.1.1 #1 – I do not believe there is a Virginia Code definition of “full-time” – and simplify the language (remove the repetitive “LMHP Team Leader”)

#11       Having the Psychiatric Provider attend weekly meetings will be both challenging and costly & for #4.1.1 #4 – define the “training” required

#12       Define the “Medicaid qualifications for CSC reimbursement” for each of the roles listed.

#13       How accessible is the training required, how expensive, how much time does it take, etc.

#14       #4.2.2 - Exclude from clinical supervision the psychiatric provider and include and explanation of who supervises the Team Leader.

#15       #4.5 change the parenthetical to be “conditional or full – annual or triennial)

#16       How is the “fidelity monitoring” done, what frequency, by whom?

#17       #5.1.1 – See comment # 1

#18       “All of the following criteria (a-c) and the listing is numeric

#19       #5.2.2.a – Medication is managed in accordance with an ISP, but in accordance with prescriber’s orders

#20       Section 6 #6.a.  This appears to eliminate the role and collaboration of the CSB/BHA – why?

#21       #7.2 can not be assessed without a rate sheet and better description of a “unit”

#22       #7.2.3 How will “minimum service” units be enforced?

#23       #9.4     H0031 is currently used in Intensive In-Home – as the intent is to have services “overlap” this code will need to be changed.

Under clinical supervision, in the draft provider manual, the following requirement is listed:

"The RPRS shall be supervised by a professional who has completed the DBHDS Peer Recovery Specialist Training".

Is this requirement indicating that the RPRS supervisor must also be a RPRS? If the RPRS supervisor is instead an LPC or LCSW, are you requiring that they receive the same 72-hour training as the RPRS or should they receive the DBHDS Peer Recovery Specialist (PRS) Supervisor training? 

The recent changes bring up concerns about the cost of on-call staff specific to this program, the reimbursement rate covering that, and not utilizing the array of crisis services and existing care coordination relationships.  Also, there would be concern around having dedicated staff for a caseload maximum of 10 and the costs associated with FTE requirement.  This would require a specific procedure and process for CSC service and medication. 

Recommend phased implementation, flexible supervision and training, clarified crisis roles, streamlined documentation, flexibility in service delivery modalities consistent with client choice, and reimbursement aligned with service expectations to ensure CPST services are sustainable and accessible.

 The proposed changes introduce significant operational, training, supervision, licensing, documentation, and crisis-response requirements that will require substantial system redesign. Based on this scope, the CSB estimates that full implementation would take 24–36 months after final guidance, including time to redesign staffing structures, train staff, integrate the CANS Level-of-Need tool into EHR systems, and align workflows with new service expectations. Implementation depends on finalized guidance, including the CANS scoring methodology and service definitions, prior to system build and training. Without phased implementation, providers may face reduced capacity and service disruptions.

 While CSC appropriately targets early psychosis in youth and young adults, it does not fully address youth-specific service needs. Additional guidance is needed on school coordination, family engagement, and planning for transition-age youth. Rigid service and duration requirements may not align with youth engagement patterns, developmental needs, or family preferences. Incorporating flexibility to support client and family choice is critical to maintaining engagement and effective care. Clarification is also recommended to ensure coordination with youth-serving systems, including schools and crisis response pathways.

 Service Intensity and Tier Structure: Although the revised draft moves away from explicit tier labeling, service intensity expectations tied to Level of Need still function as a tiered model. In particular, the expectation of 5–8 hours per week for moderate-intensity services remains operationally challenging and may not reflect clinical need, engagement patterns, or client choice. It is unclear whether these expectations are minimum weekly requirements or averages over time, creating potential audit and compliance risk. The CSB recommends clarifying expectations for service intensity, allowing flexibility based on clinical judgment, and ensuring that intensity ranges do not unintentionally reduce caseload capacity or limit access to care. The CSB also recommends narrowing the expected service intensity range or using an average rather than a fixed weekly expectation to better align with real-world service delivery and individual needs.

 Caseload and Workforce Capacity: The combined requirements for supervision, documentation, service intensity, in-person service expectations, and crisis response will reduce the number of individuals each staff member can effectively serve. Without explicit caseload guidance or adjusted expectations, providers may be forced to reduce caseloads, decreasing access to care and lengthening wait times for services. Workforce shortages further compound this issue, as recruitment and retention challenges already limit staffing capacity. Additional non-billable responsibilities will require more staffing to maintain current service levels.

