77 comments
Requiring a face to face visit in the community while ideal does not acknowledge the client's rights and say in treatment. Clients might have a mistrust of the system, don't want workers at their home, or to be seen with workers in the community. This does not allow for that option therefore affecting their rights, their access to treatment, and their say in their own treatment. There is plenty of work and help case management can provide in office, via phone, or virtually to help clients gain skills and independence within the community. Additionally taking the building of the ISP out of the hands of the clinician providing the direct service only further complicates things and puts more barriers in place for clients to receive services. These clients need individualized support from a trusted clinician they have built a relationship with not more strangers faces they see once a year/quarter and the more boxes that need to be checked effectively putting more "fingers in the pot" directing treatment only makes providing that individualized care more difficult to achieve and will negatively impact the client. Clients who have historical trust issues and documented paranoia, delusions, and trauma that are not being accounted for with these changes in regulations.
3.2.2 This comment has been made on earlier versions:
4.2 Related to this and similar requirements for staffing
5.3.2 Crisis Support
5.5 Care Coordination – see comment to 3.3.2 above
12.1 (#5) While it is understood that staff who work an excessive number of hours may not be providing their best service. And we would all like to be able to pay staff a sufficient wage to allow them to support themselves and their families without working multiple jobs, the rates paid for these services do not necessarily support a “living wage.” If staff are struggling they work additional hours (either for another provider or at the local WaWa) and that is not a discussion any employer can reasonably have!
This particular requirement is specifically troublesome
Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply. Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply. How will you know, and how will you monitor, and what are the consequences for non-compliance?
To whom it may concern,
I would like to recommend organizing an advisory/work group/commission etc. comprised of those knowledgeable/experienced in EBP services to assist with the EBP aspect of this proposal. EBP services in Virginia have been a niche service, and this design outlines a significant market shift for consumers as well as providers. Over the last several years I've spent a lot of time learning certain EBP models and becoming an advocate for these types of empirical evidenced based services that historically produce better patient outcomes and control cost. However, I do have concerns with several key areas; to include scalability and sustainability for providers (which impacts patient access to care), provider startup capital requirements and EBP model requirements being able to fully align with Federal and State regulatory requirements under CMS, DMAS and DBHDS. I also have concerns with our human capital resources as it relates to how our workforce in Virginia has shifted since Phase 1 of redesign and Covid, and if there needs to be clinical and regulatory adjustments to better reflect our current workforce market. These programs can be labor intensive.
-This group for example would assist with understanding what a new provider financial profile should consist of and if current requirements for new provider applicants are a realistic barometer based on the carrying cost associated with EBP service models. Or if EBP companies can adjust model requirements to assist with lowering cost for new provider applicants in year 1. Also evaluate areas of adjustments for agencies/companies beyond year 1.
-This group for example would evaluate current Federal and State regulatory requirements and work to see where adjustments can be made to fully align all regulations and EBP clinical models. Also work to align EBP model language with regulatory language or vice versa. This may result in developing completely different provider manuals (all chapters) and or how they are formatted (structurally, terminology/language, utilization etc.) for EBP services.
-This group for example would assist with developing a strategic EBP Statewide development plan based on market analysis and business impact studies (to include small businesses) and subsequent transition plans designed to insure long term sustainability and growth of EBP services in Virginia. This would include evaluating all existing statewide EBP data/outcomes.
Please define and provide detailed descriptions for all required modifiers within the policy.
There is a concern that the Medicaid Conduent claims system may not currently be able to accommodate the adjudication of claims submitted for the same date of service when different modifier combinations are applied. This limitation is already evident with mobile crisis response H2011 claims.
Conduent will need to ensure that its system can effectively manage the complexity of processing claims with identical dates of service but varying modifier combinations, in order to support accurate adjudication and ensure providers are reimbursed appropriately.
Medicaid cannot be trusted. It should not exist, period! Because it cannot be trusted, unfortunately.
Section 12. CPST Billing Requirements
Section 12 should be revised to include clear Place of Service (POS) billing guidance for CPST. The proposed regs expand services into natural, community-based settings (which is a positive change!). But they do not explain how providers should determine the correct POS when services occur in multiple settings during the same encounter or when billable activities, such as treatment planning or care coordination, occur from the provider's office.
Without clear guidance, providers and MCOs will interpret POS requirements differently. This creates unnecessary audit risk, recoupments, and administrative burden; even when services are delivered appropriately.
A standard DMAS POS billing policy should be established and applied consistently across FFS + MCOs, so providers have one billing standard to follow, and we’re not left guessing.
I appreciate the opportunity to provide feedback on the proposed Community Psychiatric Support and Treatment (CPST) regulations. As a provider of school-based mental health services, I am deeply concerned about the feasibility and impact of several provisions on access to care for youth and families. While the intent of the regulations is clear, the cumulative effect of these requirements will significantly limit service delivery in community and school settings.
In conclusion, without meaningful revisions to increase flexibility, reduce administrative burden, and account for the realities of school-based service delivery, these proposed regulations will significantly reduce access to care for youth and families. I strongly encourage DMAS to further engage providers and incorporate practical adjustments to ensure these regulations are both clinically sound and operationally feasible.
Section 12. CPST Billing Requirements
The proposed regulations are very prescriptive about how CPST should be delivered. However, the billing structure does not reflect that same level of specificity. The draft identifies separate required service components, but most share the same procedure code and modifier combination, with billing differentiated only by provider type rather than the service performed.
By assigning the same billing code and modifier combination to multiple required service components, DMAS and the MCOs cannot determine from claims data which required services are actually being delivered. The only way to determine whether providers are complying with these requirements is to perform a chart audit. That seems like a missed opportunity when claims data could provide this information in real time through distinct service component modifiers.
The current billing structure also creates a claims processing issue. The draft regulations permit simultaneous billing for assessment and treatment planning when clinically appropriate, yet both services share the same billing code and modifier combination used for psychotherapy, care coordination, crisis support, and other CPST service components. Without a way to distinguish these services at the claim level, claims systems may identify legitimate simultaneous billing as duplicate or overlapping services.
Suggestion: Section 12 should be revised to include distinct billing modifiers for each CPST service component. This would allow DMAS and Medicaid MCOs to monitor utilization, spending, required service frequencies, and compliance through claims data instead of relying on what was proposed during the authorization process and waiting for a chart audit to determine what actually occurred.
Right now, claims only tell DMAS that a service was billed. They don't tell DMAS which required component of the CPST model was actually delivered, just that a claim was billed.
Distinct service component modifiers would change that. This would give DMAS and the MCOs real-time visibility into how CPST services are being delivered, identify utilization trends much sooner, and confirm that required service components are occurring. This would allow earlier intervention when service delivery does not align with the intended model.
7.4 It appears that the planned “methodology” for documenting staff qualifications (i.e., completion of the “required training”) is to require that providers “submit information pertaining to the qualification of each staff person providing CPST to an external entity (CEBP at VCU) and keep information “current and active.” In addition to maintaining internally a record of staff qualifications and training for examination by DBHDS Office of Licensure and submitting, as required, the same information to all of the contracted MCOs for the purpose of supporting the billing/credentialing as needed, this appears to be either duplicative (and therefore and uncompensated cost for providers), or an attempt to add an additional layer in an attempt to compensate for systemic failure of the existing system of oversight to be effective.
If the service is provided by a staff member who is qualified, the fact the an external entity does or does not have their name on a list is irrelevant.
Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply. How will you know, and how will you monitor, and what are the consequences for non-compliance?
4.1.2 Changes to this section reflect that DMAS heard providers' concerns about operating CPST with only fully-licensed supervisors, as was the case in V2. Allowing LMHP-types to supervise within the scope granted to them by the Board of Counseling is much appreciated. However, the suggested June 30, 2029 sunset date raises an obvious question: Why plan for failure before giving the policy a chance to succeed? If the flexibility works, let it work. If it doesn't, DMAS already has the authority to revise the regulations. An arbitrary expiration date seems unnecessary when the regulations can be updated if experience demonstrates a change is needed. Also, how will the supervisees' supervision hours be tracked and reported for accountability? Who will be following up and how? If no plan for this, this seems an easy target for potential dishonesty. If there is a plan for accountability, please consider the many new reporting requirements for providers already in place in V3. Perhaps simply a requirement that supervisees' completed hours data be made available to licensure upon request?
While we support the goals of improving access, quality, and outcomes, we believe the proposal remains sufficiently complex and lacks the critical operational, fiscal, and implementation details needed to fully assess its impact on individuals receiving services, providers, workforce capacity, and long-term sustainability. At this stage, several key elements remain unclear, including:
The current draft significantly expands provider responsibilities through new requirements for implementing evidence-based practices, managing referrals, coordinating crises, measuring outcomes, communicating with MCOs, training and supervising the workforce, and providing administrative oversight. However, stakeholders have not yet received sufficient information about the assumptions underlying the proposed rates or how the expanded service expectations are intended to be operationalized. Additional transparency regarding these assumptions is necessary to evaluate implementation feasibility, workforce implications, financial sustainability, and the overall impact on the client experience. We remain concerned that the policy requirements and reimbursement structure may not yet be sufficiently aligned to support successful statewide implementation.
Before final implementation, we encourage DMAS to provide greater transparency into rate-development assumptions and to assess the redesign's cumulative impact on client access, provider capacity, workforce sustainability, and the overall client journey. The ultimate measure of success should be a system that is clinically effective, operationally feasible, financially sustainable, and easier for individuals and families to navigate.
Impact on the Client Journey: The redesigned model introduces several new decision points, including specialty service screening, referral requirements, crisis planning, treatment planning, reassessments, and transition evaluations. While each requirement may be appropriate on its own, the cumulative effect may create a more complex pathway to care than currently exists. We encourage DMAS to evaluate the redesign from the perspective of individuals and families seeking services and to ensure that implementation simplifies, rather than complicates, access to care. Success should ultimately be measured by whether individuals can access services more quickly, more easily, and more effectively.
