I have some concerns about the requirements for CBPS supports.  First and foremost is the fact that my MH Residential program currently does not have an LMHP on staff, as we do not provide psychotherapy and our clients receive this service from other providers.  Would that provider be able to write their residential treatment plans?  If the QMHP that works with them daily attended, I suppose that would solve the problem of them not being familiar with in home supports or the client's day to day activities.  It would seem more cost effective, however, to have the actual person working daily with the client to do the plan.  I am also concerned that their therapist would not be willing to do this, as completing their treatment plans and other paperwork, apparently, is not a billable service.  Why isn't completion of paperwork reimbursable?  If it is required, it should be reimbursed.  

Regarding the requirement for the staff the service the individual daily to also be available to provide 24 hour Crisis Support--is it fair to the person who normally works with 10 clients twice weekly for two hours to suddenly be available for an overnight weekend shift to support an individual in crisis?  Given that they have 10 clients--it could end up happening a lot.  What if they have already worked 40 hours that week?  What if they are not trained in the supports needed to manage individuals in crisis--such as the use of restraints--and these supports are not available in the community setting? I'm not sure having staff remain with a client who is escalating and needs a higher level of care is even a good idea, from a safety standpoint.  I would like to see more detail regarding what this support would look like--and how much more reimbursement would be received by the provider, as the provider would be working overtime, and additional staff might be needed to prevent neglect to other clients.

I am also concerned about the assumption that clients will agree to increased support and intervention.  It has been my experience that clients often refuse treatment as they become more symptomatic.  If the client refuses interventions to help them stabilize--such as a medication change--what happens?   

Finally, I am wondering what happens to individuals who are not making progress, but are currently being served in the least restrictive environment that can meet their needs.  Are they to be forced back into a higher level of care that they do not actually need?  Transitioned before they are ready to a lower level of care, which sets them up for failure and will likely result in either hospitalization or homelessness?  I am not sure how either of  these two options is advantageous over the option of letting them remain where they are, if they are stable and happy with their supports.

why are we pretending these inhome providers do anything and provide any help?  

Compass  Navigating Together - Compass  is the biggest medicaid fraud provider in the state..  a kid, usually a foster kid will get approved for 9-15 hours a week.. the agency might come out 1 time for 45 min; might call 2 other times for 5 min; and then will bill out all the approved services each week...   Chesapeake DSS only uses them so their foster kids get no services.. so do social workers in Chesapeake get paid off .. 

can we stop this fraud?  can we just open up more inpatient psych beds?  can we actually allow people to be admitted ?  can we go back and open up placements for people to end the all the other issues like homelessness and run away foster children?  or are we going to pretend anything the system is doing right now is helping; because it is not..  

medicate and let companies make money of people with mental illness .. that is all that is going on right now 

Does anyone realize how messed up things are right now?  things used to be better...  people could at least be safe in a psy ward?  now there is no solution ... right here the person points out not enough time;  not enough care;  not enough support; none of what is going on is good or working ...   drugs are not the solution .. sometimes people just need a safe place; someone to listen; some to confront them... 

what is going on right now?  it is a mess..  I have had CHKD ER release an active suicidal kid with nails still in her arm because some clerk said her checklist score wasn't high enough ..

Va Beach CSB is a massive massive massive JOKE...  there is no one to complain to the department of behavioral health lets the city investigate itself and the city always says it is wonderful and great ... even though the lazy case workers sit on their butt and let everyone suffer ..  

 have some concerns about the requirements for CBPS supports.  First and foremost is the fact that my MH Residential program currently does not have an LMHP on staff, as we do not provide psychotherapy and our clients receive this service from other providers.  Would that provider be able to write their residential treatment plans?  If the QMHP that works with them daily attended, I suppose that would solve the problem of them not being familiar with in home supports or the client's day to day activities.  It would seem more cost effective, however, to have the actual person working daily with the client to do the plan.  I am also concerned that their therapist would not be willing to do this, as completing their treatment plans and other paperwork, apparently, is not a billable service.  Why isn't completion of paperwork reimbursable?  If it is required, it should be reimbursed.  

Regarding the requirement for the staff the service the individual daily to also be available to provide 24 hour Crisis Support--is it fair to the person who normally works with 10 clients twice weekly for two hours to suddenly be available for an overnight weekend shift to support an individual in crisis?  Given that they have 10 clients--it could end up happening a lot.  What if they have already worked 40 hours that week?  What if they are not trained in the supports needed to manage individuals in crisis--such as the use of restraints--and these supports are not available in the community setting? I'm not sure having staff remain with a client who is escalating and needs a higher level of care is even a good idea, from a safety standpoint.  I would like to see more detail regarding what this support would look like--and how much more reimbursement would be received by the provider, as the provider would be working overtime, and additional staff might be needed to prevent neglect to other clients.

I am also concerned about the assumption that clients will agree to increased support and intervention.  It has been my experience that clients often refuse treatment as they become more symptomatic.  If the client refuses interventions to help them stabilize--such as a medication change--what happens?   

Finally, I am wondering what happens to individuals who are not making progress, but are currently being served in the least restrictive environment that can meet their needs.  Are they to be forced back into a higher level of care that they do not actually need?  Transitioned before they are ready to a lower level of care, which sets them up for failure and will likely result in either hospitalization or homelessness?  I am not sure how either of  these two options is advantageous over the option of letting them remain where they are, if they are stable and happy with their supports.

Good Afternoon,

I would like to recommend if applicable, adding a definition for the Clinical Director position in the opening definition section of the document. Within that section, clearly defining requirements, specific duties, and or what would be expected if an agency were to be audited for compliance as it relates to the Clinical Director position from an oversight agency. There is language in the workflow section of this document for the Clinical Director position that may allow for opposing interpretations and misalignment with the Departments intent.

For example, if an agency has an LMHP Clinical Supervisor who oversees the program and executes the duties of a Clinical Director however does not have the title of Clinical Director, would that agency be in compliance? 

For example, if an agency has a part/full-time Clinical Director and no Clinical Supervisors and fully operates remotely through telehealth, would that agency be in compliance?

For example, if an agency were to contract with a Clinical Director who contracts with several other agencies, would that agency be in compliance? 

In my experience/observations smaller agencies for various reasons (mainly financial) often hire differently from larger private and public agencies. I'm not sure if there is a small business impact study being done, however it may help guide some of the requirements and or the structuring of those requirements as we transition in June.

1. Training Requirements Remain Unfunded and Unphased
While training expectations are clearer in the updated draft, they remain extensive and unfunded. There is still no guidance regarding cost coverage, time requirements, or phased implementation. For rural CSBs facing workforce shortages, mandatory training during regular work hours will directly reduce service capacity unless offset by funding or rate adjustments.

2. School Coordination Expectations Remain Undefined
The draft continues to reference alignment between CPST services and school-based plans but does not clarify expectations for coordination with schools, participation in IEP meetings, or management of confidentiality conflicts between FERPA and HIPAA. No model MOUs, templates, or implementation guidance have been provided, leaving CSBs to independently navigate complex interagency requirements.

3. Caseload and Supervision Requirements Are Overly Complex for School Settings
The caseload formulas and supervision tracking requirements remain highly complex and were expanded in the updated draft. These requirements do not account for school calendars, closures, or fluctuating enrollment and will be difficult to operationalize without standardized DMAS tools or simplified limits.

4. Accreditation Timeline Remains Unrealistic
The draft does not address concerns regarding the feasibility of achieving accreditation within 18 months. Many accrediting bodies require longer timelines, and school-based CPST models may not align neatly with existing accreditation standards. No flexibility or technical assistance language has been added.

5. Financial Viability Concerns Were Not Addressed
Reimbursement rates remain unchanged despite increased non-billable expectations for supervision, coordination, documentation, and school collaboration. The draft does not allow billing for indirect services such as coordination with educators or IEP teams, nor does it offer start-up or capacity-building support.

6. Administrative Burden Has Increased
Weekly team meetings, expanded supervision requirements, and detailed documentation expectations remain in place. Flexibility for virtual supervision or reduced meeting frequency was not incorporated. These requirements will reduce direct service time in already resource-limited school environments.

7. Implementation Timeline Remains Aggressive
The updated draft does not include a pilot phase or delayed rollout. Introducing multiple new requirements simultaneously places a significant strain on schools and CSBs and increases the risk of inconsistent implementation and compliance findings.

