Section 5: Required Service Components

• Group Size Limitations: Capping group services at a 1:6 ratio may reduce operational efficiency, increase staffing demands, and will limit access to services.

Section 6: Provider Qualification Requirements

• Accreditation Mandate: Requiring agencies to obtain accreditation within 18 months may be financially and administratively burdensome.
• Annual MOUs with Schools: The requirement to maintain and renew MOUs with each school division or private school annually adds to administrative complexity and burden.

Section 7: Medical Necessity Criteria

• 1. Misalignment with School Staff Expectations

School personnel often operate under the assumption that mental health providers embedded in schools are available to support all students, regardless of diagnosis or level of need. However, the proposed criteria strictly limit CPST services to youth who meet specific diagnostic and functional impairment thresholds, as determined by the CANS Lifetime assessment and other clinical documentation. This creates a disconnect between what school staff expect and what providers are permitted to deliver under Medicaid guidelines.

Without adequate training and education on the complexities of CPST services, school staff may inadvertently refer students who do not meet the stringent admission criteria. This can lead to frustration, miscommunication, and a breakdown in collaboration between schools and mental health providers. It may also result in delays in care for students who need support but do not qualify for CPST, leaving school staff feeling unsupported and mental health providers burdened with managing expectations beyond their scope.

• 2. Complexity of Service Eligibility and Documentation

The criteria outlined in Section 7 are highly complex and require nuanced clinical judgment, extensive documentation, and ongoing reassessment. School staff, who are not trained in behavioral health diagnostics or Medicaid service authorization processes, may struggle to understand why certain students are not eligible for services or why services must be discontinued. This complexity can hinder the collaborative treatment planning and implementation that the regulations themselves emphasize as essential.

• 3. Risk of Undermining School-Based Mental Health Integration

By narrowly defining eligibility and requiring multiple layers of documentation and service intensity, the regulations may inadvertently discourage providers from engaging in school-based work. The administrative burden and risk of non-reimbursement for services provided outside strict criteria could lead to reduced provider participation in schools, undermining efforts to integrate mental health supports into educational environments.

• High Admission Thresholds: Requiring multiple criteria across functional domains for Tier One and Tier Two services may exclude youth with moderate needs who could still benefit from CPST.
• Caregiver Participation Requirement: Weekly caregiver engagement may not be feasible for families facing socioeconomic or logistical challenges.

Recommendations for Section 7 – CPST-School Setting Medical Necessity Criteria

To ensure the successful implementation of CPST services in school settings, the following recommendations are proposed:

1. Increase Flexibility in Service Delivery

The current criteria are highly prescriptive and may unintentionally exclude students who could benefit from mental health support. DMAS should consider allowing greater flexibility in service delivery to accommodate the diverse needs of students across school environments. This includes:

• Allowing all students who meet the medical necessity criteria to receive CPST services within the school setting on a daily basis, if clinically appropriate and supported by their Individual Service Plan (ISP).
• Permitting providers to tailor service frequency and intensity based on the student's evolving needs, rather than rigid unit limits tied to Level of Need scores alone.

2. Tiered Support Based on Clinical Complexity

Students with more complex and clinically significant needs should have access to enhanced services delivered by highly trained professionals, such as LMHPs and LMHP-types with specialized training in trauma, mood disorders, and crisis intervention. This tiered approach would:

• Ensure that students with serious emotional disturbances or early serious mental illness receive intensive, evidence-based interventions.
• Promote clinical matching, where the provider’s expertise aligns with the students’ presenting concerns, improving outcomes and reducing provider burnout.

3. Clarify Roles and Expectations for School Staff

Given the complexity of CPST eligibility and service structure, DMAS should develop clear guidance and training for school personnel to help them understand:

• The scope and limitations of CPST services.
• The distinction between mental health support and educational responsibilities.
• How to collaborate effectively with CPST providers without assuming they can serve all students or fulfill school staff duties.

4. Strengthen Collaboration and Communication

To bridge the gap between clinical providers and school teams, DMAS should encourage:

• Regular joint meetings between CPST teams and school staff to align goals and expectations.
• Shared documentation tools that allow for transparent communication while maintaining confidentiality and compliance.