Expansion of CPST Responsibilities: The revised draft substantially expands CPST's scope beyond traditional rehabilitative interventions. As proposed, CPST providers are expected to deliver treatment, coordinate care, manage referrals, participate in crisis planning and response, communicate with MCOs, monitor outcomes, and meet fidelity requirements. Collectively, these responsibilities encompass psychosocial rehabilitation, mental health skill-building, case management, care coordination, crisis prevention, and treatment planning. We encourage DMAS to clearly define CPST's intended role within the continuum and to ensure that reimbursement, staffing assumptions, and productivity expectations align with these responsibilities.
Crisis Response Responsibilities: We support proactive crisis planning and coordination. However, several provisions appear to expand CPST responsibilities into areas traditionally managed by Virginia's established crisis system, including 988, Mobile Crisis Response, CSB Emergency Services, Crisis Stabilization Units, and hospital-based emergency services. We recommend clarifying that CPST providers coordinate with existing crisis resources rather than serve as a primary crisis response entity, thereby reducing duplication and role confusion.
Continued Stay and Long-Term Recovery: We support measurement-based care and outcome monitoring. However, many individuals receiving CPST have serious and persistent mental illnesses that require long-term support to maintain stability and prevent deterioration. The policy should explicitly recognize outcomes such as avoiding hospitalization, maintaining housing, sustaining employment, remaining engaged in treatment, and preventing relapse as meaningful indicators of success. Individuals should not be required to demonstrate continuous functional improvement to retain medically necessary services.
Administrative Burden: The revised draft significantly expands requirements for documentation, reporting, referral tracking, crisis planning, MCO communication, and treatment planning. While accountability is important, excessive administrative requirements may reduce direct service time, contribute to workforce burnout, and divert resources from clinical care. We encourage DMAS to streamline documentation expectations and eliminate duplication wherever possible.
Workforce Capacity: We appreciate DMAS' recognition of workforce challenges and its temporary flexibility regarding Clinical Director and Clinical Supervisor qualifications. However, the redesigned model requires more supervision, training, documentation, care coordination, and clinical oversight, even as behavioral health workforce shortages remain significant. We encourage DMAS to closely monitor workforce impacts, provider capacity, network adequacy, and access-to-care indicators throughout implementation.
Coordinated Specialty Care and First Episode Psychosis: We strongly support Virginia's continued investment in Coordinated Specialty Care (CSC) and in developing a sustainable, Medicaid-funded service for individuals experiencing First-Episode Psychosis. As implementation progresses, we encourage DMAS to maintain flexibility in engagement strategies, family participation, telehealth use, transition planning, and fidelity expectations. Successful early psychosis intervention often requires individualized approaches that cannot always be captured by rigid service thresholds.
The following comments are submitted by the Virginia Coalition of Private Provider Associations (VCOPPA) in response to the Draft V4 CPST Provider Manual released for public comment on June 8, 2026.
We appreciate the significant work that has gone into this policy and acknowledge several improvements made between the prior draft and the current version. We submit these comments in the spirit of constructive engagement and with the goal of ensuring this service can be operationalized effectively by private providers seeking to participate in Virginia’s Medicaid behavioral health system on behalf of the Medicaid members in need of these critical services. We respectfully request DMAS consider each issue before finalizing the policy.
Section 3 requires all CPST providers to incorporate evidence-based principles, practices, protocols, and policies into treatment planning and service delivery, and to document in their SOPs which elements they are incorporating and how staff are trained. While V4 reformatted these categories — an improvement — the definitions remain functionally unclear. Specifically:
The V4 requirement that providers “clearly identify” which EBP elements they are incorporating cannot be met if the underlying categories remain poorly defined.
Section 3.2 of Draft V4 was reorganized into three subsections and now includes specific documentation requirements when a standalone EBP is unavailable at the time of authorization — an improvement over Draft V3. However, a separate and ongoing obligation relating to youth service delivery during active CPST services remains unclear.
The policy states that for youth presenting with a disorder that aligns with an EBP that cannot be provided directly through CPST, providers shall ensure EBP options are coordinated through the care coordination component. We acknowledge that Section 3.2.3 addresses the steps a provider must take when seeking authorization in lieu of a standalone EBP — documenting the barrier, notifying the MCO, recording referral efforts, and including a transition plan in the ISP. However, Section 3.2.3 addresses the authorization scenario only. The care coordination language creates a continuing duty throughout the service period, and it is not clear what active steps are required of the provider once services are underway. Specifically:
CPST is a new service type with substantial training requirements. Depending on credential type, providers must ensure staff complete: the Foundational Skills Curriculum (FSC); MAP credentialing for all youth-serving LMHPs and LMHP-types; CANS Lifetime certification for all assessment staff; the CPST Intermediate Skills (IS) Curriculum for QMHPs, QMHP-Ts, and BHTs (added in V4); and documented EBP training for all adult-track LMHPs and LMHP-types. This is a significant, largely unfunded investment. Draft V4 does not indicate whether training costs were considered in the rate study, whether any training is reimbursable, or whether accommodation exists for providers who must train staff before rendering billable services.
This training burden risks creating a landscape where only large, well-resourced agencies can enter this market. Smaller providers — including group practices and community-based organizations — may be unable to absorb training costs before generating revenue, threatening network sufficiency particularly in rural and underserved areas.
Attachment 1, Section 1 requires all youth-serving LMHPs and LMHP-types to achieve MAP Credentialed Therapist status within 18 months of enrollment or hire, and requires at least one MAP-credentialed therapist on staff at all times. This creates significant operational challenges:
Attachment 1, Section 3 requires weekly supervision contact for non-licensed staff, with monthly minimums of two hours including at least one hour of individual supervision. While robust supervision is essential, prescribing the exact split between individual and group formats within a monthly hour minimum does not allow for clinical discretion and does not reflect how supervision is typically structured in community-based settings. Supervision needs vary based on supervisee experience, caseload complexity, and the Clinical Director’s professional judgment.
Attachment 1, Section 3.4 requires DHP board-approved supervision documentation to be maintained in the employee’s employment (HR) record. This requirement is unworkable: personnel files are legally protected records. Clinical supervisors — including the CPST Clinical Director — do not have authorized access to an employee’s HR file, nor should they. These files are controlled exclusively by HR departments and subject to confidentiality protections. A clinical supervisor cannot add documentation to a protected personnel record, and an HR department cannot reasonably be expected to accept, organize, and maintain ongoing clinical supervision logs as part of its personnel file function.
This creates a difficult compliance situation for providers:
Supervision documentation is clinical and compliance-related in nature. It belongs in a location that clinical and compliance staff can access, maintain, and produce on request — such as a designated compliance file, a supervision log maintained by the program, or a staff credentialing file separate from the protected HR record. The policy also does not specify what form “official documentation” must take or how frequently it must be updated.
Section 8.4 requires Tier 2 youth caregivers to participate in at least one hour of CPST weekly, attend quarterly treatment planning meetings, and be available for crisis consultation within two hours during business days. We acknowledge the reduction from two to one hour weekly. However, the policy does not address what providers must do when caregivers consistently fail to meet these requirements during an active authorization period. The policy states that if a caregiver is not engaged following initial authorization, the ISP must be updated before reauthorization — addressing only the reauthorization scenario. Providers need guidance on what happens during the active authorization period:
Youth in Tier 2 have the greatest level of need and are most likely to have caregivers facing participation barriers. A policy that allows service discontinuation based on caregiver behavior without clinical discretion risks harming the youth it is designed to serve.
Section 12 billing tables specify that for Restorative Life Skills Training, “all professional levels of staff shall bill” using the HN modifier — the modifier associated with QMHP and QMHP-T staff — even when the service is delivered by an LMHP or LMHP-type. This means an LMHP delivering this service bills identically to a QMHP and is reimbursed at the same rate, which is inconsistent with every other clinical component in the billing table where LMHPs use the HO modifier at a higher rate.
If this is intentional — a flat-rate component regardless of credential — it should be explicitly stated so providers can plan accordingly. If unintentional, the table should be corrected. Restorative Life Skills Training is a high-volume component; billing LMHPs at the QMHP rate has direct revenue implications that affect provider financial viability and creates a disincentive to assign licensed clinicians to a service that may clinically warrant their involvement.
We appreciate the opportunity to submit these comments and strongly support expanding access to intensive community-based mental health services for Virginians with serious mental illness and serious emotional disturbance. These comments are intended to ensure the policy enables private providers to participate effectively, sustainably, and in compliance with clear and implementable standards. We respectfully request written responses to each comment and an opportunity to engage further with DMAS staff prior to finalization.
Nina Marino, Government Affairs Chair
Virginia Coalition of Private Provider Associations (VCOPPA)
The current billing structure indicated is likely to create operational challenges. While the draft permits simultaneous billing for assessment and treatment planning, these services share the same CPT codes as other CPST components. Without clear differentiation at the claim level, systems may incorrectly flag valid concurrent billing as duplicate or overlapping services.
Greater specificity in billing codes and/or modifiers is needed to clearly distinguish CPST service components. Without this clarity, both MCO and Medicaid claims systems may face implementation challenges, potentially disrupting claim adjudication and creating unnecessary administrative burden.
Ensuring sufficient billing detail is critical to support a seamless implementation and to avoid unintended negative impacts on provider reimbursement.
There continues to be concerns over crisis regulation as well as supervisory requirements. The clinical director role is more established but extremely prescriptive. The amount of supervision time will take away from the service delivery. Perhaps the regs should set a minimum amount of time particularly for clinicians that are seasoned and do not need the amount of supervision as a possible new hire. The crisis requirement still requires that staff work 24 hours. The reimbursement rate does not allow an agency to pay their staff at a rate that pays for 24 hours of availability. Why would we not allow the individuals with additional training and experitise in crisis handle crisis.
