We respectfully request that Virginia Department of Medical Assistance Services reconsider the proposed changes to face-to-face service requirements and administrative timelines for case management services.

The increase from one face-to-face contact every 90 days to two required visits per quarter, along with specifying location such as community settings, presents significant challenges for the populations we serve. DMAS case management providers often work with individuals who have complex behavioral health needs, trauma histories, and heightened concerns about privacy and stigma.

Many individuals express clear preferences regarding how and where they engage in services. Some may only be willing to meet in limited settings, while others may decline home visits or feel uncomfortable being seen with staff in public environments such as parks, workplaces, or other community locations. A more prescriptive approach to visit frequency and location may unintentionally create barriers to engagement rather than improve service delivery.

Additionally, further clarification is needed regarding how refusals will be addressed. If an individual declines a required office or community-based visit, how will this impact service eligibility and provider compliance? There is concern that rigid requirements could result in unintended service disruptions for individuals who are otherwise actively engaged in care.

We also request reconsideration of the requirement to submit new case management registrations within one business day. While we understand the importance of timely authorization, this timeframe may not be operationally feasible in all circumstances, particularly when staff responsible for submissions are unavailable due to leave or other coverage limitations.

Compounding this challenge is the lack of a standardized registration process across managed care organizations. Providers must navigate multiple systems, including portal-based submissions, registration forms, then we have gold card , depending on the payer. These inconsistencies create administrative burden and increase the risk of delays despite providers’ best efforts to remain compliant.

We encourage DMAS to consider more flexible, person-centered guidelines that allow providers to meet individuals where they are, both clinically and practically. Flexibility in visit frequency, location, and administrative timelines would better support engagement, continuity of care, and overall service effectiveness while still aligning with DMAS’s goals for quality and accountability.

Caliber Virginia appreciates the opportunity to provide feedback on the proposed updates to Mental Health Case Management (MHCM) as part of the Commonwealth’s Right Help, Right Now behavioral health redesign initiative.

We support efforts to improve coordination of care and enhance system efficiency. However, we have significant concerns regarding the proposed structure of MHCM and its potential impact on service delivery, workforce stability, and access to care across the Commonwealth.

First, the revised definition of case management shifts the service further away from direct intervention and reinforces its role as a coordination-based model. While care coordination is an important component of the behavioral health system, many individuals currently rely on case management services that include elements of hands-on support, engagement, and problem-solving. Limiting the service to coordination functions may create gaps in care, particularly for individuals who require more direct assistance navigating systems and maintaining stability.

Second, the proposed engagement and contact requirements may reduce service intensity. The minimum requirements for contact, including limited face-to-face interactions over extended periods, may not be sufficient for individuals with higher levels of need. Many individuals served through case management require frequent engagement to remain connected to services and avoid deterioration. Reduced contact expectations may increase the risk of disengagement and ultimately lead to greater utilization of crisis and inpatient services.

Third, the transition to a flat caseload cap model presents operational concerns. While the cap of 45 individuals per full-time case manager provides standardization, it does not account for differences in acuity among individuals served. A uniform caseload limit may inadvertently reduce flexibility for providers to appropriately distribute workload based on complexity and need.

Additionally, the updated requirements introduce increased documentation expectations, including detailed assessments, individualized service plans, quarterly reviews, and ongoing monitoring and documentation of all service-related contacts. While these requirements support accountability, they also increase administrative burden and may reduce the time case managers are able to spend in direct engagement with individuals.

We also have concerns regarding the potential impact on underserved and minority communities. Individuals in these communities often face additional barriers to accessing care, including transportation, employment constraints, and limited support systems. A model that relies heavily on coordination rather than direct engagement may not adequately meet the needs of these populations and may unintentionally contribute to reduced access and poorer outcomes.

Finally, we note that limiting case management providers to specific entities, such as Community Services Boards, may restrict provider participation and reduce access to care in certain regions. Expanding provider eligibility or allowing for greater collaboration with community-based providers may help ensure broader access and continuity of care.

Recommendations:

Caliber Virginia respectfully recommends the following:

• Maintain flexibility within the case management model to allow for direct engagement activities when clinically appropriate
• Consider a tiered or acuity-based caseload model rather than a flat cap to better reflect individual needs
• Increase minimum contact expectations for individuals with higher levels of need
• Align reimbursement with administrative and documentation requirements to support provider sustainability
• Expand or clarify provider eligibility to ensure adequate access to services across all regions
• Incorporate safeguards to ensure underserved and minority populations continue to receive appropriate levels of support

Caliber Virginia remains committed to working collaboratively with DMAS to ensure that the redesign of Mental Health Case Management strengthens coordination while preserving access, engagement, and outcomes for individuals across the Commonwealth.

