The following comments are submitted by the Virginia Coalition of Private Provider Associations (VCOPPA) in response to the Draft V4 CPST Provider Manual released for public comment on June 8, 2026.

We appreciate the significant work that has gone into this policy and acknowledge several improvements made between the prior draft and the current version. We submit these comments in the spirit of constructive engagement and with the goal of ensuring this service can be operationalized effectively by private providers seeking to participate in Virginia’s Medicaid behavioral health system on behalf of the Medicaid members in need of these critical services. We respectfully request DMAS consider each issue before finalizing the policy.

1. Definitions: Evidence-Based Principles, Modular Activities, and Evidence-Based Policies  —  Policy Manual Section 3

1.1 Key terms remain undefined for practical implementation

Section 3 requires all CPST providers to incorporate evidence-based principles, practices, protocols, and policies into treatment planning and service delivery, and to document in their SOPs which elements they are incorporating and how staff are trained. While V4 reformatted these categories — an improvement — the definitions remain functionally unclear. Specifically:

• Evidence-Based Principles: Defined as “modular alternatives drawn from supported protocols, applied flexibly and dynamically.” It is unclear what “modular” means clinically, what distinguishes a module from a full protocol, and what “dynamically applied” requires in practice. Without clearer guidance, providers cannot determine whether their approach meets this requirement or how to document compliance.

• Evidence-Based Policies: Described only as “mandates, differential reimbursement, or development of core competencies.” No examples are provided in any sub-category. It is unclear whether this refers to DMAS’s own policies, the provider’s internal policies, or both. Without examples, meaningful SOP compliance is not possible.

The V4 requirement that providers “clearly identify” which EBP elements they are incorporating cannot be met if the underlying categories remain poorly defined.

1.2 Requested clarifications and recommendations

• Please provide plain-language definitions of “evidence-based principles” and “modular activities” with two or three concrete clinical examples of each.
• Please clarify what is meant by “evidence-based policies” and provide examples in each of the three sub-categories (mandates, differential reimbursement, core competencies).
• Please provide a model SOP excerpt demonstrating what DMAS expects, so providers have a concrete compliance target.

2. EBP Coordination Through Care Coordination — Youth Services  —  Policy Manual Section 3.2; Section 5

2.1 Provider obligations remain unclear during active services

Section 3.2 of Draft V4 was reorganized into three subsections and now includes specific documentation requirements when a standalone EBP is unavailable at the time of authorization — an improvement over Draft V3. However, a separate and ongoing obligation relating to youth service delivery during active CPST services remains unclear.

The policy states that for youth presenting with a disorder that aligns with an EBP that cannot be provided directly through CPST, providers shall ensure EBP options are coordinated through the care coordination component. We acknowledge that Section 3.2.3 addresses the steps a provider must take when seeking authorization in lieu of a standalone EBP — documenting the barrier, notifying the MCO, recording referral efforts, and including a transition plan in the ISP. However, Section 3.2.3 addresses the authorization scenario only. The care coordination language creates a continuing duty throughout the service period, and it is not clear what active steps are required of the provider once services are underway. Specifically:

• What actions constitute “ensuring EBP options are coordinated through care coordination” during active services — referral, documentation, ongoing monitoring, or all of these?
• If a youth is on a waitlist for a required EBP, what must the provider do within CPST in the meantime? Is there a requirement to document waitlist status at specific intervals? Is there a timeline by which EBP access must be achieved before authorization is affected?
• What distinguishes an EBP that “cannot be provided through CPST” from one that is unavailable in the agency’s array or within reasonable geographic access for the youth and family?
• How does this ongoing obligation interact with the admission-level documentation requirements in Section 3.2.3?

2.2 Requested clarifications and recommendations

• Please provide explicit language on what a provider must do when a youth needs an EBP unavailable through CPST, including documentation, referral, and monitoring expectations during active services — not only at admission.
• Please distinguish clearly between the admission-level requirements in Section 3.2.3 and any ongoing care coordination obligations during active services.
• Please clarify whether EBP referral and waitlist tracking are billable under the care coordination component.