We support the intent of expanding access to trauma-informed behavioral health services in schools. However, without clearer guidance, funding support, simplified compliance structures, and realistic timelines, the CPST–School Setting model will be difficult to implement sustainably in rural communities. We strongly encourage DMAS to engage in further stakeholder collaboration and consider phased implementation, funding adjustments, and operational flexibility prior to finalizing the regulations.

Impact of CPST–School Setting Draft on Rural Community Services Boards

Rural Community Services Boards operate with limited staffing pools, large geographic service areas, and fewer community-based resources. The current CPST–School Setting draft significantly increases supervision, training, documentation, and coordination requirements without corresponding funding or flexibility. These changes disproportionately impact rural CSBs by reducing direct service capacity, increasing administrative burden, and exacerbating existing workforce shortages. Without adjustments to timelines, reimbursement, and operational expectations, rural providers may struggle to sustain school-based CPST services, limiting access for students in the communities that already face the greatest barriers to care.

why did we build out a whole crisis continuum and now we're starting a brand new service that will require individuals to jump through hoops to use those services? 

The Rappahannock Area Community Services Board would like to express gratitude to DMAS for incorporating some of the input from the previous comment period into this new draft.  Further, we are grateful for the opportunity to provide comments to address our outstanding concerns.

• Not allowing participants of CPST to utilize crisis services (appendix G services) if provided by an affiliated business creates a disruption in care.  If individuals must go out of the region to receive crisis interventions like 23-hour, residential crisis stabilization, the continuity of care is compromised.  This approach creates barriers for individuals at significant risk for getting timely and accurate care.  Individuals will spend more time in emergency rooms waiting for CSU/CRC availability outside of the area.  Transportation to crisis services poses another barrier and safety risk.  Will require more traumatizing response to receive treatment to include ECO and police transport that will likely include restraints.  This is a tremendous liability for very vulnerable populations experiencing acute psychiatric crises.  This restriction remains unchanged in the current version and will restrict CSBs from being able to provide CPST so that they can still ethically serve individuals in crisis in their own community.
• A crisis or safety plan that does not include access or referral to more intensive level of care is misleading and dangerous.  Safety plans are intended to mitigate a crisis when possible but also include numbers and references to resources that may include seeking more intensive support.  Thank you for updating the wording to reflect potential inclusion of and access to the full continuum of crisis services as appropriate.  However, we remain concerned that, as a community services board, any individuals we serve would not have access to the crisis continuum of services based on the restriction outlined in the bullet above. 
• The reimbursement rate and any potential service unit limitations are not fiscally feasible to support the cost of 24/7 availability of F:F crisis supports by the CPST provider.  Moreover, there is a requirement that if referred to a higher level of crisis services in appendix g, the CPST provider must remain involved in the services.  It is unknown if concurrent billing of these separate services will be allowed. What potential risk is there to the crisis services provider (i.e. a CRC) to be denied payment due to the billing of CPST and/or the CPST providers failure to remain involved in the care.  What responsibility do crisis service providers have to verify if there is a CPST provider involved with the individual and attempt to reach them and include them in the crisis interventions?
• The restrictive caseload, staffing requirements, reduced units, barriers to access services and complex matrices of requirements paired with the sharp increased requirement for Licensed staff are major barriers to many organizations to consider providing CPST.  We appreciate the relaxation of some of the requirements included in this draft.  However, the rates which have been presented paired with the requirements of the current draft policy still make it fiscally improbable that agencies will be prepared to provide this service.
• CPST guidelines acknowledge this service is for those with chronic mental health issues, but establishes services that do not address the lifelong nature of many individuals' challenges.  By not acknowledging the chronic nature of SMI, CPST creates barriers to true stability and recovery.  SMI by definition is an acute, persistent, and chronic mental illness.   The additional administrative efforts, decreased authorization timeframes after 18 months, and authority designated to managed care organizations to essentially be able to over-ride clinical, person-centered, team decisions still do not address the chronic and persistent nature of Serious Mental Illness.
• Currently an individual receiving psychosocial rehab, skill building, and therapy (2x month) at most receives 162 hours of support a month.  By new unit maximums the most acute individual will receive just 28 hours a month.  The reduction in resources equates to a loss of nearly 87% or 134 hours of care.  Such a drastic cut in services will create undue hardships and significantly increase risks for hospitalizations.  Current services divert individuals from hospitalization and incarceration.  We anticipate an uptick in psychiatric crises.  The new draft eliminates the grid which reflect authorization unit limits.  However, there is no guarantee that these limits will not be imposed in practice.

Point of Clarification:

Throughout the policy, the word “must” was consistently replaced with “shall”.  Can clarification be provided on the intended difference between the two words?

Section: 2.1 CPST Teams:

• Team definitions represent an extensive increase in reliance on Licensed staff.  This will greatly increase the cost to provide the service as well as impact the ability of agencies to be able to offer this service due to the severe workforce shortage already evident for licensed-type providers. The proposed updated draft is still heavily reliant on L-Type staff.  Further, the Tier/Level Team composition remains overly complicated increasing operational burden.

Section: 3.1.2 Other Clinical Assessments to Support Measurement Based Care

• Are the assessments listed in this section optional?  What is the expectation behind the “strongly encouraged” wording in the first sentence?

Section: 3.3.2 Service Delivery specific to Adults

• The first sentence indicates all adult service agencies must meet the state requirements for training in Adult Mental Health Rehabilitative Supports and Services.  The next sentence indicates all professional types must complete….  Does this mean that all professional types providing CPST must meet the requirements or does this mean that all professional types within the agency providing CPST must meet the requirements?  Many agencies provide services outside of the CPST so clarification on the agency level expectations are needed.

Section: 3.3.3 Service Delivery-Transitional Age Youth

• If you are an adult only provider of CPST, serving only individuals over the age of 18, does the sentence requiring that providers complete all the adult and youth trainings indicated above apply?  If so, would that same requirement apply for adult providers who limit their services to only individuals over the age of 25?

Section: 3.4 Required Documentation

• Recommend switching to requiring proof of compliance with training requirements to be provided at audit.  This would avoid an increase in administrative burden and allow the provision of the most up-to-date compliance information versus limiting to just annual.  This is an administrative burden that provides no direct value to the individuals served.

Section: 4.4 Collaborative Behavioral Health Services/Supervision of team members

• Minimum face to face team meeting weekly- The updated policy further defined the requirements for the face-to-face weekly meetings and seemed to add more requirements versus relaxing.  The updated policy seems to include much of the same requirements as Assertive Community Treatment without the corresponding rate structure needed to sustain.

Section: 4.5 Supervision of Individual Staff

• Weekly supervision for all non-licensed staff.  This remains overly administratively burdensome and limits time available for direct service provision.

Section: 4.5.1 Supervision of LMHPs

• Added that clinical supervision for licensure only meets the supervision requirements if provided by an LMHP employed by the CPST agency.  Please reconsider this added restriction.

Section: 4.5.2 Supervision of LMHP-R, LMHP-RP or LMHP-S

• The updated draft indicates these provider types must receive a minimum of 2 hours of supervision with LMHP Clinical supervisor per month and a minimum of 4 hours a month in “supervision-related activities”.  Part-time with caseloads less than 10 shall receive minimum 1 hour of supervision and 2 hours in “supervision-related activities”.  This adds additional administrative burden, operational costs, and limits time available for direct service provision.

Section: 4.5.3 Supervision of QMHPs, QMHP-Ts, BHTs

• The number of supervision hours is excessive, particularly for the QMHPs

Section: 4.5 Staff Caseloads

• The staff caseloads outlined create an overly-complicated, fiscally-infeasible requirements which are a barrier to the ability to provide this service. 
• The requirement for “formal log of caseload” every six months as the compliance requirement increases administrative burden and is operationally difficult based on the fluid nature of staff caseloads.  Although a few words were changed in this section, it is unclear how the changes addressed the concerns expressed.
• Adds wording that we need to document and maintain documentation for audit which discloses if an employee works for another Medicaid outside employment.
• Billable units limit further restricts the provision of service and the flexibility to maintain successful program model.  The updated draft increased to 600 CPST unit limit but kept that this is across all/any agencies which a staff member works.  This limit is untenable as one agency cannot limit or restrict another agency’s staff caseload.
• LMHP prohibited from providing supervision/oversight to more than 120 cases in a month, but then goes on to provide wording of when 120 would not be appropriate.