Thank you for allowing us the opportunity to offer recommendations to this policy. We have reviewed all policy changes and have the following recommendations.

2.4.2 Continued Stay Criteria

The policy states documentation of the individual's participation and engagement in MHCM includes at a minimum of progress toward accessing needed services is documented at the expected pace given the presence of medical/physical conditions, stressors, and level of support, as evidenced by engaging in improving severity of symptoms and functional impairment, and continued progress is expected. There is no mention of the need for stability of individuals. Recommend you consider adding or provide clarification on existing language to include the need for stability of the individual.

2.5.3 Staff Caseload Requirements

The policy states the caseload of a full-time case manager shall not consistently exceed 45 individuals as evidenced by the average number of individuals on the case managers' caseload over the most recent six months. The maximum caseload of a part-time case manager shall be proportioned to the average hours worked. Recommend adding language that the number of individuals assigned to a case manager should be based on the level of care an individual requires. There are some individuals that require a higher level of care and that should be taken into consideration when assigning caseloads to case managers, not just a specific number of cases.

Thank you for the opportunity to provide public comment on the updated MH Case Management draft policy.

We would like to thank DMAS for addressing our concerns with the original caseload matrix requirements.  Having a flat maximum caseload reduces the administrative burden to manage caseloads and assists in building in the flexibility to provide continuous care as an individual’s needs change

We ask that DMAS consider the following further edits to the policy:

2.3.3 Service/Supports Planning and Monitoring

#3.  Please reconsider the requirement to include family/caregiver from this line to maintain the choice of the individual in who attends their meetings.

#6.b.  Please remove “and family/caregiver” from this sentence as well.

2.4.2 Continued Stay Criteria

Please consider addressing the need for stability of the individual by adding wording that allows for continued services to support stability.

Thank you again for the opportunity to provide public comment.

The updated requirements hold some continued concerns:

• SMI/SED/At Risk definitions are slightly different than other regs
• Community face-to-face including workplace--this may be inappropriate and unwanted due to privacy concerns, unless in a supported employment situation.
• providers must coordinate reviews of ISP with the CM every 3 calendar months--the wording is confusing.  Should this be the responsibility of the provider or the CM? 
• ISP updates with changes in amount, type, or frequency of services rendered--should this be in the counselor's/provider's ISP rather than the CM ISP? 
• We support changes in regards to tiers and caseloads; however, tracking when caseloads go over 45 and addressing with a plan to reduce would have to be per CM, which is manual and complex, taking away supervision time. 

Regarding the requirement that services must be conducted outside of the CSB location, while community-based services are often valuable, this standard does not reflect the diverse needs, preferences, and safety considerations of individuals served. For some individuals—particularly those experiencing homelessness, shared living arrangements, or safety concerns, the CSB site may be the most private and secure setting. Others may not feel comfortable receiving services in their home, community, or workplace due to privacy, stigmatization, or appropriateness. Additionally, community visits are not always feasible due to staff safety concerns. A blanket requirement limits flexibility and contradicts a person-centered approach, which should prioritize individual preference, clinical judgment, privacy, and safety. Allowing services to take place at the CSB when appropriate would better support individualized, effective care. 

Alternate language for consideration:

At a minimum, the case manager must offer to visit the individual and family/caregiver once every 90 calendar days in a natural community-based setting. The response and any barriers will be documented in the record.

2.3.1. Reconsider the requirement that services must be conducted outside of the CSB location. Community-based services are valuable, but this does not address diverse needs, barriers, and preferences of clients. Allowing services at the CSB, when appropriate, would better support individualized care.

2.4.2. The need for stability for individuals is not being addressed in the continued stay criteria. Consider providing clarification on exiting language regarding creating an environment for stability.

2.5.3. Clients' needs vary. At times, clients may have more complex needs requiring more interventions. Flexibility is essential to providing effective MHCM and managing caseloads. 

Thank you for providing the opportunity to comment on the proposed changes. 

6.1 Service Authorization

The proposed regulation states providers must submit a registration to the individual's MCO or FFS service authorization contractor within one business day of admission.  Recommend reconsideration of the requirement for submission within one business day. While we understand the importance of timely authorization, this timeframe may not be operationally feasible in all circumstances.