7.1 Communication of DBHDS-OL Corrective Action Plans to MCOs suggests that a CAP is relevant to one or more individuals who are associated with a particular MCO – obviously that will most likely not be true. Individuals are not (for HIPAA reasons) identified in a CAP. By having a secondary review by all six MCOs – using different formats, with different criteria when it is possible that none of their clients were involved will be an expensive, and time-consuming exercise for any provider months into the future!
Any of the MCOs will be entitled to use their own criteria for review, response, and for any requirements for “corrective action”, while possibly none of the specific citations are relevant to either an individual supported by the MCO or a service paid for by the MCO.
Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply. How will you know, and how will you monitor, and what are the consequences for non-compliance?
Mental health providers across Virginia have partnered with the Department of Medical Assistance Services (DMAS), the Department of Behavioral Health and Developmental Services (DBHDS), the Department of Health Professions (DHP), members of the General Assembly, and administrations of both political parties to strengthen Virginia's community behavioral health system. Throughout this time, providers have consistently shared practical recommendations based on direct experience delivering services to Medicaid recipients, supervising clinical staff, and navigating managed care requirements.
The current draft of the Community Psychiatric Support and Treatment (CPST): Community Services Manual does not appear to reflect many of the concerns repeatedly raised by front-line providers. As written, several proposed requirements have the potential to increase administrative burden, reduce workforce capacity, and limit access to care, particularly for Medicaid recipients served by small and mid-sized community providers. The limited volume of public comments submitted on this draft should not be interpreted as broad agreement with its provisions. Rather, many providers have lost hope in the regulatory revision process.
This feedback focuses on three areas that are likely to have the greatest impact on behavioral health services throughout the Commonwealth: clinical supervision requirements, workforce development and training requirements, and operational requirements affecting provider sustainability and employee retention.
The draft CPST Community Services Manual introduces several supervision requirements that, while intended to strengthen oversight, may unintentionally reduce the availability and effectiveness of qualified clinical supervisors. Several provisions appear to conflict with established supervision practices recognized by the Department of Health Professions (DHP) and National credentialing standards for Advanced Clinical Supervisors, and do not reflect the operational realities of community-based behavioral health services.
One of the most significant concerns is the elimination of tele-supervision as an acceptable method of providing clinical oversight. Clinical supervisors have successfully utilized secure tele-supervision for well over a decade, long before its widespread adoption during the COVID-19 public health emergency. The Department of Health Professions permits licensed clinical supervisors to provide supervision through secure technology when consistent with professional standards, and nationally recognized Advanced Clinical Supervisors similarly recognize tele-supervision as an appropriate modality when implemented responsibly. Many clinical supervisors also hold the Board-Certified Tele-mental Health credential. We know tele-supervision is effective in rural and underserved communities with limited access to licensed supervisors; organizations operating across multiple service locations; agencies employing hybrid or mobile clinical staff; immediate consultation during clinical crises; post-incident debriefing and risk management; and maintaining continuity of supervision when travel is impractical or would delay clinical consultation. Removing tele-supervision from the manual may inadvertently reduce access to experienced supervisors, increase travel requirements, delay clinical consultation, and create additional workforce barriers without evidence that these restrictions improve client safety or clinical outcomes.
Section 3.4 references compliance with the "higher standard" when DHP and DMAS requirements differ. Clinical supervisors are already regulated extensively by the Department of Health Professions through statutes, regulations, continuing education requirements, supervision standards, and disciplinary oversight. Introducing additional Medicaid-specific supervision requirements that differ from DHP standards creates unnecessary regulatory complexity and increases the potential for inconsistent interpretation during audits by MCOs.
Section 4.2 requires Clinical Directors to be able to provide in-person services and travel to an individual's location when clinically necessary. While timely access to clinical leadership is an appropriate objective, the proposed language may unintentionally restrict organizations serving geographically large or rural regions. Many Clinical Directors oversee multiple schools or districts, and increasingly reside outside the communities they supervise because of workforce shortages, housing availability, or regional cost-of-living considerations. The current language may also limit agencies' ability to utilize telehealth and other evidence-based methods of consultation that have become integrated into modern behavioral healthcare delivery. A more flexible standard that requires agencies to demonstrate timely access to clinical leadership—rather than requiring routine physical proximity—would better accommodate the realities of workforce distribution while preserving high standards of clinical oversight. The role of the clinical director in providing oversight of clinical supervisors and staff in client care is confused with direct care interventions in this section and does not reflect the work of clinical directors.
Clinical supervisors already carry substantial professional liability. They are responsible for ensuring that supervisees practice within their scope of competence, monitoring clinical documentation, overseeing ethical practice, responding to high-risk situations, and maintaining compliance with DHP regulations. Additional restrictions that do not clearly improve clinical outcomes risk reducing supervisory capacity while increasing provider attrition. Effective supervision requires an environment in which supervisees can openly discuss clinical decision-making, ethical concerns, professional impairment, secondary traumatic stress, burnout, and challenges that may affect the delivery of care. These conversations strengthen client safety by allowing supervisors to identify risks early and provide appropriate guidance. The draft manual does not clearly define how supervision records will be maintained, who may access those records, or the extent to which supervision documentation may be reviewed during audits or by managed care organizations. If supervision documentation becomes subject to routine external review without clear safeguards, supervisees may become less willing to engage in candid discussions regarding professional challenges, mistakes, or emerging impairment. Such an outcome could unintentionally weaken one of the profession's most effective quality assurance mechanisms.
The 2025 Healthcare Workforce Data Center report for the VA’s LPC Workforce held information that we see as significant to explaining why maintaining a healthy workforce is difficult, such as 1 out of every 3 LPCs is under the age of 40, 87% of LPCs are female, and 29% of LPCs currently have multiple work locations. By combining multiple services into the new CPST model and requiring 24-7 coverage, such as in hospitals or CSBs, small providers will be unable to maintain the personnel for coverage, which will lead to further burnout and a workplace shortage. Unlike large health systems or Community Services Boards, small agencies employ relatively small clinical teams. The draft manual does not consider provider demographics and overly restricts referrals to entities that manage crises that result in evaluation and hospitalization after hours.
Clinical supervisors assume significant professional liability when determining service recommendations and ensuring that services remain medically necessary. When licensed staff complete comprehensive assessments and recommend services based upon their professional judgment, they remain responsible for those recommendations regardless of whether services are ultimately authorized by a managed care organization. In practice, providers frequently encounter situations in which extensive clinical documentation supports the need for services, yet authorization decisions differ because of varying interpretations of Medicaid criteria or manual language. These situations create challenges not only for providers but also for individuals and families whose access to care may be delayed or interrupted. The draft manual places substantial emphasis on provider accountability but provides comparatively little discussion regarding how differences in interpretation between providers and managed care organizations should be resolved. Greater consistency in medical necessity standards and oversight of MCOs would improve predictability for providers while reducing unnecessary administrative appeals and delays in treatment.
Career longevity in behavioral health is built upon rigorous education, supervised clinical experience, continuing education, and professional licensure. Licensed clinical supervisors typically complete graduate education, supervised internships or practica, post-graduate residency requirements, and ongoing continuing education before the Department of Health Professions authorizes independent clinical practice. These existing licensure standards are specifically designed to ensure competence, public protection, and accountability. Despite these established professional requirements, the proposed Community Psychiatric Support and Treatment (CPST) model requires licensed clinical supervisors and clinical staff to complete additional Managing and Adapting Practice (MAP) training before serving Medicaid recipients. The required MAP training represents a significant financial investment, with reported costs reaching approximately $4,500 per staff member, in addition to the time required for months of training. For many small community-based providers, these expenses are not financially sustainable. Each requirement requires additional staff time, training, quality assurance activities, administrative oversight, and financial investment. These responsibilities are not directly reimbursable under the current Medicaid payment structure.
When the Qualified Mental Health Professional (QMHP) credential was established nearly a decade ago, licensed clinicians accepted responsibility for supervising QMHP staff despite concerns regarding increased professional liability. Many organizations invested substantial time and resources into developing internal training programs grounded in evidence-based practices while maintaining cost-effective service delivery. The proposed requirements would effectively require many of these experienced supervisors to complete expensive additional training in order to continue providing services they have successfully delivered for years. This creates a significant workforce burden without clear evidence that the additional certification requirements will improve clinical outcomes beyond existing professional licensure standards.
Additional concerns exist regarding implementation of the Child and Adolescent Needs and Strengths (CANS) Lifetime assessment. Use of the CANS requires additional training, certification, and ongoing costs. At present, providers have limited information regarding how CANS data will be stored, who will have access to assessment results, what privacy protections will be implemented, and how confidential client information will be managed. Given the sensitive nature of behavioral health records, greater transparency regarding data governance and confidentiality protections is essential prior to implementation.
Behavioral health providers consistently strive to improve client outcomes through evidence-based assessment, clinical judgment, supervision, and individualized treatment planning. Rather than requiring costly proprietary training programs, providers would benefit from clearly defined medical necessity criteria, consistent authorization standards across Managed Care Organizations (MCOs), and timely reimbursement for medically necessary services. These changes would strengthen service delivery while preserving resources that could otherwise be directed toward direct client care.
Finally, implementation concerns have also been raised regarding reliance on proprietary training and assessment systems. Providers have reported inconsistencies in guidance regarding required MAP training modules, resulting in providers being guided by PracticeWise to complete incorrect MAP training modules. Because implementation relies on proprietary assessment and training systems administered by external organizations (Praed Foundation/PracticeWise), providers would benefit from greater transparency regarding vendor selection, governance, costs, data stewardship, and ongoing financial obligations associated with these required tools.