Section 5.  Required Service Components

• Max of two hours provided in licensed location per week. Does this requirement apply to CPST services provided in-home when the individual resides in a licensed location?

Section: 5.2 Treatment Planning

• Requirement for ISP to be signed by all team members is overly restricted and not required in most, if not, any other service.
• Required participation by all members face to face/in person is further over-restriction that exceeds the requirements in most, if not, any other service.

5.5 Care Coordination

• The updated draft adds an entirely new list of required care coordination activities which may not have been included in the rate study as they were not included in the original policy.  This adds additional time, costs, and burden which is not supported by the rates assigned for this service.

Section: 6.3 Provider Accreditation

• Will a CPST specific accreditation be required or if we are currently accredited by CARF, is that sufficient?

Section: 7.6 Continued Stay Criteria

• How is “not making sufficient progress” measured to trigger need for alternative service plan within 180 days.  How does this support the needs of individuals with chronic, persistent, serious mental illness.  The authority given to Managed Care Organizations to override plans created by the team and agreed to by the individual should be reconsidered. 
• How does the requirement of expectation of improvement at current level of service if individuals are at baseline but still meet the eligibility criteria?

Section: 8. Exclusions and Service Limitations

1.  The following are not reimbursable:

• How does the restriction around individual being present during documentation impact the practice of concurrent/collaborative documentation?

2.  Admission and Concurrent Services Limitations
   • “The CPST provider or affected provider or business of the CPST provider shall not provide Mobile Crisis Response, 23-hour Crisis Stabilization or Residential Crisis Stabilization to any individual receiving CPST”.  This will be a barrier to any Community Services Board’s ability to provide CPST services. 
   • Just because an individual meets the admission criteria for one of the listed services does not mean that that service is available in the area and it limits individual choice of services/providers .  Although this wording was slightly adjusted, we ask DMAS to consider removing this restriction.
   • Putting the authorization of additional behavioral health services in the hands of the MCOs to authorize or exclude based on participating in CPST services could limit access to needed sources such as psychiatry services, substance use support services, etc could be a barrier to clinically indicated care.  Allowing the MCOs that flexibility to make that decision could be unethical as they have a financial benefit as a result of that decision.   

Section: 9. Service Authorization

• The ability to MCOs to have the power to recommend a “more clinically appropriate service” based on their review is not appropriate.  At this point, there have been many requirements for the individual and treatment team to explore all options.  The MCO has a vested financial interest in this decision and many of the service authorization staff are not licensed providers qualified to make or override clinical appropriateness decisions. 

The CANS Lifetime is still in development.  There is no evidence that it has been normed or evaluated to ensure reliability and validity for the populations included for CPST, specifically individuals with SMI or anyone in the adult population.  The policy relies so heavily on evidenced-based practices, yet does not included an evidenced-based assessment for access to the services.  Using an assessment tool not validated to assess a specific population to determine level of care is negligent, especially when it is the gatekeeper of access to a critical service.

we already have a shortage of LMHP providers and this service is LMHP intensive. this will cripple the behavioral health system

1. The draft regulation requires psychotherapy to be billed under CPST at a lower reimbursement rate than traditional outpatient therapy. Clarification is requested regarding the intent of this requirement and why the rate would be lower?  

2. The staffing expectations seem to require a significant increase in licensed staff. Workforce shortages will make this difficult and provide additional barriers.

3. The requirement for 24-hour service availability necessitates on-call staffing and compensation. Can you please explain how these rates will allow for this added staffing?

4. The drafted policy and procedure requirements appear to exceed what is reasonably necessary and are quite stringent.

5. Are the titles of staff required to be the same as in the manual in order to meet the requirements?

6. The regulation requires agencies to maintain a formal schedule and describe how coverage is ensured during turnover and high caseload periods. Can you please provide an example of what a “formal schedule,” looks like?

7. The crisis mitigation plan is new language and the requirement specifies completion within 30 days and signatures from the full team. Will an example of what this is supposed to look like be provided?

8. The regulation notes that MCOs may waive authorization requirements during recovery. What does this mean?

9. When crisis referrals occur, CPST providers are required to remain engaged. Is this duplicate billing or care coordination?

10. Does a tier change require new authorization submission?

11. The draft limits billing to 600 CPST units per month and requires monitoring of outside Medicaid billing. Does record of approved outside employment go in the personnel file?

12. LMHP’s cannot effectively supervise 120 cases a calendar month and complete all other duties. This would mean we would need to hire more staff or have a waitlist. Will rates cover the additional needed staff to meet the requirements? Workforce shortages will also make this difficult and provide additional barriers.

Questions:

1. Does a change in Tier require submission of a new service authorization or Continued Stay request? What is the estimated turnaround for authorization review- Could authorization approval timelines prevent a barrier to an increase in unit delivery for Tier 1 clients who demonstrate an increased need for Tier 2 level of service?

2. When clinically indicated, may CPST services for youth be provided concurrently in both home and school settings, and if so, how would authorization be structured?

The draft continues to reflect an increased reliance on licensed (LMHP/L-Type) staff at a time when shortages persist statewide. Requirements for in-person LMHP assessments, multi-tiered team structures, weekly team meetings, and supervision requirements will increase operational complexity and costs, potentially affecting providers’ ability to deliver CPST services.   

The proposed training requirements remain extensive and are not accompanied by guidance on cost, staff time, or phased implementation. For providers already in operation, completion of required training during standard work hours will reduce ability to serve existing clients in absence of funding or rate adjustments.

Additionally, the model does not fully account for the chronic and ongoing nature of SMl. Shortened authorization timeframes, increased administrative requirements, and expanded managed care oversight may create challenges in supporting long-term stability and person-centered treatment.

Without additional clarification, funding alignment, streamlined requirements, and phased implementation, providers will struggle to comply with CPST model requirements by the anticipated 7/1/2026 implementation date and experience difficulty in sustaining ongoing operations. Continued stakeholder engagement and consideration of rate and operational adjustments are encouraged prior to finalization.

To support successful statewide implementation, we respectfully request that DMAS increase flexibility in supervision, allow training equivalencies and portability, publish and pilot the CANS algorithm, adjust Tier Two intensity, revise crisis requirements to consultation-based models, define the licensing category, extend accreditation timelines, allow wraparound and transitional services, and streamline documentation requirements.

1. Supervision Requirements

The revised draft sets weekly face-to-face supervision, minimum monthly supervision hours, and a supervision load per LMHP that together exceed feasible operational capacity and significantly reduce billable time. Permit flexible supervision models, including group supervision, tele-supervision, team-based case review, and case-based supervision equivalencies aligned with DBHDS standards. A higher LMHP oversight capacity should be permitted when licensed staff conduct structured team reviews.

2. Training, MAP Credentialing, and CEP-VA Requirements

Mandatory MAP credentialing, Foundational Skills curricula, and additional CBT requirements create redundant and excessive training burdens that overlap with existing DBHDS-required training. Recommend accepting equivalent prior training (e.g., CBT, TF-CBT, MI, trauma-informed care), implementing a phased credentialing timeline of 24–36 months, clarifying MAP supervisory roles, and allowing portable online modules compatible with existing learning management systems.

3. CANS Lifetime Tool and Authorization Pathways

The CANS Lifetime Level-of-Need algorithm remains undefined, yet it directly determines admission, tier assignment, service intensity, and staffing. This creates uncertainty for providers and payers. Recommend releasing the scoring algorithm for public review, pilot-testing LON thresholds with a representative group of providers, and publishing a clear crosswalk between CANS domains and functional criteria.

4. Tier Two Service Frequency

Tier Two CPST requires 5–8 hours per week, approaching IICRT/ICT-level intensity without the corresponding staffing model or reimbursement. This intensity is not operationally feasible for all individuals. Recommend reducing Tier Two expectations to 3–6 hours per week unless higher medical necessity is documented, and clarifying that the range is an average rather than a mandatory minimum.

5. Crisis Response Requirements

Requiring CPST providers to deliver in-person crisis response 24/7 before referral to 988, CSB Emergency Services, or Mobile Crisis effectively mirrors crisis stabilization services. This expectation creates duplication and unfunded liability. Recommend limiting CPST responsibilities to 24/7 on-call consultation and safety planning, ensuring immediate access to external crisis services when safety concerns arise, and aligning requirements with the existing Mobile Crisis model.

