Thank you for the opportunity to provide feedback:

• Temporary variance expiration: Ending the staffing variance on June 30, 2029 assumes workforce recruitment and retention challenges will be resolved within three years. There is no evidence to support that assumption, and ongoing clinical workforce shortages are expected to persist.

• Supervision requirements: DMAS should align supervision requirements with DHP regulations by allowing LMHP-Types to supervise QMHPs and appropriately trained QMHPs to supervise QMHP-Ts and BHTs. LMHPs receiving board-approved supervision within their agency are qualified to supervise less-credentialed staff.

• LMHP workforce constraints: Requiring LMHP involvement in assessments, treatment planning, supervision, and oversight creates a dependency on an already limited workforce. Although LMHP caseloads are capped, sufficient licensed staff will still be needed to supervise teams, making LMHP availability the primary constraint on program capacity. This will likely reduce enrollment, increase waitlists, and contribute to clinician burnout.

• Clinical Director requirements: Requiring Clinical Directors to provide in-person services and travel when clinically necessary will limit providers serving large geographic or rural areas. Many Clinical Directors oversee multiple locations and increasingly rely on telehealth and other evidence-based consultation methods. Regulations should require timely access to clinical leadership rather than routine physical proximity. The section also blurs the distinction between the Clinical Director's oversight role and direct clinical service delivery.

• MAP training requirements: Requiring licensed clinicians to complete additional MAP training, despite already meeting licensure standards, creates significant financial and administrative burdens. MAP training can cost approximately $4,500 per clinician, in addition to months of training time. These costs, along with expanded documentation, quality assurance, and oversight requirements, are not reimbursed under the current Medicaid payment structure and may be unsustainable for community providers.

• Assessment and referral to standalone EBPs: Expecting CPST providers to assess eligibility for ACT, CSC, FFT, MST, and other specialized evidence-based practices is unrealistic. These programs require proprietary training and expertise beyond CPST qualifications. Mandatory documentation of referrals and ongoing attempts to access standalone EBPs increases administrative burden, may delay treatment, does not account for individual preferences, and could increase reliance on crisis and inpatient services.

• 24/7 LMHP availability: Requiring around-the-clock LMHP access and after-hours coverage will worsen workforce shortages and staff burnout unless accompanied by reimbursement. DMAS should clarify how this requirement complements existing crisis services, including 988 and Mobile Crisis, rather than duplicating them.

• Crisis authorization flexibility: Regulations should clearly state that providers will not be held responsible when authorized crisis units are exhausted. Alternatively, DMAS should establish an expedited process for adding provisional crisis units and require MCOs to honor those provisional authorizations.

• Administrative burden: The proposed requirements add substantial administrative work, including expanded documentation, ongoing MCO coordination, repeated efforts to locate standalone EBPs, documentation of those efforts, and ISP updates reflecting discharge and referral plans. These activities reduce time available for direct patient care.

• Individualized Service Plan (ISP) development: Removing ISP development from the treating clinician creates unnecessary barriers to care and weakens the therapeutic relationship. Individuals with trauma histories, paranoia, delusions, or trust challenges benefit from continuity with the clinician providing direct services. Requiring additional personnel to direct treatment increases complexity without improving care. LMHP review and signature should provide appropriate oversight while allowing the treating clinician to lead ISP development.