In 3.2.2, The statement: “Prior to authorization of CPST services . . . individuals must be assessed for and referred to any clinically appropriate standalone EBP for which they meet admission criteria, regardless of whether the agency completing the CANS Lifetime offers the EBP" turns private providers into veritable VICAP assessors of days gone by and represents a very time-consuming, non-reimbursed burden for providers who are not experts in the admission and exclusion criteria for each stand-alone EBP. Will there be yet another assessment developed for this purpose?
In section 3.2.3, the provider is charged with several more administratively burdensome tasks to include documentation; care coordination with the MCO; continued, on-going efforts to seek the standalone EBP; documentation of said efforts; and additions to the ISP to include the plan to discharge and refer the client to that EBP if and when it becomes available. Fortunately, the regulations state that a plan to transition will be made "if . . . clinically appropriate" because it would not, of course, ever be clinically appropriate to discharge and refer any client who was making sufficient progress with their current services. And, if the clinicians were successfully building trust and safety with the client (reflected in the research to be strongly correlated with treatment outcomes), ending services in favor of a standalone EBP would likely result in harmful loss for the client, interfering with our duty to uphold standards of beneficence and nonmaleficence. Therefore, the provider should only be expected to seek the availability of a standalone EBP if and when the current services are either unsuccessful and/or insufficient, wherein a referral is always warranted.
Please consider defining and including the Registered – Certified Peer Recovery Specialist (R-CPRS) designation in this program. It would also be helpful to both define and integrate the following roles into this program: Certified Peer Recovery Specialists (CPRS), Peer Recovery Specialists (PRS) and Family Support Partners (FSP). They are all important roles within the community (even if and/or especially because they are non-clinical in nature).
Any R-CPRS is billable, and I am not entirely sure why this part of the workforce is not included within the CPST framework proposed. Willing to answer further questions in relation to and/or offer support in how to integrate this information.
Staffing & Clinical Oversight
Pg. 5: The requirement that the CPST Clinical Director be available to provide in-person support at the individual’s location when clinically indicated may not be operationally feasible. A single individual cannot maintain continuous availability due to leave, illness, and competing responsibilities. The draft does not address delegation to another LMHP. Additionally, since each team tier already includes an LMHP, it is unclear why in-person involvement from the Clinical Director specifically is required.
Pg. 14: The requirement for LMHP Clinical Supervisor involvement when individuals show limited progress or lack engagement may create operational burden. Clarification is needed on thresholds for involvement and whether this expectation is scalable across caseloads.
Pg. 36: The requirement for an LMHP to either document a review every 30 days or co-sign all non-LMHP notes may be administratively burdensome. Consider clarification or flexibility in supervision expectations.
Assessment Requirements
Pg. 8: It is unclear whether the CANS Lifetime assessment replaces the CNA or is completed in addition to it. If it replaces the CNA, clarification is needed on whether it satisfies Licensing requirements, given the number of additional recommended assessments.
Pg. 12: If a CANS Lifetime completed by another DMAS provider within the past 12 months must be used, this may conflict with Licensing requirements for completion of an initial, comprehensive CNA upon admission. Clarification is needed on compliance expectations.
Pg. 12: A copy of the CANS Lifetime tool has not yet been provided for review, limiting the ability to assess feasibility and alignment with requirements.
Pg. 13: Additional information is needed regarding the length, cost, and recertification requirements for CANS training.
Pg. 30–31: The requirement to complete a CANS Lifetime for step-down determinations and monitor changes over a 90-day period raises questions about frequency of administration. Clarification is needed on how often the CANS must be completed, given the time burden of the assessment.
Service Scope & Access
Pg. 10: If services such as Assertive Community Treatment (ACT), Coordinated Specialty Care (CSC), Functional Family Therapy (FFT), or Multisystemic Therapy (MST) are indicated but not available within the CSB, referral is required. It is unclear whether sufficient provider capacity exists in the community. Questions remain regarding availability of private providers and whether CSBs will accept out-of-catchment referrals, which may create strain on larger CSBs.
Pg. 18: The requirement for care coordination by CPST team members may duplicate services already provided by Mental Health Case Managers (MHCMs), who are qualified to perform this function without needing QMHP credentials. Clarification is needed to avoid redundancy.
Pg. 36: The draft indicates that care coordination is required but may not be billable unless conducted face-to-face with the individual or caregiver. This may create financial and operational challenges.
Crisis Coverage
Training Requirements
Pg. 40: The requirement for all LMHPs/LMHP-eligible staff providing CPST Youth services to obtain MAP (Managing and Adapting Practice) credentialing within 18 months presents a substantial training burden. This includes curriculum training, six months of consultation, and portfolio review.
Pg. 41–42: Additional DBHDS and EBP training requirements for both youth and adult services are noted. Clarification is needed on overlap, sequencing, and feasibility of completing all required trainings within specified timeframes.
Compliance & Reporting
Caseload & Documentation Tracking
Please find below our formal comments and requests for clarification regarding the proposed CPST draft policy.
1. Crisis Response Requirements (Sections 4.5 and 5.3)
We are concerned that the requirement for 24/7 LMHP access and after-hours coverage will exacerbate staff burnout and workforce shortages. Furthermore, it is unclear how providers will be reimbursed for these extended responsibilities. We request clarification on how these requirements will complement, rather than duplicate, existing Virginia crisis systems such as 988 and Mobile Crisis.
2. Psychotherapy and Service Duplication (Section 4.3)
The allowance for LMHP contacts to include psychotherapy may create overlap with existing outpatient services. We suggest more distinct language to differentiate CPST from outpatient therapy to ensure clinical appropriateness and avoid service duplication.
3. Care Coordination and MCO Involvement (Sections 3.2.3 and 5.3)
The proposed reporting expectations appear to increase administrative burdens without necessarily improving outcomes. We ask for a review of these requirements to ensure they do not exceed current authorization and utilization review processes.
4. Documentation Burden (Sections 4.3, 4.4, and Related Requirements)
The cumulative documentation, supervisory review, and tracking requirements may reduce time spent on direct service delivery. We encourage DMAS to streamline these requirements to maintain a focus on community-based support.
5. Reimbursement
Has a final reimbursement rate for CPST been established? Given the increased staffing and crisis response expectations, sustainable reimbursement is essential for provider participation.
6. Caseload Requirements (Section 4.7 and Attachment 1, Section 4)
We request clear guidance on how caseload limits will be calculated and monitored across various staff positions and service intensities.
7. MAP Dashboard Requirements
There is currently no strategy regarding the long-term management or funding of MAP resources. We require clarification on how agencies are expected to afford MAP training and account maintenance for each student.
8. LMHP-E Type
While we appreciate the extension of supervision to LMHP-E eligible staff through 2029, will there be a funding increase to support the retention of licensed staff once this provision expires?
9. Clinical Documentation Reimbursement
How will the additional hours of clinical documentation required by CPST be reimbursed? The current draft does not provide a mechanism for billing these administrative hours.
10. Service Overlap Restrictions
What is the rationale for restricting the overlap of CPST School and IIH when the treatment goals remain distinct?
11. MCO Coordination
Care coordination should remain the responsibility of the MCO. We request direct contact information for care coordinators during crises and clarification on reimbursement for the additional provider hours spent on these coordination.
Comment #1: Concerns with MCOs Increasing Power of Oversight with Little Protection for Providers
Thank you for the opportunity to share feedback on the most recent draft of CPST - Community regulations. We appreciate several of the changes made including the provision allowing certain LMHP-Types to act as supervisors for a time and raising the number of units permitted each month for non-licensed staff. While we acknowledge that some beneficial changes for providers were made, our agency also has several concerns with some of the changes that were made, particularly the increased regulations surrounding MCO communication and oversight and the number of separate agencies who have been given regulatory power.
Concerns with increased requirements and regulations for interactions with MCOs
The increased requirements to contact and update MCOs (sections 3.2.3, 5.3.2, 5.5) are concerning due to the level of difficulty we have experienced attempting to contact and communicate with MCOs as well as the significant increase in documentation and administrative burden that this will add for staff. Often, providers are stuck in never ending phone trees that result in dropped calls, voicemails that are never returned, or overall inability to get ahold of MCOs (and specifically, Care Coordinators). We have also experienced where MCOs will not divulge Care Coordinator’s contact information until an authorization is in place due to confidentiality.
Providers and MCOs will need a better plan for how to get ahold of MCOs, including increased accountability on MCOs to participate in this process. Please ensure that providers can contact MCO care managers in efficient ways to honor provider’s time and to specify that providers will not be held accountable by the MCOs if we cannot get hold of them. If contact with MCOs is not improved, this will negatively impact both providers and clients as it can lead to a delay in getting services started (especially if CPST providers must now also contact MCOs to explore EBP availability with other providers), and providers do not have an avenue for reimbursement for the time spent coordinating and attempting referrals.
Additionally, the comment in section 10.1 #6 about service authorizations potentially being removed as a requirement (similar to outpatient therapy where no pre-auth is required) is concerning, especially if the MCO can claim in a future audit or when reimbursement is submitted that an authorization was never in place.
Here are the specific areas that we believe need to be addressed:
Responsibility for securing referrals to EBPs should either be placed on the MCOs
-OR- CPST providers should be provided with efficient methods for securing reimbursement for the administrative time spent on care coordination as the reimbursement listed in the rate study is not sufficient for the requirements listed in the draft regulations.
There needs to be a streamlined process for MCOs to be efficiently contacted for CPST and EBP referrals specifically. MCOs need additional accountability for providing efficient contact methods and ensuring appropriate response times for providers.
To make coordinating services easier, MCOs should provide Care Coordinator information for CPST clients on the front end rather than requiring that an authorization be in place -OR- should have a dedicated CPST referral contact person (MCOs should not be permitted to gatekeep the Care Coordinator contact info until an authorization is in place).
