Thank you for the opportunity to comment on the draft Clubhouse regulations. Alleghany Highlands supports the goal of strengthening rehabilitative services for adults with SMI, however we have concerns about areas that will create barriers to access or imposes administrative and staffing requirements that will be difficult to achieve in rural communities. 

Below are the concerns AHCS would like the Department to consider:

1. Observation without Intervention as Non-Billable: The policy states that observation alone is not billable. This conflicts with how adults with SMI often engage. Some adults attend Clubhouse programs because it offers a safe place where they can be present, even on days were active participation is minimal. Allowing adults with SMI to have a safe, quiet place with minimal participation is part of their recovery. 
2. Restrictions that may limit Participation: The draft regulations imposes new barriers that are inconsistent with the model. 1. Prohibiting members from receiving Community Stabilization while also participating in Clubhouse. 2. Requiring comprehensive assessments and authorizations within a single day. 3. Requiring additional physician documentation for diagnoses already established. 4. Time -limited enrollment expectations from MCOs that conflict with the Clubhouse Model standard of "membership without time limits". The will reduce adults flexibility whose participations fluctuates due to symptoms. 
3. Non-Billable In-House Educational Opportunities: The draft regulations excludes in-house educational programming from reimbursement, even thought CI standard 25 explicitly includes excess to both in-house and community-based educational opportunities. Education is vital to recovery and should remain reimbursable. 
4. Billing Structure is unclear: The proposed change from three units to one diem unit presents a significant reduction in allowable billing. The manual also lists 240 units per year which conflicts with the current 360 unit allowance. This reduction will limit program hours and weaken sustainability in programs that already operate within low reimbursement rates and limited funding sources. 
5. Risk of Excluding Adults: The CI model is inclusive of adults whose mental health fluctuates. Several proposed changes will exclude adults: 1. active symptoms, 2. limited social capacity. 3. low motivation. 4. difficulty engaging at a clinical pace. These adults are among the most likely to benefit from the psychosocial, non-clinical supports.
6. Impact on Rural Areas: Rural areas already face challenges with transportation, staff shortages, lack of private providers, stigma, and low funding. The draft regulations increase administrative expectations, limit who can participate, and reduction in reimbursement. We urge DMAS to consider rural barriers and avoid requirements that unintentionally restrict access. 
7. Board of Directors requirement: AHCS operates in a rural, economically challenged region. Recruiting and maintaining a board with the level of specialized expertise would be extremely challenging. Community leaders are limited in numbers and are often already spread across multiple nonprofit boards. Continuously maintaining a board at this level will be burdensome and may jeopardize accreditation or compliance solely due to geographic limitations and not quality of service. A more flexible governance is needed in rural areas. 
8. Dedicated Facility Requirements: AHCS currently operates our Clubhouse program out of an older house that requires ongoing maintenance. Purchasing or constructing a new dedicated facility would be a financial burden and unrealistic. 
9. Required Staff Training Costs: CI model training expectations references in the draft regulations, are costly without a funding stream. The trainings typically require 2-3 weeks of onsite participation and cost between $5,000-47,000 per staff, not including travel and lodging. For small, rural, CSBs, this is prohibitive.