6. Undefined Licensing Category

The CPST licensure category remains “To Be Determined,” which prevents providers from planning for compliance, staffing, and licensure timelines. Recommend publishing the draft CPST licensure category alongside the service definition and clarifying whether CPST aligns with Outpatient Services, Psychoeducational Rehabilitation, or a new licensure category.

7. Accreditation Timeline

Requiring CARF, COA, or TJC accreditation within 18 months of July 1, 2026, is not feasible for most providers. Recommend extending the accreditation timeline to 36–48 months to support realistic implementation.

8. Exclusion of Individuals Eligible for Other EBPs

The revised draft excludes individuals eligible for services such as Assertive Community Treatment, Coordinated Specialty Care, Multisystemic Therapy, Functional Family Therapy, or Applied Behavior Analysis unless those services “fail.” This restriction risks care fragmentation and service gaps. Recommend allowing CPST as a wraparound or step-down service when clinically justified and permitting concurrent CPST during transition periods of up to 90 days.

9. Documentation Requirements

The documentation requirements are highly prescriptive and may exceed federal Medicaid standards, increasing the administrative burden without corresponding clinical benefit. Recommend simplifying progress notes to core elements (intervention, response, progress toward ISP goals, and next steps) and permitting co-signatures or scribing when clinically appropriate.

Overall

1. The service as defined will be very difficult to sustain financially.  The model relies heavily on licensed mental health professionals, already in short supply, and limits the number of hours that can be billed, regardless of need.
2. The service definition prohibits organizations providing CPST from referring individuals to crisis services run by the same organization.  This practice would prevent a resident who needs crisis services from using those crisis services developed by their locality and might result in long waits for CSU or CRC availability outside their locality. It makes it impossible for a CSB to deliver CPST services.
3. The evidence base supporting CPST relates to the evidence supporting Managing and Adapting Practice (MAP), a requirement for those delivering CPST services to children and adolescents. MAP is only one component of CPST.  
4. CPST does not address supports to individuals with ID/DD, other than those with autism.   

Sections

Section 2

1. The teams and tier matrix is complicated and documenting movement from one tier to another is excessively burdensome.
2. There is no definition for "younger children".

Section 3

1. In the list of assessments, it is not clear what "recommended" and "strongly encouraged" mean.  
2. It is not clear if the referral to Applied Behavior Analysis (ABA) when a primary diagnosis of autism is present is a requirement prior to receiving CPST, although the language within the draft is "shall." If so, it is not family or patient-centered as not all people with autism benefit from ABA.  Other services included in the list do not reflect family choice or issues of system capacity.  What if there is no provider in the area or there are lengthy waitlists?
3. There is no definition of "transition age youth." The training requirement is confusing.

Section 4

1. The caseload and supervision matrices are overly complicated.  The number of supervision hours is difficult to implement and sustain, particularly for QMHPs.
2. Caseload maximums are not fiscally sustainable.

Section 5

1. What does "CPST provider" mean in Section 5.3.5? Does it mean the agency providing CPST or does it mean the individual's actual assigned provider? 
2. Were the activities listed in the Care Coordination section included in the original rate study?
3. The requirements, proposed rate structure, and service limitations will prevent CPST providers from delivering the required level of crisis care. It is not fiscally sustainable.

Section 9

1. The prohibition of an agency delivering CPST to provide any of the crisis services in Appendix G prevents a CSB from providing CPST.
2. Does the requirement limiting covered services in a provider's DBHDS licensed office location include licensed group homes?

I would like to highlight the impact of these draft regulations on provider operations, particularly related to reimbursement rates. The proposed requirements will increase administrative, staffing, and compliance costs for providers. While reimbursement is addressed, current rates do not appear sufficient to offset these requirements.

Without an increase in reimbursement rates, providers may face challenges sustaining services as outlined. Please consider adjusting reimbursement rates to more accurately reflect the true cost of implementing and maintaining these services, to help ensure continued access to quality services for individuals and families. 

Thank you for the opportunity to bring up questions regarding the manual. We appreciate the opportunity to provide feedback and address direct concerns from the provider’s perspective and implementation of the CPST program.

While we appreciate the detail that is being put into the roll out of this program, our primary concern remains the overabundance of tasks placed on an LMHP. May of the tasks could be facilitated by an LMHP-E. The rigid numbers (monthly limits, supervision requirements, direct care requirements, in-person requirements, increased assessments, implementation of EBP, tracking and audit increases) also make it challenging and do not account for potential turnover, staff out on leave and overall are very restrictive. If an LMHP leaves, there is no flexibility to cover for students in services which causes clinical and ethical issues. It is important to broaden the role of the LMHP-E to give providers flexibility to not only build but maintain a successful program. The LMHP shortage and high turnover for agencies has been well documented across the state.  

Additional questions include the following:

3.2 Many of the services are not available in the area. If CPST starts, and then another service becomes available, it should be up to the provider and client if both (new service and CPST) services are appropriate. Many families can benefit from both services as they target several different areas (MST and CPST/MAP can be used simultaneously per the training). In addition, it is not person centered to discharge from one program solely due to enrollment in another.

3.3 The cost or details of the QMHP training has not been disclosed. Agencies cannot set long term planning goals without knowing costs without these long term projections.  

3.4 Oversight to ensure ethical work is important. However, there is no reimbursement for agencies that are now accountable to insurance companies, licensure and VCU as well as the agency. This is an abundance of reporting when already adding case management, team meeting and LMHP responsibilities. What is reported to each agency is also not clear.  

4.1 Thank you for adding details to the crisis section. However, please describe how billing (as there are limits on QMHPS, LMHPS and hours for clients) works. Please also describe a plan for agencies when this service is not available. Agencies are already short-staffed, what happens when staff leave unexpectedly?  

4.2 Increased coordination and no reimbursement.

4.3 Caseloads are very rigid and do not allow for flexibility if staff resign, are out on leave, etc. which leaves the agency out of compliance or at risk for allegations of abandonment from the board.

5. What does the first sentence mean? It is not clear what CPST offices are considered and is not realistic that they only utilize a CPST room twice a week. Especially given the curriculum for EBT which often involves a lot of office time. The state mandated program requires ongoing tracking, implementation of therapeutic interventions that will need to take place in the office.

5.1 CANS is not required to be facilitated in person for social services; it is overly cumbersome to add this responsibility without increased reimbursement. This will hinder clients in rural areas from accessing services especially those with transportation issues.  

5.3 Crisis services remain a duplication of programs that have already been put in place. There is no clear reimbursement description for this service. There is no explanation of how this is billed given the strict caps and restrictions on hours and caseloads for staff. The addition of crisis services seems to be trying to combine two services/jobs into one with minimal pay. Staffing this will be impossible for smaller agencies. It is also not ethical for many EBPs that the ongoing therapist is the crisis response therapist (ex. DBT). The push for EBPs and combining crisis response is actually counterintuitive.

5.5. It is not clear if employment exploration is covered. One section states that it can be billed under Restorative Life Skills but the other section indicates it is not billable under CPST. Case management services through the MCO should be the responsibility of the MCO. Responding should be the responsibility of the CPST counselor but we cannot be responsible for insurance companies not appointing workers or those workers not communicating with staff. This has been an ongoing issue with MCOs.

6.0 The team approach to assure ethical services is a great idea. However, the CPST worker, supervisor providing services and the client being enrolled in outpatient (and case management) creates a duplication of some services or possibly different therapeutic approaches/styles being applied at the same time. Outpatient (and coordination with the outpatient counselor) should count as the meeting with LMHP staff.

8.1 Clarification question: Staff are completing an agency assessment, SDQ, CANS Lifetime, an initial SRA, ISP and complying with EBP. We were under the impression CANS Lifetime would reduce some of the cumbersome enrollment process to focus more on treatment. This is more responsibility, limiting staff who can perform the tasks and the reimbursement is not clear as far as the assessments. Will insurance companies be able to deny and reduce units (like they do now) with the additional information. It is an ongoing concern that the information is not reviewed (we will be filing two complaints this week alone addressing this concern). We were not able to access this form.

As an agency, we have appreciated the request for feedback, questions and concerns. When the program was presented, it was expressed that it was to help children access services. This program, by setting so many limitations and expectations on LMHPs will make it challenging for kids in rural areas to access the services. It also places an abundance of responsibilities on LMHPs who will likely seek employment in higher paying, less responsibilities positions. As it is now, it appears to be moving away from client centered and more towards limiting services.