If pre-authorizations are removed as a requirement, a registration process should still occur where providers can get an Authorization # and Units approved to help avoid lack of reimbursement during future audits or billing issues with MCOs. The agreement should document that providers are approved and authorized to bill for services.
DBHDS CAPS Submitted to MCOS (Section 7.1)
There are issues with the requirement that DBHDS CAPs must be sent to MCOs. This is concerning on multiple levels including but not limited to:
DBHDS has a core focus on quality management and enforcing fidelity of services provisions, and CAPs are currently used to improve the quality of services. However, having every CAP reported to MCOs will lead to a lack of trust and fear between providers and DBHDS and likely decrease reporting areas of improvement needed and action planning to improve those areas.
Also, from experience with a variety of Licensing Specialists, the level of audits and attention to details varies greatly where some Licensing Specialists are more detailed and others are less. So, some agencies may receive CAPs from a more detailed auditor, while other agencies could have similar areas for improvement overlooked.
Currently, we have a great licensing specialist who has used CAPs to help us improve our services and support clients better, but if there is now a fear of MCO involvement, it breaches that trust. The focus changes from improving services and recognizing areas of potential deficiency to preventing loss of funding (recoupments, additional audits from MCOs), that could negatively impact the stability of community programs for clients, staff, and agencies. Providers need close, safe, and trust-based working relationships with their DBHDS Licensing Specialists that can help find areas needing improvement without fear of MCO retribution.
Since DMAS is in control of funding and coordinating more closely with MCOs, it would feel more appropriate for DMAS auditors to issue CAPs that go to MCOs rather than DBHDS audits.
MCOs will not use CAPs to help providers improve their services. It will only be setting up MCOs to find more ways to recoup funding and take back money than they already do currently. This is only harmful for providers, specifically those who are striving for compliance and who are actively making corrections.
Here are the specific areas that we believe need to be addressed:
Only CAPS issued by DMAS should be sent to MCOs -OR-
Allow “good faith” and discernment for Licensing Specialists to decide if CAPs should be sent to MCOs. For example, severe compliance issues or fraud should be sent to MCOs, but areas where providers are showing “good faith” and attempting to abide by regulations, those CAPs should not be sent to MCOs.
Conclusion and Summary
At this time, it feels that significant power has been given to MCOs as many small requirements have been added onto providers, any of which can be used by MCOs to deny payments or justify audits. It does not seem like very many protections have been put into place for providers who are providing quality services. Even the CANs - Lifetime assessment, which was meant to offer standardized units and authorizations for providers and clients, has many potential issues with obtaining the assessment between agencies, accuracy, and frequency of recompletion without guaranteed reimbursement (Specifics will be listed in another comment from our agency). Please add more accountability for MCOs and protection for providers.
Comment #2 - Areas of Draft Policy Needing Clarifying Details
Our agency has a few areas in the regulations that we feel need more detail and specification in order to eliminate potential misinterpretation or differing interpretations between MCOs and agency providers.
Questions and Unclear Policy Requirements
Section 2.3, bottom paragraph states: "When services are delivered to younger children, the services shall be delivered with a caregiver or legally authorized representative participating with the youth as the services are delivered." What is the age range considered to be “Younger Children” that requires parental involvement at all times during services? This age range needs to be defined (or clearly written in the regulations that agencies are able to define this for themselves in policies/procedures), so that MCOs and Agencies are working from the same standard.
Section 5.1, #2: How quickly do assessments completed by LMHP-Types need to be approved by LMHPs? This timeframe needs to be clarified so that MCOs and Agencies are working from the same standard.
Please clarify the guidelines or process for recompleting the CANS assessment within the same year. For example, a youth completes a CANS that recommended MST 9 months ago, but they have since resolved their criminal concerns and are off probation, yet they still have major mental health needs. Who is responsible for recompleting the CANS - the MST agency that is discharging or the CPST agency? Does the CPST provider still have to refer to MST since the CANs recommended it? Will MCOs automatically deny CPST if we don’t make MST referrals because it is no longer recommended as part of the updated CANs? There are currently no clear guidelines on who is responsible for the CANS when an EBP ends or who will be held accountable to act on the CANS suggestions.
There also need to be clear policies expressing how providers are able to be paid for updating or completing new CANS assessments for major changes in clinical presentation or when EBPs are no longer clinically appropriate. Some portions of the regulations require a new CANS assessment (5.1 #1, iii; 8.7), and providers are expected to continually assess clients by reviewing their CANS-lifetime. Documented Progress is considered a positive change in LON within 18 months, something that can only be determined by completing a new CANS-Lifetime assessment. However, providers are only permitted to bill for 1 CANS per year. Please consider stating clearly in the regulations that providers will be able to bill for completion of a new CANs lifetime assessment, even if this is a different CPT code. You mentioned in the recent open office hours that this could be billed as a 90791 or a direct service code; please clearly outline this in the regulations.
Please clarify the protocols if CANS recommends more than one EBP. If the Crosswalk (eventually created) recommends multiple EBP, the regs need to clarify what providers have to do in regard to the other EBPs. If MST fails, do they have to do another EBP before beginning CPST? Who’s responsible for that decision - agencies, MCOs, clients, etc.?
Regarding Section 10.1 Section 8, the requirement for referring to EBP and contacting MCOs about EBPs before initiating CPST will lead to a delay in all services starting (CPST, FFT, MST, etc.). Contacting MCOs and other providers about their availability is not a quick process. A recommendation is to allow CPST to start immediately for a short period of time while also pursuing if another more appropriate EBP can get established (MST, FFT, etc.). This will also allow clients to start getting clinical services and provide transitional (Stop Gap) support while waiting on potential waitlists (even short waitlists) for other EBPs to get put into place.
Currently it stays that MCOs MAY provide a provisional auth to help start services while waiting to determine eligibility for CPST and EBP availability with other providers, but only if the CANS Lifetime cannot be completed. This needs to change to WILL provide a provisional auth (even if limited to low number of units) and that CPST Providers may initiate stabilizing services temporarily to give providers and clients assurance that services can start ASAP while waiting on coordination with MCO and screening EBP.
This recommendation would also provide reimbursement to CPST staff who are providing all of the requirements in the regulations including care coordination, “warm handoffs” to EBPs, contacting MCOs, and more to support this transition. Otherwise, private providers become responsible for anyone who is being assessed even if they are not admitted as a client, leaving no options for reimbursement.
Crisis Support Feedback
Thank you for clarifying some of the crisis policy regarding CPST vs. external referrals! Here are some additional thoughts and concerns about the Crisis Support regulations.
Suggestion for requirements to provide 24/7 Crisis Support (Section 5.3)
24/7 coverage is a major financial liability for private providers. Please allow flexibility to bill different CPT Codes for services that occur well outside of regular business hours (For example, any CPST units billed 8pm to 8am are allowed to be billed at the Mobile or Community Stab Rates).
Also, there needs to be language in the regs that providers will NOT be held accountable for any Crisis support that is not provided when units have run out -OR- the regs need to create a quick way to get provisional units added to the auth due to a crisis situation. Please also add accountability that MCOs must honor provisional units added to authorizations.
Section 5.3.2 Section C - For agencies with 24/7 hotlines for all programs (Outpatient, TFC, Crisis, CPST), can agencies utilize staff who are not trained in CPST to support CPST Clients if clients call their agency’s hotline? This needs to be specified in the language. For Example, if we have LPCs staffing the hotline who are not trained in CPST, and a CPST client calls the hotline, can the LPC bill for that time? Or, if it is a CPST staff member who is not on the client’s team (and has not signed their ISP), can this person provide those services?
Section 5.5 Section C Point iii - Please Define a “Warm Handoff” and what is expected of each agency (the current provider and new provider). Also, clarify if MCOs will allow overlapping auths to help with the handoff. Please avoid language that states MCOs “May” allow overlapping auths, as MCO will then default to never allowing it (as has been our experience with Crisis services). If an MST and a CPST provider are providing services concurrently during a “Warm handoff,” this should be reimbursable to both providers.
Concerns with CANS - Lifetime
The desire to have a standardized assessment that can cross agencies is a great idea in theory! However, there are numerous questions that need to be addressed in order for this to be a successful practice. Here are some specific questions and points of feedback:
How will agencies share the assessment?
How will one agency know if a CANS-Lifetime has already been completed by another agency?
Will ROIs be required in order to share CANS between providers? This should absolutely be a requirement, and that leads to potential service delays, HIPAA violations (if ROIs are not properly obtained), miscommunication (if mistakes are made or erroneous information is included in an assessment), denials by clients to share assessments between providers, etc.
If a client is receiving services from multiple providers, which provider will be responsible (and reimbursed) for completing the CANS at reassessment?
What happens if 2 agencies determine different LON for the same client?
Will insurance companies honor the LON determined by the agency, even if it is different from the initial LON at first assessment?
Will the receiving agency be held liable for the quality of the CANS assessment done by the initial agency or for any administrative errors?
I know you all have stated that you will be planning these components later on, but these are critical considerations for providers as we are formulating our CPST policies. Our priority is our client’s wellbeing, and we desire to provide quality services. However, reimbursement is a critical piece of service provision that agencies must consider in order to remain stable and maintain the ability to retain experienced staff and provide quality services. Please consider adding additional protections for agencies by clarifying these policies and by more clearly securing protection for agency reimbursement.
Comment #3 - Practical Feedback
Residents Serving as Clinical Directors
We want to acknowledge the improvement in the policy of allowing LMHP - Residents who are more than halfway through their hours to serve as clinical supervisors for a time! There is great potential in this policy to genuinely improve the quality of services while also supporting agencies with staffing and competitive hiring in the field. Here are a few thoughts on and recommendations for this policy:
The provision to temporarily allow LMHP-Types to serve as Clinical Supervisors is a tremendous support for smaller and/or more rural agencies who will face a challenge in staffing enough licensed people to meet the requirements of the previous drafts! We agree that there is a need for a licensed person to serve as the Clinical Director of the program; all clinical programs should have a licensed individual supervising, and we believe that the provision for allowing LMHP-Types to serve in that role should end in 2029.