2.3.1 Case Management Engagement

The proposed regulation states at least one face-to-face contact shall occur in-person at a natural community-based setting outside of the CSB location (e.g., the individual's home, workplace, or other community value. Recommend reconsideration "at a minimum, the case manager must offer to visit the individual once every 90 calendar days in a natural community-based setting. The response from the individual and any barriers shall be documented within the record to reflect the preference of the individual. 

2.4.2 Continued Stay Criteria

The stability of the individual is not being addressed in the continued stay criteria. Recommend reconsideration to add or provide clarification on existing language to include the need for stability of the individual. 

2.5.3 Staff Caseload Requirements

The proposed regulation states the caseload of a full-time case manage shall not consistently exceed 45 individuals as evidenced by the average number of individuals on the case manager's caseload over the most recent six months. Recommend adding language that the number of individuals assigned to a case manger shall be based on the level of care an individual requires as individual's needs may vary, flexibility is essential to managing caseloads and tracking & addressing when caseloads go over 45 will be an administrative burden that will take away from supervision time. 

2.3.3 Service/Supports Planning and Monitoring

Providers must coordinate reviews of the ISP with the case manager every three calendar months.  Recommend clarifying the requirement either provider or CM. 

Revise the ISP whenever the amount, type, or frequency of services rendered by the ISP providers change. Recommend reconsideration as the provider requirement and not the CM requirement. 

2.3.1 Case Management Engagement     Reconsideration of the Requirement that services must be conducted outside of the CSB location. This standard does not reflect the diverse needs, preferences, and safety considerations of individuals served.

For some individuals—particularly those experiencing homelessness, shared living arrangements, or safety concerns, the CSB site may be the most private and secure setting. Others may not feel comfortable receiving services in their home, community, or workplace due to privacy, stigmatization, or appropriateness. Additionally, community visits are not always feasible due to staff safety concerns.

A blanket requirement limits flexibility and contradicts a person-centered approach, which should prioritize individual preference, clinical judgment, privacy, and safety. Allowing services to take place at the CSB when appropriate would better support individualized, effective care.

2.4.2 Continued Stay Criteria      The need for stability is not addressed for individuals. Case management is creating an environment for stability.

2.5.3 Staff Caseload Requirements          Flexibility is essential to providing effective case management and managing caseloads.

The CSB recommends maintaining flexibility, preserving the stand-alone MHCM, supporting workforce capacity, and ensuring alignment with crisis systems.

The CSB recommends a phased 12–24-month implementation timeline because successful implementation will require policy updates, staff training, EHR modifications, and coordination across multiple service systems. Without sufficient time, providers may face operational disruptions and reduced capacity to serve individuals. Given concurrent redesign across multiple behavioral health services, a phased timeline is necessary to avoid system strain and ensure continuity of care.

 Client Choice and Person-Centered Care: The CSB emphasizes the importance of preserving client choice in service delivery. Individuals should have the flexibility to choose the location, modality, and level of engagement for case management services based on their preferences and clinical needs. The CSB supports maintaining the current MHCM contact framework with modality flexibility based on client preference and clinical need. Some individuals may be uncomfortable receiving services at home or in public settings, while others may prefer telehealth or less frequent contact. Requiring that the service location be explicitly aligned with the ISP may add an additional documentation burden and limit flexibility in selecting appropriate meeting locations.

 Policies that mandate specific service modalities or locations may unintentionally override client choice, reduce engagement, and create barriers to care. This is especially important for youth and individuals with privacy, cultural, or stigma-related concerns. The CSB recommends that service requirements support, rather than restrict, person-centered care and allow providers to tailor service delivery to individual preferences. The CSB also recommends strengthening family-centered language and expectations across MHCM activities for youth and children.

 Preservation of Stand-Alone MHCM: MHCM remains a foundational service that supports individuals with complex needs through care coordination, system navigation, and continuity of care. However, the draft does not fully address the unique needs of youth, which require greater coordination with families, schools, and community systems, as well as more flexible engagement strategies. The lack of youth-specific guidance on caseload expectations, family involvement, and school coordination may increase administrative burden and reduce staff capacity.

Additional clarification is recommended to support effective coordination and continuity of care for youth and transition-age populations. Stand-alone MHCM should remain a viable service when an individual’s primary need is coordination rather than rehabilitation, because limiting MHCM risks creating service gaps.

 Caseload and Workforce Risk: High caseload expectations, combined with increased documentation, coordination, and engagement requirements, already strain workforce capacity. Although the draft does not establish a formal caseload requirement or cap, operational benchmarks such as 45 individuals per case manager may be infeasible under expanded expectations. As non-billable responsibilities increase, providers may need to reduce caseload sizes to maintain compliance, which can decrease access to care and lengthen wait times for services. This reduction in effective caseload capacity may affect access to services across the system.