We do find it helpful that authorizations are 6 months. And we really appreciate the state providing free MAP training (which our staff have enjoyed) to get the program going. We have also appreciated the opportunities to share our concerns prior to the rollout.

1. Due to the provision in Appendix G prohibiting CPST providers from providing any crisis services would carve all CSBs out of CPST. In our area, private providers do very little mental health skill building under the current regulations so there would be little to no CPST available in our catchment area if this prohibition stands.
2. This revision continues to exclude CPST recipients from Clubhouse services, MHIOP, community stabilization and ARTS services. It is unrealistic to expect CPST to offer all the elements of this array of services within CPST, particularly given the very short duration of CPST services expected in this version of the manual.
3. The expected duration of services (3-12 months) does not reflect an understanding of the challenges individuals with serious mental illness face nor a realistic timeline around recovery for this population. Also, explicitly states that MCOs have broad latitude for determining medical necessity. MCOs have demonstrated that these decisions are made with cost saving, rather than member clinical needs, as the guiding principle.
4. The new section in this draft requiring case coordination is totally duplicative of Targeted Case Management.
5. Currently an individual receiving psychosocial rehab, skill building, and therapy (2x month) at most receives 162 hours of support a month.  By new unit maximums the most acute individual will receive just 28 hours a month.  The reduction in resources equates to a loss of nearly 87% or 134 hours of care.  Such a drastic cut in services will create undue hardships and significantly increase risks for hospitalizations.  Current services divert individuals from hospitalization and incarceration.  We anticipate an uptick in psychiatric crises. 
6. The reimbursement rate and any potential service unit limitations are not likely to support the cost of 24/7 availability of F:F crisis supports by the CPST provider.  Moreover, there is a requirement that if referred to a higher level of crisis services in Appendix G, the CPST provider must remain involved in the services.  There is no clarity provided on if the two services can be billed concurrently, if not what potential risk is there to the crisis services provider (i.e. a CRC) to be denied payment due to the billing of CPST and/or the CPST providers failure to remain involved in the care.  What responsibility do crisis service providers have to verify if there is a CPST provider involved with the individual and attempt to reach them and include them in the crisis interventions?
7. Must demonstrate that OPT was insufficient and don’t know how we’d do that without unnecessarily delaying the start of CPST just to show that OPT “failed.” An uptick in hospitalizations will occur while people have to move through these steps to prove they need it.
8. Must show “significant improvement within 90 days” or ISP must be rewritten also seems like authorizations happen every 90 days so service would likely not be reauthorized. As above this is not a realistic timeframe for individuals with serious mental illnesses.
9. Continued concern that everything hinges on CANS lifetime which is only tested for ages 5-21 for children/adolescents with serious emotional disorders. This tool was not designed to assess adults with serious mental illnesses nor does it include categories relevant to adults. Also, the training for the current CANS is quite lengthy and has be renewed annually creating substantial administrative burden.
10. The team constitutions across the tiers continues to be far too heavy on licensed providers which has an impact on cost of services and ability to provide CPST due to ongoing, severe workforce shortages for licensed staff particularly in 24-7 programs.
11. QMHP staff are referred to throughout the document as paraprofessionals which misrepresents the required education and experience required for this certification, which has only become more onerous in the last revision of QMHP requirements. The supervision requirements for QMHPs does not account for or respect the many years of experience many QMHPs working in the field already have.
12. Many pieces of the CPST requirements read as duplicative of ACT creating confusion about where CPST sits on the service continuum. If designed to be less intensive than ACT (as skill building currently) is the 24-7 crisis elements and requirements to provide day programming, OPT/IOP and crisis services seems more intensive than ACT without commiserate billing rates.

I want to acknowledge that several common concerns were addressed in this policy revision. Thank you for taking feedback and adjusting! I have some ongoing questions about specific terminology and some requirements that I believe need to be more clearly defined.

1. The parent/guardian requirement is extensive, particularly with “younger clients.” This is something that I think is beneficial when possible. My feedback is to be more specific on certain aspects and to include exceptions to these requirements:

   1. What ages are considered “younger clients?” Without a definition, this becomes very subjective. My experience is primarily with elementary schools, so 3 and 4 years old is “younger” for me while a Kindergartner is pretty average age.

   2. Does the same family member/caregiver have to participate each week? For example, if a child has divorced parents and lives in multiple homes, it would be beneficial to engage a different guardian each week. Or if a client lives with both parents - could hours be combined? So if mom and dad were both participating for 1 hour, would that meet the 2 hour requirement?  It would be very helpful if multiple guardians could be included in the participation. One idea is for the caregivers and guardians to be specified somewhere on the ISP and allow time to be spent with any caregiver or guardian listed on the ISP. This would also be easy to update as needed.

   3. What about situations where children change living arrangements such as foster care? Would a client lose services due to moving to a new foster home in which the guardian was unwilling or unable to participate?

   4. There also needs to be criteria for clients whose guardians are unavailable. For example, what if the primary guardian is hospitalized or has health concerns that renders them unable to participate in services?

   5. My primary concern is that clients are able to access needed services without being penalized for lack of guardian participation. I completely agree that family involvement greatly benefits the client, but many clients may qualify for CPST due to symptoms stemming from lack of guardian involvement in their lives. It often takes time to build trust and rapport with guardians, but that cannot be attempted without initiating services in the first place.

2. Please clarify what is meant by “Administrative Supervision” and the statement that “An LMHP must review documentation of non-licensed team members at least every 30 calendar days as evidenced by a progress note in the individual’s chart written by the LMHP or a co-signature on the non-licensed team member’s progress notes.”. Does this mean that ALL paperwork must be reviewed and signed by an LMHP, or that only some documentation needs to be reviewed? 

   1. For example, I am a QMHP who works as a compliance specialist and have trained many staff on clinical documentation. The current wording sounds like I could not review/approve paperwork even for QMHP-level services. It would be a tremendous help for agencies to be able to utilize QMHPs in this role rather than requiring LMHPs to review all documentation in order to decrease administrative burden on licensed staff.

3. My biggest concern with the current timeline is that I do not believe there will be enough time to complete all of these requirements before the July 1st deadline (DBHDS Licensure, MCO licensing, staff training, etc.). It would be prudent to have a time period of “phasing out” in which the retiring services and the new services overlapped so that clients could more slowly transition into the new services. If licenses will not even be available until the Spring, then several providers will be pushing to get licensure completed, then trying to coordinate with each MCO. Many agencies will likely not be able to start immediately on July 1. I fear that many clients will suddenly be without services or have to be discharged. I know your office may not have complete control over timing, but please advocate for a longer timeline of implementation for the benefit of clients, agencies, and staff.

4. For crisis services, how will agencies to request additional units?

   1. For example, if a client at LON 3 or 4 is experiencing a crisis, they could rapidly use up their permitted hours for a month. If the CANS Lifetime cannot be repeated, how will clients move between LON?

   2. Also, MCOs could deny additional service hours for clients and hold to the current maximum hours allowed despite the additional need. Would agencies need to file a new SRA in that situation? Please elaborate on these processes to ensure that clients are able to receive the services needed and that agencies can properly be reimbursed from MCOs.

   3. It would also be beneficial to allow agencies to refer to their own crisis programs when appropriate. This would increase continuity of services and decrease wait times between services. It is reasonable for agencies to document the clinical necessity for the referral and to ask CPST providers to document/be involved in the decision-making process, but to require referrals to an outside agency poses challenges particularly for rural communities with limited service options.

5. If the CANS Lifetime cannot be repeated, then providers will have to rely on an assessment completed by another agency. How can providers ensure the accuracy of their assessment and conclusions (such as diagnosis or Level of Need)? Is this something an agency can reevaluate if they feel the need?

   1. Additionally, if the CANS Lifetime is relying on client self-reporting, how do we ensure the accuracy of LON? It would be beneficial for this assessment to be released and have a trial period before the initiation of services and for providers to be able to offer feedback before its implementation.

6. Finally, the draft states that referrals to EBPs and collaboration with MCOs are required, but this time is not reimbursable. So an agency is expected to spend much time on Care Coordination without any reimbursement. Please clarify these points or reconsider the requirements as that is a burden on agencies and does not adequately compensate providers or staff for their time. This will also create longer delays to begin services and require clients to be invested enough to engage with a new provider, creating greater chances for service dropouts. 