 Financial and Operational Sustainability: Expanding supervision, documentation, training, crisis responsibilities, and expectations for in-person services introduces additional non-billable time that may not be reflected in reimbursement structures. This increases the risk that the cost of delivering CPST services will exceed reimbursement, potentially affecting provider participation and long-term sustainability.

 Crisis Response Requirements and System Risk: Requiring CPST providers to deliver in-person crisis response before referral introduces significant clinical and operational risk. Delaying or limiting access to Emergency Services or Mobile Crisis may create safety concerns and conflict with established crisis systems. CPST is not designed to serve as a primary crisis response service. The CSB recommends clarifying that providers may immediately refer to Emergency Services or Mobile Crisis when clinically indicated, while continuing to provide consultation and safety planning support.

 Training and Supervision: The proposed training requirements, including MAP credentialing and foundational skills training, may duplicate existing DBHDS requirements and delay onboarding. A phased approach over 24–36 months, along with recognition of equivalent training, is recommended. Supervision requirements should allow tele-supervision and team-based models to reduce administrative burden.

 CANS and EHR Integration: Reliance on the CANS tool introduces additional implementation complexity. Integration with EHR systems will require the development of building, testing, training, and reporting. Providers need finalized scoring methodologies, crosswalks, and reporting expectations before implementation to avoid rework and delays. The CSB recommends pilot testing the CANS tool and associated workflows with a representative group of providers before statewide implementation to identify operational challenges, ensure consistent application, and support a smoother rollout. The CSB also recommends evaluating whether both CANS and WHODAS are necessary in all cases or whether aligning or consolidating assessment requirements could reduce duplication and improve efficiency.

 Documentation and Audit Risk: Highly prescriptive documentation requirements increase the administrative burden and introduce audit and recoupment risk when they are interpreted inconsistently by providers and payers. Documentation should align with core Medicaid standards and focus on demonstrating medical necessity without unnecessary duplication.

 Service Delivery Modality and Access: Rigid expectations for in-person, one-to-one service delivery may not reflect the realities of community-based care or client preferences. Some individuals may not feel comfortable receiving services at home or may prefer alternative settings or modalities. These requirements may increase travel time, reduce scheduling flexibility, and create billing risk when individuals are unavailable, hospitalized, or decline in-person services. Limiting flexibility in service modality may also reduce engagement, particularly among youth and individuals with transportation or access barriers. Greater flexibility, including appropriate use of telehealth and alignment with client choice, is recommended to support engagement, continuity of care, and access.

System-Wide Impact: These changes are occurring alongside MHCM and Clubhouse redesign efforts. If implemented simultaneously without coordination, the cumulative effect may reduce overall provider capacity and create unintended barriers to access.

Several proposed requirements, particularly those related to encounter thresholds, in-person service expectations, billing constraints, and crisis response, do not align with CSC’s service delivery in fidelity to the evidence-based model. The CSB recommends aligning reimbursement structures with existing, fidelity-consistent service delivery approaches rather than introducing requirements that shift care toward compliance-driven models.

 Implementation Timeline and System Readiness: To maintain continuity of care and fidelity to the model, a 24–36-month phased implementation timeline is recommended. Without sufficient time, providers will be forced to adopt rigid structures that are not yet operationally feasible. Several proposed requirements may not be operationally feasible within existing community service delivery systems without reducing access, increasing workforce strain, or disrupting care.

 Service Intensity and Engagement Approach: Current CSC-aligned service delivery is flexible and engagement-driven, with service intensity varying by clinical need, illness phase, and individual engagement. This approach allows providers to meet individuals where they are and adjust services over time. The proposed model introduces fixed service thresholds, including minimum encounter expectations and required in-person, one-to-one contacts. These requirements do not align with the evidence-based model and may limit providers’ ability to adapt to individual needs. Aligning service expectations with flexible engagement models is critical to maintaining fidelity and effectiveness. Requirements tied to fixed service thresholds may unintentionally incentivize service delivery based on billing criteria rather than clinical need.

 Billing Structure and Service Delivery: The proposed billing model introduces encounter-based thresholds and modality requirements that may influence service delivery decisions. This represents a shift away from clinically driven care toward compliance with billing requirements. The CSB recommends designing reimbursement structures that support coordinated, team-based care without imposing rigid service thresholds that conflict with clinical care.

 Reimbursement Adequacy and Sustainability: If reimbursement structures do not reflect the full scope of CSC services, providers may be unable to sustain fidelity-aligned approaches. Ensuring that reimbursement covers both billable and non-billable components of care is essential for long-term sustainability.