 The CSB also notes that the draft does not address youth-specific caseload considerations. Youth case management requires greater coordination with families, schools, and community systems, resulting in higher time demands per individual. Without recognizing these differences, staff capacity may be further reduced, limiting access to services for youth and families.

 Financial Sustainability: Increased expectations for documentation and coordination create additional non-billable workload that may not be reflected in reimbursement structures, thereby risking long-term service sustainability.

Coordination with Other Services: The CSB recommends removing or revising the limitation to two pre-discharge periods within a 12-month period, as this restriction does not align with the needs of individuals experiencing multiple or prolonged hospitalizations. These limitations may reduce support for safe discharge planning and increase the risk of delayed discharges, service gaps, and hospital readmissions.

 The CSB also recommends including MHCM guidance tailored to youth that outlines coordination expectations with systems such as schools (IEPs), juvenile justice, DFS/foster care, wraparound supports, and family engagement. Additional guidance is needed for transition-age youth to ensure continuity of care as they move from youth to adult systems.

 The draft does not establish a formal tiered model for MHCM services. If acuity-based or tiered case management approaches are intended, additional guidance will be needed to define criteria, expectations, and system support to ensure consistent application across providers. Without clear guidance, tiering may be applied inconsistently, leading to variability in service delivery and documentation expectations.

 Crisis System Alignment: Policies should reinforce, not disrupt, the use of Emergency Services and Mobile Crisis systems. Case managers must retain the ability to refer immediately to appropriate crisis services without delay or conflicting service requirements.

 EHR and Administrative Burden: Changes will require updates to EHR workflows, including documentation requirements, potential tier classification, and service location tracking. Increased documentation expectations may also create audit and recoupment risk if applied inconsistently across providers and payers. Sufficient implementation time is necessary to support system build, training, and consistent application.

 System-Level Impact: Simultaneous redesign across services increases the risk of system strain, reduced provider participation, and decreases access to care if not implemented in a coordinated, phased manner.

 Without these adjustments, the combined effect of these requirements may reduce provider capacity, limit access to care, and create unintended barriers for individuals and families seeking services.

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.

Thank you for providing us with the opportunity to make comments and to seek clarification of the proposed Mental Health Case Management changes.

I am submitting this comment to provide feedback on the proposed draft update. While I support efforts to improve service quality, I am concerned that several of the proposed changes may create unintended barriers to care, reduce access to services, and negatively impact both individuals and the case management workforce.

1. Face-to-Face Contact Requirements

• Requiring two face-to-face contacts every 90 days, including one in a community setting, may not be feasible for all individuals.
• Some individuals struggle with public outings, prefer staff not in their homes, value privacy, or have behavioral/safety concerns.
• Mandating these contacts for all could reduce access to needed services.

2. Documentation Expectations

• Increased documentation requirements may create administrative burden.
• Could reduce time for meaningful engagement and individualized support.
• May contribute to staff burnout and turnover.

3. Client and Family Involvement

• Mandating family participation for every review may be impractical.
• Some individuals prefer privacy or lack family support; strained dynamics may exist.
• Could compromise autonomy and participation.

4. Linkage to Resources

• Some individuals only require monthly monitoring and do not need resource linkage.
• Resources are limited in many communities, making universal linkage unrealistic.
• Mandatory linkage could divert focus from critical individualized support.

5. Workforce and Service Continuity

• Proposed changes may overwhelm staff and increase turnover among experienced case managers.
• Could reduce continuity of care, timeliness of services, and overall support for individuals.

6. Service Registration Timeline

The next concern is regarding the expectation that new case management service registrations be submitted within one business day. While timely submission is important, this requirement may not be realistic given the scope of responsibilities case managers carry.

Case managers must balance direct service delivery, coordination with providers, and documentation requirements. In many cases, additional time is needed to ensure that all required information is accurate and complete prior to submission.

Additionally, factors such as limited availability of individuals, delays in obtaining information, and coordination with other providers can impact the ability to meet a one-day deadline.

Recommendation: A more flexible timeframe, such as 5-10 business days, would better support accurate submissions and allow case managers to maintain quality service delivery while remaining compliant.

Thank you for considering these recommendations:

• Maintain flexibility in face-to-face frequency and modality.
• Keep documentation clinically relevant and focused.
• Encourage, but do not mandate, family involvement.
• Recognize resource limitations and individual needs.
• A more flexible timeframe for service registrations.

These changes would help ensure that case management services remain accessible, individualized, and sustainable for both individuals and providers.