Thank you for your consideration of the feedback and public comments!

We greatly appreciate being able to provide comment and feedback to the current iteration of the CPST model and framework.  We applaud the tremendous amount of thoughtful work that went into this document, and its intention to increase the quality and standards of service delivery and the goal to  effectively help members who are engaged in these services.  We especially appreciate the focus on trauma-informed care and evidence-based practices as we think these will benefit Medicaid members substantially.  Our intention with this feedback is to ensure that quality care and standards are in place and that they are done in a feasible and practical way that won’t limit network providers being able to comply with some of these requirements. 

This feedback on the CPST policies and procedures contains several key concerns and requests for clarification regarding provider requirements, evidence-based principles and policies, training mandates, position titles, and documentation standards within a behavioral health services framework. It highlights ambiguity in terminology and implementation expectations, extensive training requirements, and addresses administrative burdens related to supervision and recordkeeping. Recommendations are provided to ensure clearer definitions, practical guidance for providers, and adjustments to policy language for improved feasibility and compliance across different provider types.

1. Evidence-Based Principles and Policies

Page 5, Sub-heading 3, Number 1: There is uncertainty regarding the meaning of ‘evidence-based principles’. Specifically, clarification is needed on what this term entails and how it should be implemented by providers in a practical sense. The phrase ‘modular activities’ also requires a clearer definition, as does the concept of these being ‘dynamically applied’. The current language directs providers that they shall implement these items, but it is not clear what this refers to in practical terms.

Page 5, Sub-heading 3, Number 3: The requirement for providers to have evidence-based policies covering mandates, differential reimbursement, or development of core competencies needs elaboration. Examples of such policies in these three areas would be helpful for providers to better understand expectations.

Page 7: 3.3.1 Service Delivery- Specific to Youth:

For youth presenting with a mental health disorder, that aligns with an evidence-based treatment approach, that cannot be provided directly through the CPST service structure, CPST providers shall ensure that the EBP options are coordinated through the care coordination component of the service. Application and education on clinical best practice guidelines and evidence-based approaches shall be a priority focus in supervision and other reflective and professional development opportunities offered by the agency to support staff.

This is vague and unclear in terms of what is expected of the provider, specifically around the care coordination if an EBP is not available.

A more precise definition of the requirements in this section would be beneficial.

2. Training Requirements and Reimbursement

Page 6, Section 3.3.1: The mandate that all providers—including multiple provider types—must be trained in Managing and Adapting Practice (MAP) raises questions about reimbursement. It is unclear whether this training will be financially supported or if it is an unfunded requirement for providers. When considering MAP, CANS Lifetime, and statewide foundational training, the extensive amount of required training should either be reimbursed or factored into the provider rate and this clearly shown in the rate breakdown for transparency. There is also a question as to whether these additional training requirements were considered in the original rate study as much of these requirements have come out after the initial rate study.

Page 7: Additional foundational training is required. It would help if would be further clarified- is this in addition to MAP, CANS Lifetime, and specific evidence-based practice (EBP) training? The volume of required training appears burdensome, especially for smaller providers, and may limit the availability of a sufficient provider network statewide.

3. CPST Clinical Director Title and Position Requirements

Page 8, Section 4.1: The requirement for agencies to designate a “CPST Clinical Director,” defined as a full-time LMHP with an active Virginia license providing oversight for the CPST program, may create complications related to position titles and pay structures. This title is commonly used in various ways and often carries responsibilities outside the scope of DMAS, falling under agency-specific business decisions. It is recommended that the title requirement be removed, as the position expectations can be maintained by referencing “LMHP” alone.

4. Supervision Requirements

Page 9, Section 4.2: The stipulation for weekly face-to-face supervision is viewed as overly prescriptive and may not be suitable in all cases, depending on individual needs, caseloads, and the LMHP’s responsibilities. While general supervision requirements are important, it is suggested to set broader guidelines (e.g., supervision at least monthly) rather than detailed specifics, such as required documentation in employee HR files. Supervising staff typically do not have access to HR files, which could make compliance difficult and increase administrative burden. A more general requirement—that documentation be maintained and provided upon request—would be preferable.

5. Crisis Mitigation Plan Requirements

Page 13, Section 5.3.10: Clarification is requested regarding whether every individual receiving CPST services must have a crisis mitigation plan, regardless of their history of crisis.

6. Restorative Life Skills Training Applicability

Page 13, Section 5.4: It is important to clarify whether Restorative Life Skills Training applies to all individuals receiving services or only to those identified as needing it based on assessments. Additionally, further explanation is needed on how this relates specifically to youth services.

8.4 Additional Tier Two CPST Criteria for Youth

Page 20 8.4 Additional Tier Two CPST criteria for youth states: There shall be an identified caregiver or legally authorized representative available and willing to participate. a. The caregiver shall be a responsible adult who lives in the same household as the youth and is responsible for engaging in family/caregiver psychotherapy and service-related activities to benefit the youth. b. The family/caregiver(s) shall commit to participating in ≥ two hours of CPST covered service components a week. c. The family/caregiver(s) shall attend treatment planning meetings quarterly. d. The family/caregiver(s) shall be available for crisis consultation within two hours during business days.

If the designated caregiver does not participate as required, it is important to clarify the provider's responsibility in these cases. Specifically, guidance is needed on whether services must be discontinued or if documenting attempts to engage the caregiver would allow the youth to continue receiving some level of intervention. This is particularly relevant if the specified response timeframe cannot be consistently met. It is recommended that the strict timeframe requirement for crisis consultation be reconsidered or removed, as it may not be feasible in all situations and there may be valid reasons for non-compliance by the caregiver that shouldn’t negate the child’s need for treatment.

There are a few concerns alongside some of the other comments that I have read through so far.

1. LMHP Documentation Review Requirements and Administrative Burden
There is clarification needed on whether LMHPs are required to review and/or co-sign all documentation completed by non-licensed staff. As written, the draft suggests a high level of ongoing clinical oversight, which appears to include regular review of progress notes and service documentation.

When considered alongside the additional LMHP requirements—

• weekly supervision of non-licensed staff,

• weekly team case reviews,

• quarterly reviews (QRs),

• ongoing assessment and ISP oversight, and

• 24/7 on-call availability for crisis consultation—

this expectation represents a significant administrative and operational burden on LMHPs. We are concerned about the sustainability of these cumulative responsibilities, the impact on clinical capacity, and the potential risk to timely service delivery if expectations are not clearly defined and appropriately scaled.

Clarification is requested on:

• Whether all non-licensed documentation must be reviewed by an LMHP,

• The required frequency and format of such reviews, and

• Whether co-signature is required for every note or only at defined intervals.

2. Weekly Supervision Requirements vs. Team Meetings
The draft indicates weekly supervision requirements for non-licensed staff. Please clarify on whether existing weekly team meetings, case staffing meetings, or interdisciplinary rounds may satisfy this requirement, or whether separate, individual supervision sessions must be conducted and documented in addition to team-based meetings.

This distinction has substantial implications for scheduling, staff capacity, and administrative workflow, and clear guidance is needed to ensure compliance without duplicative processes.

3. Program Supervisor Title Requirements and Role Alignment
There is language suggesting changes or standardization of program supervisor titles. This presents challenges as our organizational structures and HR frameworks are aligned to established roles and titles.

4. Level of Care Changes and Clinical Fluidity
As is common in community-based services, individuals’ levels of care can change based on a variety of clinical factors including stabilization, decompensation, hospitalization, engagement, or life circumstances.

• How transitions between CPST tiers will be operationalized in real time,

• Whether new service authorizations will be required each time a level of care changes, and

• How continuity of care will be maintained during these transitions to avoid service gaps or delays.

5. CAHN Assessment Timeline
Has a projected timeframe been established for the completion and release of the CAHN assessment? This information is critical for workforce planning, role design, and program implementation decisions.

6. Transition of Current Clients / Grandfathering / Authorization Process
We are also seeking direction regarding how current clients and cases will be transitioned into the CPST model:

• Will existing clients be grandfathered into the new service structure?

• Will new service authorizations be required for all current clients?

• Will agencies be expected to reassess and tier all current clients prior to transition, or will there be an automatic conversion process?