3. Training Requirements and Financial Burden  —  Policy Manual Section 3; Attachment 1, Sections 1–2

3.1 Training volume is not proportionate to provider rate

CPST is a new service type with substantial training requirements. Depending on credential type, providers must ensure staff complete: the Foundational Skills Curriculum (FSC); MAP credentialing for all youth-serving LMHPs and LMHP-types; CANS Lifetime certification for all assessment staff; the CPST Intermediate Skills (IS) Curriculum for QMHPs, QMHP-Ts, and BHTs (added in V4); and documented EBP training for all adult-track LMHPs and LMHP-types. This is a significant, largely unfunded investment. Draft V4 does not indicate whether training costs were considered in the rate study, whether any training is reimbursable, or whether accommodation exists for providers who must train staff before rendering billable services.

3.2 Disproportionate burden on smaller providers

This training burden risks creating a landscape where only large, well-resourced agencies can enter this market. Smaller providers — including group practices and community-based organizations — may be unable to absorb training costs before generating revenue, threatening network sufficiency particularly in rural and underserved areas.

3.3 Requested clarifications and recommendations

• Please confirm whether MAP, FSC, IS Curriculum, and EBP training costs were included in the rate study.
• Please specify whether any training costs are reimbursable through the service rate or a separate mechanism.
• Please consider reducing training requirements to a more feasible level. We understand the goal of a well-trained workforce and high-quality service delivery.
• Please consider a phased onboarding period allowing providers to begin service delivery while completing training requirements.
• Please include language on how DMAS intends to support provider network sufficiency.

4. MAP Credentialing Timeline  —  Attachment 1, Section 1

4.1 Eighteen-month timeline creates operational risk

Attachment 1, Section 1 requires all youth-serving LMHPs and LMHP-types to achieve MAP Credentialed Therapist status within 18 months of enrollment or hire, and requires at least one MAP-credentialed therapist on staff at all times. This creates significant operational challenges:

• MAP credentialing requires the PracticeWise Direct Services Curriculum, six months of PracticeWise consultation, and a portfolio review. PracticeWise is the only named pathway, so providers have no alternative route. The six-month consultation alone consumes one-third of the 18-month window, and PracticeWise availability and portfolio timelines are outside the provider’s control.
• If an agency’s only MAP-credentialed LMHP departs, the agency is immediately out of compliance with no grace period specified.
• No provision exists for PracticeWise delays or capacity constraints beyond the provider’s control.

4.2 Requested clarifications and recommendations

• Please clarify what process applies when an agency’s sole MAP-credentialed therapist separates and how long the agency has before service delivery must cease.
• Please allow a grace period so providers do not lose the ability to deliver services when a credentialed therapist vacates.
• Please specify whether DMAS will extend the 18-month timeline when PracticeWise delays are documented, and what documentation is required to request an extension.
• Please clarify whether “in the process of becoming a MAP Credentialed Therapist” constitutes billing compliance during the 18-month window and what documentation satisfies this for auditors.

5. Supervision Requirements and Personnel File Documentation  —  Attachment 1, Sections 3–3.4

5.1 Supervision requirements are overly prescriptive

Attachment 1, Section 3 requires weekly supervision contact for non-licensed staff, with monthly minimums of two hours including at least one hour of individual supervision. While robust supervision is essential, prescribing the exact split between individual and group formats within a monthly hour minimum does not allow for clinical discretion and does not reflect how supervision is typically structured in community-based settings. Supervision needs vary based on supervisee experience, caseload complexity, and the Clinical Director’s professional judgment.

5.2 HR file documentation requirement is not operationally feasible

Attachment 1, Section 3.4 requires DHP board-approved supervision documentation to be maintained in the employee’s employment (HR) record. This requirement is unworkable: personnel files are legally protected records. Clinical supervisors — including the CPST Clinical Director — do not have authorized access to an employee’s HR file, nor should they. These files are controlled exclusively by HR departments and subject to confidentiality protections. A clinical supervisor cannot add documentation to a protected personnel record, and an HR department cannot reasonably be expected to accept, organize, and maintain ongoing clinical supervision logs as part of its personnel file function.

