CIBH’s public comment response to DMAS Clubhouse Draft Policies due 12/3/25

Thank you for the opportunity to review and provide feedback on the draft DMAS policies relative to behavioral health redesign and its impact on clubhouse/PSR services.  Following are our suggestions or concerns as they relate to the draft policies:

Financial Burden of Clubhouse International Alignment

• Significant cost implications: Aligning with Clubhouse International standards requires substantial investment in accreditation, staff training, overtime hours to meet expanded schedule, travel, and restructuring to meet staffing and operational expectations. These costs are not currently reimbursed or subsidized by DMAS.
• Infeasibility under current reimbursement models: Many CSBs and community-based programs operate within tight budgets. If proposed billing reductions and unit limitations are implemented, programs will not have the financial capacity to meet Clubhouse standards.
• Unfunded mandates threaten program viability: Without additional funding or reimbursement adjustments, requiring Clubhouse-level standards is unrealistic and places programs at risk of downsizing or closure, ultimately reducing access to care for vulnerable populations.

Client Impact and Program Effectiveness

• Loss of structure may harm client outcomes: Our current PSR model emphasizes structured, therapeutic engagement throughout the day. Members thrive under this model, and loosening participation requirements could lead to disengagement, reduced progress, and poorer outcomes.
• Risk of losing satisfied members: Members who have found stability and success in our structured environment may leave if the program shifts toward a less structured, less engaging model. This would be a disservice to individuals who rely on consistency and accountability.
• Exclusion of ACT and Sponsored Residential clients is harmful: The proposed exclusion of individuals receiving ACT or living in sponsored residential settings would disqualify approximately one-third of our current participants. These individuals would lose critical social supports and community integration opportunities.
• Shifting focus to employment/housing may exclude others: While employment and housing are important, many members attend for wellness, socialization, and skill development. A narrow focus could alienate individuals whose primary goals are not vocational, but rather emotional regulation, community inclusion, social skills, or daily living skills.

Physical Space and Facility Requirements

• “Staff-only” space restrictions are impractical: While our program has a dedicated space separate from institutional settings, we maintain “staff-only” areas for privacy, safety, and administrative purposes. Requiring fully open spaces without exceptions is not feasible for CSBs and may compromise safety and confidentiality.
• Facility costs for extended hours: Expanding programming to evenings, weekends, and holidays would increase utility, maintenance, and security costs. These expenses are not currently budgeted and would require additional funding.

Service Planning, Documentation, and Staffing

• Restrictive ISP oversight language: Limiting ISP authorization to Clinical or Program Directors excludes qualified licensed professionals (LMHP, LMHP-R, LMHP-RP, LMHP-S) who are already permitted to complete assessments. This change would reduce flexibility and efficiency in clinical oversight.
• Progress note authorship requirement is overly rigid: The policy stating that only the staff who delivered the service may write the progress note does not reflect the team-based, milieu approach used in many programs. Staff often collaborate to document client progress, and this policy would reduce efficiency and documentation quality.
• Monthly documentation should remain sufficient: Requiring documentation more frequently than monthly would create unnecessary administrative burden. Monthly progress notes, when written to include goals, interventions, and clinical relevance, are sufficient to demonstrate medical necessity and appropriateness.
• LMHP review frequency is excessive: Requiring LMHPs to review non-licensed staff documentation every 30 days is burdensome, especially for programs with limited LMHP availability. Suggest allowing an LMHP review and co-signature every 90 days is clinically sound  and in alignment with other services and should be maintained.

Authorization and Intake Timeline Concerns

• One-day turnaround for assessments and ISPs is unrealistic: The proposed requirement to submit both the assessment and ISP within one business day of admission is a drastic shift from the current 30-day window. This would require significant operational changes and may delay access to services.
• Inconsistency with current manual guidance: The current DMAS manual allows for discretion by MCOs and the FFS contractor regarding documentation submission. The proposed policy should align with this existing flexibility to avoid confusion and ensure compliance with varying MCO requirements.

Governance and Oversight Requirements

• Advisory board requirement is duplicative for CSBs: CSBs already report to a Board of Directors that oversees financial, legal, and operational matters. Requiring a separate advisory board for the Clubhouse program would duplicate efforts and potentially create conflicting guidance. Flexibility should be granted to allow existing governance structures (i.e. CSB Board of Directors) to fulfill this role.

Evening, Weekend, and Holiday Programming

• Unfunded expectations for extended hours: Requiring evening, weekend, and holiday programming is burdensome for CSBs, many of which are government agencies with fixed staffing models and budgets. Staff job descriptions do not include coverage during these times, and adding such requirements would necessitate new funding and staffing plans.
• Staffing and retention challenges: Recruiting and retaining staff willing to work nontraditional hours is already difficult. Adding these expectations without increased compensation or staffing support will likely lead to vacancies, burnout an/or higher turnover.
• Holiday pay and on-call coverage: Additional programming would require compensating staff for holiday pay, arranging on-call coverage, and potentially increasing facility expenses—none of which are currently accounted for in program budgets.
• Cultural and religious sensitivity concerns: Mandating holiday programming may conflict with the diverse cultural and religious practices of our members. A more inclusive and flexible approach would be to state: “These activities may occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.”

Eligibility and Diagnostic Criteria

• Limits on qualifying diagnoses are too restrictive: Requiring a physician’s letter for certain diagnoses could exclude approximately half of our current members. Many individuals with serious mental illness or trauma histories may not have recent documentation or access to a physician for verification.
• Recommendation to expand eligibility: Consider aligning eligibility with the broader definition of serious mental illness, including individuals with significant trauma histories, without requiring additional physician documentation.

Consensus-Based Decision-Making Concerns

• Consensus may not be appropriate in all situations: While member input is valuable, there are situations—such as behavioral issues, safety concerns, or cognitive limitations—where consensus-based decision-making may not be feasible or appropriate.
• Need for alternative decision-making processes: Programs must retain the ability to make timely, staff-led decisions when consensus cannot be reached or when member safety and program integrity are at risk. Clear guidance is needed on how to navigate these situations.

Privacy and Confidentiality Concerns

• Outreach and group discussions may compromise privacy: Discussing individual member concerns in group settings or during outreach efforts raises confidentiality issues. Programs must be allowed to maintain HIPAA-compliant practices that protect member privacy.

Regulatory Alignment Challenges

• Conflicting standards across systems: Programs are already navigating complex and sometimes conflicting requirements from DMAS, CCBHC, Licensure, MCOs, and internal agency policies. Adding Clubhouse International accreditation standards—especially when they don’t align with state or federal regulations—creates confusion and administrative burden.
• Need for regulatory harmonization: DMAS should work to align expectations across systems and provide clear guidance on how to prioritize or reconcile conflicting requirements.