Given the volume of clients served and the clinical complexity of many cases, this process will require significant planning and clear guidance to avoid disruption in services.

Thank you for the opportunity to respond to the latest draft of CPST regulations.  We appreciate the changes you have made in response to our voices.  Here are additional thoughts relating to the latest draft:

1. - Page 6.  3.2
“Individuals shall be referred to and their needs assessed for any clinically appropriate standalone EBPs of which they may meet admission criteria, prior to the authorization of CPST services, regardless of whether the agency completing the CANS Lifetime offers the EBP.”

How will this be monitored?

Will CPST providers be held accountable for providing CPST, in good faith, when a referral to EBPs was not made, unbeknownst to the CPST Provider?

2. - Page 10. 4.3(7)
“A single LMHP is prohibited from providing supervision/oversight of more than 120 cases in a calendar month. The total number of cases a single LMHP provides oversight to, shall take into consideration the other staff involved in the care of cases, for example, if supervising a number of LMHP-types who are completing the assessment, treatment planning, and psychotherapy components of CPST, 100 cases may be appropriate. If the LMHP is supervising primarily paraprofessionals and providing the assessment and treatment planning components of the service directly, oversight of 120 cases would not be appropriate.”

We appreciate the change in supervision requirements allowing LMHPs to oversee max case loads instead of numbers of staff.  We still believe, however, that there will be predictable gaps in accessing sufficient licensed people for this purpose.
The new regs allow for LMHPs to supervise a staff over a max case load of 100-120.  If the case loads are smaller (eg. 8), the number of staff an LMHP may supervise can be as high as 15.  This is an improvement from the max of 9 in the previous regs.  However, if the case loads reach 20 as allowed, the number of staff an LMHP may supervise may be as low as 5 (100/20).  There simply aren't enough fully licensed individuals interested in this work to allow for a sustainable service model.  Providers will enter into a bidding war for LMHPs leading to a large-scale consolidation of the providers with the deepest pockets.  Access will diminish significantly.

Additionally, there is no practical allowance or accommodation provided for losing an LMHP supervisor.  Are services expected to precipitously stop?  What will this accomplish other than to hurt the client and create instability?  The regs state that the Clinical Program Director may assist in this case, but what will this mean for their other duties?  What if a larger provider loses more than one LMHP, especially when they are lured away by another provider who needs them?

• We believe that LMHP-Es should be allowed to operate in these roles as they do today.  This solution is pragmatic and will allow for a sustainable and functional system.

• Furthermore, we would ask that providers are allowed more than one clinical director (regional clinical directors)so that we may fill the gaps should we lose more than one LMHP at the same time.

• Lastly, in the event that more LMHPs or LMHP-Es depart than may be backfilled by a clinical director, we ask that a window of time be granted to rehire (eg. 2 months)

• LMHPE-s being allowed to act as clinical supervisors will alleviate much of this need.

3. - Page 12. 5.3.(4-5)
“In-person crisis support shall be offered and available 24 hours per day, seven days per week, 365 days per year. The individual’s needs, preferences and specific crisis mitigation plan shall be the determining factor regarding whether crisis supports are provided in-person, face-to-face (telemedicine), or audio-only.”
"In-person crisis support shall be provided by the CPST provider prior to any referral to a Comprehensive Crisis and Transition Services (Mental Health Services Manual, Appendix G) unless the referral to Comprehensive Crisis and Transition Services or other emergency service is due to an acute crisis situation with safety concerns. If a referral to another type of service to assist with the acute crisis situation (911, 988, Emergency Room, CSB Emergency Services, 23-Hour Crisis Stabilization, Residential Crisis Stabilization Unit) is made by the CPST provider, the CPST provider shall remain engaged in the situation and with other service providers that are involved."

Must we respond to every crisis in some manner?
What if the client calls 988 on their own, unbeknownst to the provider?  Will the provider be held accountable?

4. - Page 21.- 9.1.(C)
“Phone contacts including attempts to reach the individual by telephone to schedule, confirm, or cancel appointments are not reimbursable.”

It appears that phone contacts are acceptable for crisis management but not reimbursable for other CPST services.  Is that the case?
Ref: page 12 - 5.3.(4-5):The individual’s needs, preferences and specific crisis mitigation plan shall be the determining factor regarding whether crisis supports are provided in-person, face-to-face (telemedicine), or audio-only.”

5. - Page 21 - 9.2(d)
“Individuals receiving CPST may not be simultaneously serviced authorized to receive the following services:
i. Applied Behavior Analysis with a primary diagnosis of Autism Spectrum Disorder,
ii. Assertive Community Treatment,
iii. Coordinated Specialty Care,
iv. Community Stabilization,
v. Functional Family Therapy,
vi. Mental Health Intensive Outpatient,
vii. Multisystemic Therapy,
viii. Psychiatric Residential Treatment Facility (PRTF) or
ix. Therapeutic Group Home (TGH) services.”

How will this be monitored?  How will CPST providers know if the client is receiving community stab, or other services?

6.
We would like a better understanding of how telehealth may be used.  We ask that this be spelled out directly with a simple explanation of who is eligible for telehealth, when they are eligible, and in what capacity.  It appears that telehealth may allow for all services to include crisis management, but not for Rehabilitative Skills Practice.

Thank you again for your hard work and willingness to collaborate.

QMHP/Ts are professional staff. This is the highest credential for this level of degree, and they are labeled “Qualified Mental Health Professionals”. Identifying them throughout as paraprofessionals is confusing, and that language should be adapted.

LMHP-Es should be able to function as LMHPs for all roles accept the clinical director role to include supervision, crisis consultation, assessment, etc. This is consistent with legacy service regulations and LMHP-Es are under supervision in order to be able to learn the skills to operate as full LMHPs upon licensure. This is an opportunity to ensure that they are receiving weekly guidance, and it is consistent with the supervision requirements by the DHP. At the proposed rates of services, hiring enough fully licensed staff to offer these services will be nearly impossible providing significant barriers to access to CPST services.

There is inconsistency is section 4.2.1 regarding supervision. In bullet #1 it is mentioned that QMHP types and LMHP-Es must have weekly supervision. However, in bullet #5 it is outlined differently. LMHP-Es should be permitted to provide supervision to QMHP/Ts and BHTs and it should be a monthly requirement as this is consistent with DHP regulations.

Assessments should be, at the very least, permissible as telemedicine-assisted, but ideally through Telehealth. Barriers in rural communities mean that it is often difficult for individuals to access care and virtual options should be allowable. This also supports the significant concern with availability of LMHP-type individuals in the workforce.

90-day face-to-face team meetings for ISP review as well as quarterly progress review requirements are excessive. One or the other makes sense, but requiring both is excessively burdensome to both agencies and the client’s families.

Access to other crisis services should be permitted for safety concerns BUT also should be permitted in geographies with significant geographic spread when the in-person on-call staff cannot get to the client in-person as quickly as mobile crisis response or alternative referrals. While this appears to be more permissible in the crisis mitigation section, it is contradicted in the initial language of 5.3 bullet #5 Additionally, it should be notated how billing works when CPST remains engaged simultaneously with other crisis services.

One barrier under the current services is the requirement that services must be initiated within 31 days. This is consistent in these draft regulations to begin services within 30 days. Language to outline exceptions would reduce burdens for reassessments when/if services are not initiated for reasons outside of provider/client control (i.e., MCOs not providing approvals in a substantial amount of time, client hospitalization, etc.). Audio-only collaboration with client/guardians during this time, should be permissible to provide more flexible service initiation when clinically indicated.

In section 9, #2.b.i. – it restates that providers are not permitted to provide crisis services to someone who is receiving CPST services. MCR specifically is dispatched via geolocation by 988 hubs and declining dispatches to individuals seeking this support would be clinically inappropriate and administratively burdensome on MCR teams to determine. This is also disruptive to smaller communities with limited providers offering multiple services (including CSBs).

Although some changes have been made in CPST policy since the last iteration, seems that there are still so many impractical expectations and requirements. The larger, general categories of concern have to do with restrictions on number of individuals that a particular supervisor can supervise, restricting caseloads, expectation of internal crisis services, increased need for licensed professionals, and disallowance for individuals to receive both PSR services and CPST services.  Overall, the outcome of redesign will be that individuals in need of services receive less services and many providers will not be able to provide the new services for reasons mostly related to workforce, cost, and controls of MCO’s.  This design will most definitely hurt our system rather than help.