One request is to extend the allowance for LMHP-Types who are more than 50% done with their hours and who have a certain amount of experience with CPST or related populations to serve as CPST Clinical Supervisors under the direction of a licensed CPST Clinical Director. There is justification for this under the definition of Collaborative Behavioral Health Services (§ 54.1-3500). Additionally, LMHP-Types will still be required to complete 4 hours of supervision-related activities including at least 2 hours of supervision with the licensed Clinical Director.
Extending this provision will
1) Increase the available workforce for community-based services
2) Provide career advancement opportunities for residents to allow smaller, rural agencies to remain competitive in the job market and
3) Increase the likelihood of LMHP-Types continuing in community-based roles once they have acquired their license.
I do appreciate and agree with the desire for licensed people to supervise and direct the CPST program. However, there need to be reasonable ways for agencies to fill these roles when licensed people may not be available -OR- when a very capable resident is ready for career advancement. There are sufficient ways to hold agencies accountable for supervision of residents. Examples include maintaining requirements for oversight by licensed individuals including signatures on documents like the CANS assessments and Treatment Plans; consistent supervision; and availability of an LMHP for consultation at all times. These elements are already required for CPST and are sufficient means of accountability that would allow LMHP-Types to effectively serve as Clinical Supervisors.
Level of Oversight and Requirements on Providers
There seems to be great efforts for collaboration between different agencies such as DMAS, DBHDS, the MCOs, CEP-VA, and PracticeWise! However, we have some concerns that so many agencies will have oversight and that the administrative burden needs additional scrutiny. Here are some specific examples:
Section 7.4 - CEP-VA CPST Finder - Having to maintain and update individual staff’s information in a 3rd party portal as part of the regulations is cumbersome and potentially leads to issues with MCO enforcement. What if an MCO looks up a staff’s info into the CEP-VA CPST Finder but CEP-VA hasn’t updated their portal? How often does the portal need to be updated? What are the potential consequences of not updating the portal? Can MCOs use that requirement to deny services or to recoup funding?
Recommendation: Please change the requirement so that the CEP-VA Finder tool only requires registering programs and locations as opposed to specific staff. This is more feasible and allows for less chance of admin errors. Only require providers update their Programs and Locations within the Look Up Tool as opposed to individual staff (especially since QMHPs have a high level of turnover which will cause extra work on CEP-VA and Providers since providers are constantly updating their staffing rosters).
Typos
I noted 2 typos in the draft policies.
Page 27: Point c. Personal Care and Daily Living Skills - This section mistakenly includes that the individual must demonstrate significant impairment in “person safety and self-regulation,” which is the section below (point d). It should instead read “significant impairment in Personal Care and Daily Living Skills"
Page 50, Chart 4A: This chart mistakenly lists the old draft requirement that the non-license staff billing cap is 600 units instead of 750
Sections 3.1, 8.1, and 8.3 (pages 8–9 and 22–26) tie admission criteria and levels of need heavily to CANS Lifetime scores. Adults living with chronic schizophrenia, bipolar disorder, psychotic disorders, severe depression, and other serious mental illnesses often experience fluctuations in functioning that may affect scoring without reflecting meaningful changes in their need for support. As written, the draft risks creating situations where individuals lose access to services due to minor changes in assessment scores rather than true clinical improvement.
On page 5, the draft states that the Clinical Director must be available to provide in-person support at the individual's location when clinically indicated. This expectation appears difficult to operationalize in practice. The draft does not address whether this responsibility may be delegated to another licensed mental health professional when the Clinical Director is unavailable. Additionally, each service tier already includes licensed clinical staff as part of the treatment team. It is therefore unclear why the Clinical Director would be expected to personally provide in-person intervention when other qualified licensed clinicians are already available to meet the individual's clinical needs. Clarification regarding delegation authority and the intended role of the Clinical Director in direct field-based intervention would be helpful.
On page 8, it is unclear whether the CANS Lifetime is intended to replace the Comprehensive Needs Assessment (CNA) or be used in addition to it. If it is intended as a replacement, clarification is needed regarding whether it satisfies existing licensing requirements for a comprehensive assessment. If it is intended to supplement the CNA, providers may be required to complete multiple overlapping assessments, significantly increasing administrative burden without necessarily improving clinical decision-making.
On page 12, providers are also instructed to utilize a CANS Lifetime completed by another DMAS provider within the previous twelve months. However, current licensing requirements generally require an initial and comprehensive assessment upon admission to a service. It is unclear whether reliance on a previously completed CANS Lifetime would satisfy licensing requirements or whether providers will be required to complete both assessments. Furthermore, the draft repeatedly references the CANS Lifetime as a critical component of admission, service authorization, treatment planning, level-of-care determinations, and step-down decisions, yet many stakeholders have not had the opportunity to review the actual assessment tool. Before implementation, providers should have access to the CANS Lifetime instrument itself in order to evaluate its content, clinical applicability, and operational impact.
Page 13 references training requirements, but no information is provided regarding the length of training, certification standards, recertification requirements, or associated costs. Given the substantial workforce challenges currently facing Virginia's behavioral health system, additional training requirements may have significant staffing and financial implications. Providers need a clear understanding of these expectations before implementation.
Pages 30 and 31 require a CANS Lifetime assessment to support movement from Tier 1 to Tier 2 services and reference monitoring individuals for ninety days following a step-down to identify worsening CANS scores. These provisions raise important questions regarding how frequently the CANS Lifetime must be completed. The answer has significant implications for administrative burden, staffing, training costs, and service delivery. If the assessment is lengthy or requires extensive training, repeated administration may divert resources away from direct clinical services.
Page 10… If the CSB doesn't provide and/or does not have availability for admission to Assertive Community Treatment, Coordinated Specialty Care, Functional Family Therapy, or Multisystemic Therapy and the service is indicated then the CSB must refer out. Will there be private providers for all these services? Are CSBs going to accept and serve out-of-catchment referrals? This might overburden larger CSBs.
The draft creates potential duplication regarding care coordination services. Page 18 requires care coordination activities as part of CPST, yet many of these responsibilities already fall within the scope of Mental Health Case Management. Qualified mental health case managers routinely coordinate appointments, facilitate access to services, connect individuals with community resources, and support continuity of care. Requiring CPST team members to perform these same activities may create duplication of effort and inefficient use of limited workforce resources. Consideration should be given to allowing qualified mental health case managers to fulfill care coordination functions where appropriate.
page 21… providers report DBHDS Corrective Action Plans (CAPs) to Managed Care Organizations. This requirement appears unique to CPST and does not appear to exist for other behavioral health services. Additional explanation regarding the rationale for this requirement and its intended use by MCOs would be beneficial.
Section 9.2(4) on page 32 appears to prohibit concurrent authorization of CPST and Psychosocial Rehabilitation services. As psychosocial rehabilitation transitions toward the International Clubhouse model, clarification is needed regarding whether individuals receiving CPST will be eligible to participate in clubhouse services. CPST and psychosocial rehabilitation serve distinct but complementary functions. CPST focuses on symptom management, treatment coordination, crisis prevention, and stabilization, while psychosocial rehabilitation emphasizes community integration, social connection, employment readiness, and functional skill development. Restricting access to both services may increase social isolation, reduce community participation, and ultimately contribute to higher-cost interventions such as crisis services, emergency department utilization, and psychiatric hospitalization.
We appreciate the significant effort that has gone into redesigning the Community Psychiatric Support and Treatment (CPST) service model and support the goal of improving quality and consistency of care. However, the proposed model is not financially or operationally feasible under the reimbursement rate currently proposed.
The proposed rate is based on the lowest end of the range identified in the Mercer rate study, while the draft manual substantially expands provider responsibilities through increased documentation, staffing, supervision, training, reporting, assessment, care coordination, and administrative requirements. These new expectations represent a significant increase in the cost of delivering CPST that is not reflected in the proposed reimbursement.
As written, providers will be required to absorb substantial unfunded administrative costs. This will divert resources away from direct clinical care, reduce provider capacity, worsen workforce recruitment and retention challenges, and may ultimately reduce access to services for individuals who rely on CPST.
If the reimbursement rate cannot support the full model, the administrative requirements should be scaled to match the available funding. A phased implementation would allow providers to focus resources on delivering high-quality clinical services while preserving access to care until a sustainable reimbursement rate is established.
The following requirements should be removed, delayed, or substantially streamlined until reimbursement adequately supports the proposed model.
The CANS Lifetime should either replace existing assessment requirements or remain optional until conflicts with current licensing requirements are resolved. Providers should not be required to complete multiple comprehensive assessments covering the same information.
Documentation expectations should be limited to information necessary to support medical necessity, treatment planning, and quality care.
The following requirements should be removed or deferred:
Several proposed reporting requirements create significant administrative work without improving clinical care.
The following should be eliminated:
Care coordination already performed by Mental Health Case Managers should not be duplicated by CPST staff. Existing qualified case management services should continue to satisfy care coordination expectations whenever those services are already in place.
Current supervision expectations require substantial increases in licensed staff time that are not reflected in reimbursement.
The following should be reconsidered:
Implementation should avoid creating unnecessary barriers to workforce recruitment.
Until reimbursement supports these expectations, providers should not be required to:
Providers should not be required to maintain formal monthly caseload calculations and six-month averaging logs solely for compliance purposes. Existing quality assurance and staffing processes are sufficient to monitor workloads.
