Comments regarding proposed case management requirement changes

Face-to-Face Contact Requirements - Increased Frequency (90-Day to Twice-Per-Quarter):

The proposed increase from one face-to-face contact every 90 days to two required visits per quarter significantly increases burden on providers and individuals, without clear evidence that increased frequency improves outcomes for all individuals served.

Minimum contact requirements as written may not adequately address the needs of individuals with higher acuity, while simultaneously being overly prescriptive for individuals who are stable and engaged in care.

Overly rigid frequency requirements risk disengagement and may ultimately drive greater utilization of crisis and inpatient services.

Location Requirements (Community Settings)

Requiring visits to occur in community settings (e.g., parks, workplaces, public locations) may be clinically inappropriate, unwanted, or unsafe for many individuals — particularly those with trauma histories, privacy concerns, or stigma-related fears about being seen with behavioral health staff.

Community visits in workplace settings are especially problematic unless the individual is in a supported employment context; such visits risk unwanted disclosure of an individual’s behavioral health status to colleagues or supervisors.

For individuals experiencing homelessness, living in shared housing, or facing safety risks, the CSB office may be the most private and appropriate setting. A blanket prohibition on office-based visits directly contradicts person-centered care principles.

Community visits are not always feasible due to staff safety concerns in certain neighborhoods or settings.

A prescriptive visit location mandate undermines individualized care and clinical judgment. Providers request that the policy allow visits to occur at the CSB when clinically or practically appropriate.

Handling of Refusals

The changes do not specify how a provider should document or respond when an individual declines a required visit. Providers need explicit guidance on whether and how refusals impact service eligibility and provider compliance standing.

Absent clear refusal policies, rigid requirements risk triggering unintended service disruptions for individuals who are otherwise actively engaged in their care.

Caseload Cap and Acuity Considerations (Section 2.5.3)

The flat caseload cap of 45 individuals per full-time case manager does not account for differences in acuity. Some individuals require substantially more intensive engagement than others; a uniform number-based cap may result in case managers who are either under- or over-stretched in terms of actual workload.

A tiered or acuity-based caseload model would more accurately reflect individual needs and allow supervisors to distribute workload based on complexity rather than raw case counts.

Tracking compliance with the 45-person cap and developing corrective plans when thresholds are exceeded must be done at the individual case manager level. This is a manual, labor-intensive process that diverts supervisor time away from clinical oversight and staff support.

One-Business-Day Registration Requirement is an administrative and documentation burden

The requirement to submit new case management registrations within one business day is operationally infeasible in many situations, particularly when staff responsible for submissions are on leave or when coverage is unavailable.

Lack of Standardized MCO Registration Processes

There is no standardized registration process across managed care organizations. Providers must navigate multiple, incompatible systems (portal submissions, paper forms, gold card processes, etc.) depending on the payer. These inconsistencies compound the burden of the one-business-day deadline and increase the risk of inadvertent non-compliance.

Increased Documentation Expectations

The updated requirements significantly increases documentation requirements, including detailed assessments, individualized service plans, quarterly reviews, and documentation of every service contact. Although these serve accountability goals, they substantially reduce the time case managers can spend in direct engagement with individuals.

Reimbursement rates are not aligned with the increased administrative burden, creating financial sustainability concerns for providers.

Service Definition and Scope

The revised definition of case management moves the service further from direct intervention and more firmly into a pure coordination structure. Many individuals currently rely on case management for hands-on engagement, problem-solving, and navigation support — functions that extend beyond coordination. Restricting the service to coordination may leave critical care gaps.

The requirements should retain flexibility to allow direct engagement activities when clinically appropriate, rather than being limited solely to coordination functions.

Individual Support Plan (ISP) Policy Concerns

 The requirement that providers coordinate ISP reviews with the case manager every three calendar months is ambiguously worded. It is unclear whether this coordination responsibility falls on the provider or the case manager; the policy should explicitly assign this responsibility.

The requirement that the case manager’s ISP reflect updates in the amount, type, or frequency of services rendered raises a question of appropriate document ownership: should such service-level changes be documented in the counselor’s or provider’s ISP rather than the case manager’s ISP?

Continued Stay Criteria (Section 2.4.2)

The continued stay criteria are focused exclusively on demonstrable progress toward accessing services and symptom/functional improvement. The criteria do not address the need for stability as an independent justification for continued services. Many individuals need ongoing case management specifically to maintain stability rather than achieve new gains. 

Family/Caregiver Inclusion Requirements (Section 2.3.3)

Sections 2.3.3 #3 and #6b require the inclusion of family members or caregivers in service planning meetings. Providers request that this language be removed or made discretionary to preserve the individual’s right to choose who participates in their care planning. Mandatory family/caregiver inclusion may conflict with individual autonomy, privacy rights, and the preferences of individuals whose family relationships are strained or harmful.

Definition Inconsistencies

The definitions of Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), and “At Risk” in the proposed MHCM policy differ slightly from the definitions used in other Virginia behavioral health regulations. Inconsistent definitions across regulatory frameworks create confusion and compliance challenges for providers delivering services across multiple programs.

Equity and Access to Care

A model that emphasizes system coordination over direct engagement may be insufficient for individuals in underserved and minority communities who face compounding barriers such as transportation limitations, employment constraints, and limited informal support systems. These individuals often need more intensive direct engagement, not less.

The policy should include explicit safeguards to ensure that the redesign does not inadvertently reduce access or worsen outcomes for historically underserved populations.

Provider Eligibility Restrictions

Restricting case management service provision to Community Services Boards or other specified entities may limit provider participation and reduce access to services, particularly in regions where CSB capacity is insufficient to meet demand.

Expanding provider eligibility or encouraging collaborative arrangements with community-based providers would support broader geographic access and service continuity across the Commonwealth.