The biggest concern regarding CPST is that there is no feasible way that the system will be ready to begin providing the new CPST services or other redesigned services on 7/1/2026. Given the policies & documents that will need to be created and the coordination between DMAS, DBHDS, and the MCOs before providers can begin to have a full understanding of what it will take in terms of staffing and training to achieve what is required to deliver the service, this plan is unattainable in this timeframe. Also, the education of members and community stakeholders in unachievable by this date. Listed below are many other concerns with the CPST paradigm.

1. CPST Teams: - Team definitions represent an extensive increase in reliance on Licensed staff. This will greatly increase the cost to provide the service as well as impact the ability of agencies to be able to offer this service due to the severe workforce shortage already evident for licensed-type providers.  The requirement for 24-hour service availability necessitates on-call staffing and compensation. Can you please explain how these rates will allow for this added staffing? The staffing expectations, and supervision requirements, seem to require a significant increase in licensed staff. Workforce shortages will make this difficult and provide additional barriers. The new section in this draft requiring case coordination is totally duplicative of Targeted Case Management.
2. Measurement Based Care: The CANS is an issue as it is an untested and not validated assessment. Also, there is an excessive amount of "recommended" assessments. Will all of these assessments become required?
3. Required Oversight & Supervision: Clarification of the word "direct" is needed. Does this mean within the same agency? On-site? Certain level of hours of supervision? The requirement for the licensed provider to provide in-person services every 90 days further increases the cost to provide services which is exacerbated by workforce storages. Management of providing this level of direct service as well as the required hours of supervision based on the provider type of staff decrease the feasibility of managing the multiple, increased requirements. The following describe the increased burden on LMHP staff:  minimum face-to-face team meetings weekly; weekly supervision for all non-licensed staff; supervision documentation maintained in employee records; LMHPs to write progress notes reviewing non-licensed team members every 30 days; DHP just create a pathway for QMHP-Ts to be supervised by experienced QMHPs. Because agencies worked together in forming the BH Redesign, why are QMHPs not allowed to supervise under CPST?
4. Crisis Support: CPST 24/7 crisis services are unnecessary due to the already established Emergency Services, Mobile Crisis Response, Regional Crisis Hubs, and 988 programs. Why are crisis services being limited for this program but not for other programs?
5. Psychotherapy: Why is Psychotherapy being provided under the CPST code at a lower rate than under outpatient?
6. Continued Stay Criteria: How is "not making sufficient progress" measured to trigger the need for an alternative service plan within 90 days? Nitey days is NOT sufficient time to make "sufficient progress."
7. Discharge Criteria: Four to twelve months is very limiting as it can take months to build therapeutic rapport with a client. Duration of services from 4-12 months is unrealistic, as is looking for improvement within 90 days from the start of services. These timelines need to be increased or removed. 
8. Exclusions & Service Limitations: The regulations state that members may not participate in both CPST and Clubhouse services. These are two very different programs that complement each other, and members should be able to participate in both. The regulations state that the provider shall not provide Mobile Crisis Response, 23-hour Crisis Stabilization, or Residential Crisis Stabilization to any individual receiving CPST. This will be a barrier to CSBs ability to provide CPST services. 
9. Summary: The BH Redesign needs to be responsive to the needs of Virginians with Serious Mental Illness. Currently CPST does not achieve this.

Thank you to everyone who has been working so diligently on Medicaid redesign and for allowing ample public comment.  In comparing the first draft of the policy to this draft, it appears that only fairly minor changes have been made.  In reviewing all the comments, the patterns and consistencies are obvious.  I think the comments are fair, comprehensive, and reflect accurately on the services from the perspective of those who provide them.    I will isolate my comments to only three areas.

1.  The overall flavor of the document is overly prescriptive in terms of defining the way that agencies need to manage their staff.  It suggests that DMAS does not trust agencies to train, supervise, and monitor staff appropriately.
2. The focus on the services not being long-term in nature reflects a poor understanding of the nature of the SMI/SED population.  I think that all of those who work with this population and are highly invested in those they serve would be thrilled if natural supports could take the place of professional/paid services.  Sadly, this is not the case for most of those we serve.  Many clients have extensive trauma histories due to abuse suffered in their families of origin, have families with untreated mental health and addiction issues that affect their capacity to provide support, and have financial, transportation, and residual mental health symptoms that are genuine barriers to making and sustaining friendships.  All of this is exists within the context of an epidemic of loneliness and isolation that has been well documented and extends beyond those with SMI.
3. The necessity to provide a face-to-face, in-person response 24/7 continues to be a concern.  While I appreciate that crisis mitigation plans will be an integral part of the treatment model, anyone who has worked extensively with this population knows that these written plans are never 100% effective, especially in the early stages of treatment.  It has been stated that an in-person response should be needed only very rarely due to crisis mitigation plans.  This is simply not true and hints at being out of touch with the realities of providing services to this population.  Additionally, we serve a very large, very rural area.  Cell phone coverage is sketchy or non-existent in many areas we cover.  Expecting staff to respond to crisis events after hours and alone is not reasonable or safe.  This may be the deciding factor in whether or not we can continue to provide what is essentially mental health skill building services.  I  do not exaggerate when I say that this is a life-saving service for some of our individuals.  Details provided upon request.

Thank you for the opportunity to provide comments on the CPST services and revisions.

Even with these draft changes there continues to be an over-reliance on LMHP type staff. Our rural CSB can barely find QMHPs let alone enough LMHP type individuals to support this.

If we are unable to provide these CPST services in our rural communities what happens to our individual’s who were participating in programs that allowed them to be in their least restrictive environment. We are also supposed to take away their only support systems in most cases. Some individual’s are used to be provided services up to 4+ hours per week and it is likely that without services in place or at least a tiered reduction/plan in services these individuals will decompensate and predictably end up in the hospital or having other emergency situations. Many of the individuals in our rural community participate in MHSS services. This is there only socialization and support. Due to the rural nature of our CSB, trauma in individual's lives, and just lack of ability to engage with others due to symptoms and personal reasons, taking away a service that they rely on heavily is doing them a disservice.

It states that individuals must show “significant improvement within 90 days” or ISP must be rewritten also seems like authorizations happen every 90 days so service would likely not be reauthorized. This is not a realistic timeframe for individuals with serious mental illnesses. If an individual is new to a service they are still building rapport at this point.

It does not seem realistic for a QMHP to work a 40 hour week and then have to be “on-call” to provide emergency services to individuals. It is my understanding that the person who works specifically with the IND would be the one who needs to respond during an emergency. Will there be training for QMHPs for managing emergencies and learning how to handle these situations?

The transition is supposed to happen July 2026. It is already almost the end of January, yet there has been no mentioning of trainings for these services. Yes community/child services had one training however it was not even enough room to scratch the surface of individuals who will need the training. There has been no mention of when another training will occur. This deadline is quickly approaching and I fear we will not be adequately prepared for the transition.

This draft reflects efforts to address some of the concerns voiced by providers. Thank you for that. It's getting closer but there is more work to do. As CPST will likely be postponed until January of 2027, I'd love to see manual amendments paused in favor of a deeper focus on business sustainability alongside client care. Perhaps this extension will allow time to take a deeper look at what has gone well and what has not in other states. Perhaps accountability can be further sorted. Putting Virginia at the forefront of behavioral health care seems like an optimistically reasonable goal, right? A girl can dream. :) At the very least, we have a chance to make this better. It's not a lot of time, but let's make the most of it. 

CPST services will be extremely challenging for CSB's to implement.  Some primary concerns that we have are the following:

1. The CPST teams heavily rely on licensed staff in an environment where workforce shortages are prevalent.  This is a primary reason that we will not be able to offer CPST is the requirements for licensed and licensed eligible staff delivering in-person services and the required reliance on LMHP's to be able to offer the service.  
2. Requirements for failed services prior to the implementation of CPST would be difficult and cause significant delays in accessing needed services.  This would lead to increased reliance on inpatient treatments.  Many of these required failed options are not available or not easily access in rural service areas.  
3. Reimbursement rates do not support the required activities by providers.
4. Restricting the use of existing crisis staff to deliver crisis response to individuals receiving CPST and requiring the provider to offer crisis response within the CPST treatment model itself is not an efficient use of resources.  In rural areas, staffing shortages and increased cost will prevent providers from being able to deliver this service.