When specialized evidence-based practices are unavailable, providers should only be required to document that appropriate alternatives were considered. Extensive documentation regarding referral efforts, provider availability, and Managed Care Organization coordination creates significant administrative burden without improving access when services do not exist in many communities.
Until reimbursement reflects the actual cost of the proposed service model, implementation should focus on maintaining access to direct clinical services by:
The proposed clinical model may ultimately improve quality, but it cannot be implemented successfully if reimbursement does not support the infrastructure required to operate it. Without meaningful reductions in administrative requirements or a sustainable reimbursement rate, providers will face increased operating losses, reduced staffing capacity, and diminished access to medically necessary behavioral health services.
We respectfully request that DMAS align regulatory expectations with available funding by either establishing a reimbursement rate that reflects the true cost of the proposed model or reducing administrative requirements until sustainable funding is available.
Thank you for the opportunity to provide comments on the draft Community Psychiatric Support and Treatment (CPST) Provider Manual. We appreciate the work that has gone into developing a more standardized framework for CPST services and support the overall goals of improving service quality, expanding access to evidence-based practices (EBPs), and promoting person-centered care.
However, we have significant concerns regarding several provisions that, as currently written, may create unintended barriers to service delivery, increase administrative burden, reduce workforce flexibility, delay access to care, and create conflicts with existing licensing requirements. We respectfully request that the following issues be clarified or reconsidered before implementation.
Several proposed requirements appear operationally unrealistic or unnecessarily duplicative.
The requirement that the CPST Clinical Director be available to provide in-person support whenever clinically needed does not account for vacations, illness, competing responsibilities, or other routine staffing limitations. The manual does not address delegation of these responsibilities to another licensed mental health professional (LMHP), despite LMHPs already serving on every CPST team.
Additional clarification is needed regarding:
The proposed implementation of the CANS Lifetime assessment raises several concerns.
It is unclear whether the CANS Lifetime replaces or supplements the Comprehensive Needs Assessment (CNA). If it replaces the CNA, clarification is needed regarding whether it satisfies current DBHDS licensing requirements for an initial comprehensive assessment. If it supplements the CNA, providers will face duplicative assessment requirements.
Additional clarification is requested regarding:
The draft introduces substantial new documentation requirements that will require significant revisions to agency documentation systems, policies, electronic health records, and staff workflows.
Examples include:
Collectively, these requirements significantly increase administrative workload without clear evidence that they will improve clinical outcomes or patient care.
While supporting the use of EBPs, we are concerned that the proposed referral requirements may unintentionally delay treatment and reduce person-centered decision making.
Questions include:
The manual also appears to require referral when individuals demonstrate limited progress after 18 months, regardless of their preferences. Clarification is needed regarding whether individuals may decline referrals and continue receiving medically necessary CPST services.
Several proposed responsibilities duplicate services already performed by Mental Health Case Managers.
Care coordination should continue to be performed by qualified case managers and should not unnecessarily duplicate existing services delivered by CPST staff.
Additional clarification is requested regarding:
Several key terms lack operational definitions, making consistent implementation difficult.
Clarification is requested regarding:
The proposed training requirements represent a significant expansion of workforce expectations.
These include:
Requiring documentation in multiple tracking systems, including DBHDS LMS and CEP-VA, creates unnecessary duplication. Existing provider learning management systems or documentation submitted during audits should satisfy compliance requirements.
Several provisions appear inconsistent with principles of person-centered care.
Requirements directing referrals based solely on duration at a particular level of need, allowing MCOs to recommend alternative services after provider assessment, or implying mandatory service transitions without considering individual preferences may undermine informed choice and continuity of care.
The manual should clearly state that individuals retain the right to accept or decline recommended services and that treatment decisions remain collaborative among providers, individuals, and care teams.
We respectfully request that the requirement for Behavioral Health Technicians (BHTs) to complete the DBHDS Behavioral Health Technician Academy be reconsidered. Limiting compliance to a single state-sponsored training pathway is unnecessarily restrictive when the Virginia Board of Health Professions has already established a statewide credentialing process that recognizes multiple pathways to qualify as a Behavioral Health Technician.
The Board of Health Professions' credentialing framework was intentionally developed to provide flexibility in how individuals demonstrate competency while maintaining consistent professional standards. Requiring completion of only the DBHDS Behavioral Health Technician Academy effectively excludes individuals who have obtained the state-recognized BHT credential through other approved pathways, despite meeting Virginia's competency requirements.
This requirement creates an unnecessary barrier to recruitment and retention at a time when behavioral health providers continue to face significant workforce shortages. Agencies would be limited to hiring individuals who have completed a single training program rather than drawing from the broader pool of credentialed professionals recognized by the Commonwealth. This restriction reduces workforce flexibility, increases onboarding timelines and costs, and may delay access to services for individuals in need of care.
Additionally, requiring providers to track and document completion of the DBHDS Academy, even for staff who already hold a valid Virginia BHT credential through another approved pathway, creates duplicative administrative burden without providing additional assurance of competency or improving quality of care.
We recommend revising the requirement to recognize any Behavioral Health Technician who holds a valid credential issued through the Virginia Board of Health Professions' approved credentialing process, regardless of the pathway used to obtain that credential. This approach would maintain consistent competency standards, align with existing Commonwealth policy, reduce unnecessary administrative burden, and expand the qualified workforce available to deliver behavioral health services while preserving provider flexibility.
Thank you for the opportunity to review the proposed revisions to the Community Psychiatric Support and Treatment (CPST) service model. We appreciate the intent of the redesign to improve clinical structure, accountability, and consistency of care. However, significant concerns continue with the current draft revision.
The model assumes a workforce capacity that does not currently exist in most parts of Virginia, particularly rural and high-need regions. This creates an underlying structural concern when the system shifts more responsibility to teams, but does not meaningfully expand the available clinical workforce to support that shift.
The model as written assumes a workforce structure that is not stable enough to support it. Required LMHP involvement in assessment, treatment planning, supervision, and oversight creates a structural dependency on clinicians who are already in short supply. LMHP caps (75–120 cases depending on structure) still require enough licensed staff to supervise increasingly structured teams. That means LMHPs are no longer just clinical providers—they become the rate-limiting step for entire program capacity. In practice, this will likely lead to agencies capping enrollment not based on need, but based on LMHP availability, longer waitlists for Tier 2 entry, and LMHP burnout due to dual clinical + administrative oversight roles.
The model increases reliance on QMHPs and BHTs for direct service delivery, but recruitment and retention for these roles is already unstable. Turnover rates are high in many provider agencies and agencies may further struggle to maintain stable staffing ratios required for Tier 2 intensity. Tier 2 depends heavily on QMHP/QMHP-T/BHT delivery of: crisis support, rehab skills practice, care coordination, and community-based implementation. But pay levels remain relatively low, expectations are significantly higher (real-time crisis intervention, environmental structuring, frequent community work), and billing caps (750 units/month per non-licensed staff) limit flexibility. This creates a high-demand / high-burnout role with limited sustainability.
An LMHP supervisor is simultaneously responsible for: clinical oversight, documentation quality control, crisis consultation availability, and treatment planning approval workflows. This creates a system where LMHPs function as: clinician + supervisor + compliance officer + utilization reviewer. That combination is not realistically sustainable at scale without increasing administrative staff support (which is not clearly funded in the model).
Training requirements are significantly expanded and formalized, which maintains the previous concern that implementation timelines are not realistic. Training expectations are clinically coherent but operationally heavy, with unclear statewide capacity to deliver training at scale before rollout deadlines.
MAP training requirement adds a delayed workforce pipeline problem. For youth services, MAP credentialing is required. This creates a 12–18 month training lag before full compliance, productivity loss during training period, and higher turnover risk for newly trained staff (poached by higher-paying systems). Smaller agencies will struggle to maintain enough “fully credentialed” staff to scale services.
Multiple layered training systems (Foundational Skills Curriculum, Intermediate Skills Curriculum, BHT Academy, EBP-specific training requirements (CBT variants, trauma-informed modalities, etc.)disadvantage smaller agencies, staff without formal psychotherapy training pipelines, and highlight training infrastructure limitations
Supervision is expanded in a way that is clinically reasonable and geared towards best practice but is operationally underestimated. Supervision is no longer “one meeting a week”, it now includes: weekly sessions, documentation review requirements, case consultation, co-treatment, direct observation expectations, and crisis oversight responsibilities. This effectively creates a second full workload layer that is not directly tied to billable production.
The model as written introduces layered documentation requirements that go beyond typical service authorization systems. CPST shifts toward a highly structured, compliance-heavy model that increases administrative workload significantly without proportional increases in billable efficiency, creating concern about “paper compliance vs clinical time”. The integration of Level of Need (LON), CANS Lifetime assessments, domain-specific impairment thresholds, and tiered eligibility criteria introduce a high level of documentation complexity. This raises concerns that: documentation requirements may reduce time available for direct care, providers may experience increased audit risk due to layered eligibility criteria, and administrative burden may disproportionately impact smaller and rural agencies.
CANS Lifetime dependency (required for admission, LON, continued stay, step-down decisions) creates heavy reliance on standardized assessments that require training and time to administer. Layered documentation requirements with frequent ISP updates require frequent formal updates even in more stable cases. Outcome tracking mandates place a burden on providers to demonstrate symptom reduction, crisis reduction, functional improvement, and rationale for lack of improvement with expected trajectory. This does not account for “real life” where there are frequent changes in client needs and symptoms based on unpredictable circumstances. Supervision documentation requirements expand significantly with required tracking, related activities, case oversight logs, and caseload monitoring. With the heavy increase in documentation requirements and increased billing constraints (tight rules on face to face requirements, simultaneous billing, individual versus group time, and nonbillable activities) the time required to meet administrative requirements makes CPST as written a financial risk for agencies.