 Client Choice and Engagement: Current service delivery emphasizes client choice, enabling individuals to access services through a range of modalities and settings, including telehealth, clinic-based care, and community-based services. This flexibility is essential for maintaining engagement, particularly among youth and young adults. The proposed emphasis on in-person and one-to-one service requirements may limit this flexibility and may not align with individual preferences. Aligning CSC requirements with existing person-centered approaches will support engagement and continuity of care.

Family Engagement and Cross-System Coordination: The proposed model acknowledges the components of family involvement and coordination with schools and employment systems, but it does not fully account for the operational demands of these activities. These activities require significant time, flexibility, and coordination across systems, and these demands should be reflected in service expectations and reimbursement structures.

 Age Span and Access Considerations: Rigid age criteria and limited guidance on transitions in the proposed model may restrict access or disrupt care. Aligning eligibility criteria is necessary to support continuity and clinical judgment.

 Access, Waitlists, and Time Sensitivity: Early psychosis intervention is time-sensitive, and delays in access may affect long-term outcomes. System capacity limitations may lead to waitlists for CSC services. The CSB recommends setting expectations for timely access and establishing interim service pathways, including case management, outpatient services, and crisis supports, to ensure individuals receive appropriate care while awaiting CSC enrollment.

 Crisis Response and System Coordination: CSC-aligned services currently coordinate with established crisis systems, including Emergency Services and Mobile Crisis. Providers support individuals during periods of instability and leverage these systems to respond to crises. The proposed requirement for CSC providers to deliver in-person crisis response before referral may conflict with the existing system design and introduce delays in accessing appropriate care. Aligning CSC with established crisis pathways will support safety and system efficiency.

 Assessment Tools and Clinical Decision-Making: Current service delivery relies on clinical judgment, supported by standardized assessment tools. Although measurement-based care is important, it is integrated into a broader clinical framework. The proposed reliance on a state-specific assessment tool as the primary determinant of eligibility and service intensity represents a shift away from evidence-based practice.

 Training, Supervision, and Administrative Burden: The proposed model introduces additional administrative and supervisory requirements that may increase the burden and reduce time available for direct care. Aligning these requirements with existing supervision structures will support sustainability and workforce capacity.

 Documentation and Administrative Requirements: Current documentation practices support care coordination, clinical decision-making, and compliance with Medicaid requirements without being overly prescriptive. More rigid documentation requirements may increase administrative burden and divert focus from service delivery. Aligning documentation expectations with existing Medicaid requirements will support efficient and effective care.

 System-Level Impact: Implementing CSC as a separate, highly structured model without alignment with existing systems may create fragmentation and strain provider capacity. Coordinating CSC implementation with current service delivery structures is essential to maintaining access and continuity of care.

The proposed model introduces requirements that do not align with evidence-based approaches and may shift service delivery toward a compliance-driven framework. Maintaining fidelity to established CSC models is essential to achieving expected clinical outcomes. The CSB recommends aligning CSC reimbursement and service expectations with fidelity-consistent practices to ensure that implementation supports, rather than disrupts, effective care delivery.

Section 7.2.3 requires individuals to receive no fewer than 24 consecutive months of service, raising a major concern because not all individuals need a full two years in the program, and this requirement may conflict with person-centered care; allowing discharge based on clinical readiness would better align with individualized treatment. Section 3.8 identifies the CSC provider as a primary crisis contact in the individual’s crisis plan, which is clinically appropriate but may conflict with real-world practices in which individuals access 988, emergency rooms, or CSB emergency services; this could be reframed to emphasize coordination rather than primary responsibility in all situations. Section 9.2 requires at least four in-person encounters per calendar month, which may not reflect client preferences, the effectiveness of telehealth, or the operational realities for CSBs serving rural or geographically dispersed populations; increased flexibility for telehealth when clinically appropriate would better support engagement and retention.

Thank you for providing us with the opportunity to make comments and to seek clarification of the proposed Coordinated Specialty Care policy changes. We do seek reconsideration for the proposed changes within Section 5. Medical Necessity Criteria, specifically regarding subsection 5.1.2. Age Requirements.  Expanding the eligibility criteria to include individuals up to 30 years old is expected to significantly increase the volume of referrals and service recipients. This change may challenge the capacity of established CSC teams to maintain the required staff-to-participant ratio of 1:20. Meeting this requirement would likely necessitate hiring and training additional CSC team staff, which could create operational strain and affect service quality. We recommend reassessing the proposed age expansion to ensure programming integrity, workforce sustainability, and continued compliance with staffing standards.