This creates a difficult compliance situation for providers:

• Clinical supervisors must route documentation through HR after every session, adding administrative burden to both clinical and HR staff with no clinical benefit.
• During a DMAS or DBHDS audit, reviewers would need access to protected HR files to verify clinical compliance — raising privacy concerns inconsistent with how clinical documentation reviews are typically conducted.
• If supervisors lack HR file access — standard in most agencies — there is no mechanism by which they could fulfill this requirement at all.

Supervision documentation is clinical and compliance-related in nature. It belongs in a location that clinical and compliance staff can access, maintain, and produce on request — such as a designated compliance file, a supervision log maintained by the program, or a staff credentialing file separate from the protected HR record. The policy also does not specify what form “official documentation” must take or how frequently it must be updated.

5.3 Requested clarifications and recommendations

• Please replace “employment records” with “designated staff compliance or credentialing file, available upon request” to preserve accountability without requiring access to legally protected HR records.
• Please broaden supervision frequency requirements to set minimums without prescribing individual/group format splits, leaving that to the Clinical Director’s judgment.
• Please clarify what constitutes “official documentation” of DHP board-approved supervision for audit purposes.

6. Caregiver Non-Participation in Tier 2 Youth Services  —  Policy Manual Section 8.4

6.1 Provider obligations during active services remain unaddressed

Section 8.4 requires Tier 2 youth caregivers to participate in at least one hour of CPST weekly, attend quarterly treatment planning meetings, and be available for crisis consultation within two hours during business days. We acknowledge the reduction from two to one hour weekly. However, the policy does not address what providers must do when caregivers consistently fail to meet these requirements during an active authorization period. The policy states that if a caregiver is not engaged following initial authorization, the ISP must be updated before reauthorization — addressing only the reauthorization scenario. Providers need guidance on what happens during the active authorization period:

• Whether services must be reduced or discontinued when a caregiver does not participate at the required level.
• Whether documented provider engagement efforts are sufficient to continue services when caregivers are unable or unwilling to participate.
• What obligation exists when a caregiver cannot meet the two-hour crisis availability window due to work schedules, transportation, disability, or other factors outside their control.

Youth in Tier 2 have the greatest level of need and are most likely to have caregivers facing participation barriers. A policy that allows service discontinuation based on caregiver behavior without clinical discretion risks harming the youth it is designed to serve.

6.2 Requested clarifications and recommendations

• Please clarify that documented provider engagement efforts — reflected in the ISP — are sufficient to continue services during an active authorization when caregivers do not meet participation minimums.
• Please clarify that the two-hour crisis availability window is a target, not a hard requirement, with documented provider efforts constituting compliance.
• Please address how providers should handle and document caregiver non-participation attributable to circumstances outside caregiver control.

7. Restorative Life Skills Training — Billing Modifier Clarification  —  Policy Manual Section 12

7.1 All staff bill at the QMHP modifier level for this component

Section 12 billing tables specify that for Restorative Life Skills Training, “all professional levels of staff shall bill” using the HN modifier — the modifier associated with QMHP and QMHP-T staff — even when the service is delivered by an LMHP or LMHP-type. This means an LMHP delivering this service bills identically to a QMHP and is reimbursed at the same rate, which is inconsistent with every other clinical component in the billing table where LMHPs use the HO modifier at a higher rate.

If this is intentional — a flat-rate component regardless of credential — it should be explicitly stated so providers can plan accordingly. If unintentional, the table should be corrected. Restorative Life Skills Training is a high-volume component; billing LMHPs at the QMHP rate has direct revenue implications that affect provider financial viability and creates a disincentive to assign licensed clinicians to a service that may clinically warrant their involvement.

7.2 Requested clarifications and recommendations

• Please confirm whether it is DMAS’s intent for all staff levels, including LMHPs, to bill Restorative Life Skills Training with the HN modifier.
• If unintentional, please correct the billing table to reflect the HO modifier for LMHP and LMHP-type staff, consistent with all other service components.

We appreciate the opportunity to submit these comments and strongly support expanding access to intensive community-based mental health services for Virginians with serious mental illness and serious emotional disturbance. These comments are intended to ensure the policy enables private providers to participate effectively, sustainably, and in compliance with clear and implementable standards. We respectfully request written responses to each comment and an opportunity to engage further with DMAS staff prior to finalization.

Nina Marino, Government Affairs Chair

Virginia Coalition of Private Provider Associations (VCOPPA)