Rural CSBs face unique structural constraints that are not fully accounted for in the current model design, including: significant travel time between clients limiting billable efficiency, LMHP recruitment and retention challenges, smaller supervisory staffing pools, higher per-client administrative overhead, and limited funding for training and infrastructure costs.
CPST assumes frequent community-based services, but rural providers have long drive times between clients, low client density per geographic area, and high cancellation impact on scheduling. The result is significant non-billable travel time that is not offset in reimbursement structure.
The CPST model assumes a level of staffing density and service clustering that does not exist in rural regions. As a result, there is concern that rural providers may experience: reduced service capacity, increased per-client cost of delivery, difficulty maintaining compliance with supervision and documentation requirements, and potential service withdrawal from low-density areas.
Fixed supervision burden hits rural agencies harder with requirements for weekly supervision, documentation review, case tracking logs, and caseload management systems are the same regardless of agency size. But rural CSBs have fewer supervisors, fewer administrative support staff, and smaller workforce pools to distribute workload This means fixed overhead becomes disproportionately expensive per client served.
LMHP recruitment problem becomes service capacity ceiling. Rural areas already struggle with LMHP shortages and now LMHPs are required for: nearly all core service components, high-frequency supervision, and oversight caps. This will likely result in capped enrollment regardless of demand, inability to expand CPST coverage geographically, and increased reliance on crisis services instead of preventative care.
We support the Commonwealth's goal of ensuring that providers are well-trained, competent, and equipped to deliver high-quality behavioral health services. However, we are concerned that several provisions in the proposed manual require participation in proprietary training programs, specific credentialing processes, accreditation organizations, and administrative systems that rely on outside entities rather than establishing competency through objective standards.
The cumulative effect of these requirements creates unnecessary costs for providers while directing significant financial resources to third-party organizations without clear evidence that these expenditures improve clinical outcomes beyond existing professional licensing, credentialing, and accreditation requirements.
Examples include mandatory MAP credentialing, required participation in the DBHDS Behavioral Health Technician Academy rather than recognizing other state-approved credentialing pathways, ongoing reporting through CEP-VA, and references to specific accreditation requirements that may require providers to engage with particular accrediting organizations. Individually, these requirements increase costs; collectively, they create a substantial unfunded administrative infrastructure that providers must support in addition to delivering direct clinical care.
Many of these requirements also create unnecessary dependence on organizations outside of providers' control. Training availability, consultation schedules, portfolio reviews, credentialing timelines, system access, recertification requirements, and reporting processes are all subject to the policies, capacity, and timelines of third-party organizations. Providers may experience implementation delays or compliance challenges that are unrelated to the quality of services they provide but instead stem from the availability or administrative processes of external entities.
From a fiscal perspective, these requirements represent ongoing operational costs that extend well beyond initial implementation. Agencies must budget for registration fees, consultation costs, staff time away from billable services, travel when applicable, credential maintenance, multiple reporting systems, and ongoing administrative oversight. These costs are particularly concerning given that the proposed reimbursement rate does not account for the expanded administrative infrastructure required to maintain compliance.
The proposal also limits provider flexibility by prescribing specific methods of demonstrating competency rather than recognizing equivalent qualifications. In many cases, providers already employ licensed professionals, nationally certified staff, accredited quality management systems, and robust internal learning management systems that meet or exceed the intended objectives of the proposed requirements. Requiring participation in specific programs instead of recognizing equivalent credentials or documentation creates duplication without improving accountability or quality.
These provisions also create barriers to workforce recruitment and retention. Qualified clinicians and paraprofessionals who already meet Virginia licensing or credentialing requirements may nevertheless be ineligible to provide services until they complete additional organization-specific training or credentialing processes. This narrows the available workforce at a time when behavioral health providers across the Commonwealth continue to experience significant staffing shortages.
A more sustainable approach would establish performance and competency standards while allowing providers flexibility in how those standards are achieved. Rather than requiring participation in specific proprietary programs or administrative systems, DMAS should recognize equivalent training, credentials, certifications, accreditation, and documentation that demonstrate compliance with the underlying competency requirements.
Specifically, we recommend that DMAS:
Publicly funded behavioral health services should prioritize investment in direct patient care rather than creating ongoing financial obligations to third-party organizations. Standards should focus on outcomes, competency, and accountability—not on requiring providers to utilize specific proprietary systems or vendors. A more flexible, performance-based approach would maintain quality while reducing unnecessary administrative costs, preserving provider choice, and strengthening the behavioral health workforce.
We respectfully request that the Department clarify ambiguous language, reconcile conflicts with existing licensing requirements, reduce unnecessary administrative burden, preserve provider flexibility, and ensure that implementation supports rather than impedes timely access to high-quality, person-centered behavioral health services.
We encourage continued collaboration with providers prior to finalizing the manual so that implementation is clinically feasible, operationally sustainable, and aligned with the shared goal of improving outcomes for individuals receiving CPST services.
CPST is a highly structured clinical model built on layered accountability, but it is being deployed into a workforce and service environment that cannot sustain the requirements. The CPST model as written clearly benefits certain populations and agencies while making much needed supports not feasible to provide or access for others.
Overall:
Primary winners: well-resourced urban CSBs, large urban provider agencies, clinically structured EBP-aligned organizations, clients who respond well to structured outpatient care
Primary losers: rural providers and CSBs, LMHP workforce, QMHP/BHT workforce, small agencies, schools relying on TDT-style daily structured support, high-acuity youth
What Is Most Likely to Break First in Implementation- these are the pressure points most likely to fail first once CPST goes live with the current draft requirements.
Issues: every pathway runs through LMHPs (assessment, treatment planning, oversight of teams, documentation compliance). LMHPs are the limiting step in the system, even if QMHP/BHTs are available they cannot function independently
Leads to: intake delays, authorization delays, backlogs in reassessments, and waiting lists.
Issues: MAP certification is incredibly time intensive and Intermediate/FSC/BHT training rollouts depend on external systems
Leads to: agencies onboarding staff faster than they can be fully trained which further leads to a partially qualified workforce, delayed billing eligibility, and increased compliance risk.
Issues: frequent ISP updates, CANS driven LON reassessments, structured progress documentation, continued stay justification with objective metrics
Leads to: LMHPs become documentation limited and authorizations slow down because of missing data, delayed reassessment, incomplete outcome metrics
Issues: the model increases role stratification: LMHP = gatekeeper/clinical authority, QMHP/BHT = execution layer
Leads to: high turnover meaning constant retraining load, supervision overload, disrupted continuity of care
Issues: requires supervision infrastructure, credentialed clinicians, training access, multi-role staffing teams – rural agencies cannot maintain full staffing model
Leads to: reduced service availability, long waitlists
Issues: supervision is both clinical and regulatory, but treated as equal weight – requires clinical oversight, compliance auditing, performance evaluation, frequency requirements vs real capacity- frequency minimums, supervision related activities, supervision time not billable = competes with direct care time, documentation time, crisis response time
Leads to: Supervision becomes a catch-all administrative bucket rather than a structured clinical development system.
Issues: LMHP caps (75–120 cases) assume: stable staffing beneath them, predictable caseload complexity- but in practice: cases are variable intensity, crisis load is uneven, travel/time burdens vary widely
Leads to: LMHPs may be “within cap” but still functionally overloaded
Issues: the system requires: symptom reduction tracking, crisis count tracking, functional domain improvement, LON score changes, structured ISP goal metrics, clinicians must translate complex human behavior into standardized metrics repeatedly, ncreased “documentation frequency loops”- documentation is required at multiple points: admission (CANS + ISP), ongoing service notes, supervision review cycles (30-day LMHP review), continued stay (objective outcomes), step-down planning, imbalance of high required work with limited billability
Leads to: agencies must absorb overhead internally, pressure increases on billable unit production
Issues: over-reliance on hierarchical care teams- model assumes: LMHPs supervise, QMHPs execute care coordination and skills, BHTs provide hands-on practice. But, real-world cases are not cleanly divisible: crisis work blends with therapy, skills training overlaps with psychotherapy, coordination overlaps with clinical decision-making
Leads to: high turnover amplification because CPST requires: structured training, role clarity, supervision access- turnover creates: immediate productivity loss, retraining burden, supervision instability
Issues: fundamental mismatch in service models - TDT model: structured school-day programming, consistent daily therapeutic environment, group-based behavioral reinforcement, educational integration. CPST model: episodic community-based intervention, home/school/community visits, individualized skill building. TDT functioned as a controlled environment for behavior shaping. CPST does not replicate the daily structure, peer cohort consistency, continuous reinforcement loop
Leads to: for high-need youth: increased reliance on crisis services, hospitalization, fragmented outpatient supports, school attendance reductions (absences/suspensions)
For the purpose of this draft review. The focus will be on general CPST service concerns with some additional school CPST considerations in order to give the benefit of the doubt that the upcoming school CPST draft will be more realistic and in addressing the overall concerns and the concerns specific to the school setting. As written, aside from the ongoing concerns, community and school CPST show promise as an additional supportive service, not as adequate replacements for the identified legacy services.
General observations:
Improvements
Concerns:
Specific questions, concerns, and areas for reconsideration:
I am very concerned about what appears to be a very heavy reliance on entities that are external to Virginia State Government - eg
However, the single greatest concern is that the cost and admin burden associated with any or all of the activities described above appear specifically designed to make it virtually impossible for smaller provides to survive. If that is the intent, then perhaps it would be best said now.
Pg 5 - CPST Clinical Director has to be available to provide in-person support at the individual's location when clinically needed. This face to face requirement seems excessive when every tier of CPST requires LMHP supervision. There's no indication of the opportunity to delegate when unavailable, provide consultation, etc.
Pg. 5- The oversight of the CPST Clinical director needs further clarification. Can the CPST Clinical Director oversee both CPST and Clubhouse within same agency? It only specifies that can serve both an adult and child program within the same agency.