It is very difficult to determine how the services as proposed will have any positive impact for either the individuals served or communities.  This service dramatically increases the cost of delivering care over the current services.  In July we heard DMAS state this redesign had to be "cost neutral".  To avoid increasing costs for claim payments, the proposed services have been limited so substantially that they will fall far short of meeting the needs of those we serve.  Small providers will not be able to afford to deliver care and those who attempt to implement this service risk operating at a substantial loss.  The proposed regulations appear disconnected from both the needs of individuals and the operational realities of service delivery on the ground. 

Rate assumptions: 

DMAS shared in a webinar that rates were based more than 32 hours per week of billing and a 5% absenteeism rate.  Full time staff work 40 hours per week and must be given breaks at regular intervals as well as a lunch break, leaving only around 35 hours of possible billable time per week.  This is an unrealistic assumption based on an apparent lack of understanding about how much time documentation of services takes. A low estimate in my experience would be 4-5 hours per week. This documentation burden will be worse with the requirement to complete the CANS, which has limited clinical utility.  DMAS also shared than a 5% absenteeism rate was used in calculating the service rates- 5% absenteeism would not allow someone to take off the Virginia state holidays for 2025. 5% is the equivalent of 104 hours absent annually for one FTE.  Assuming an 8 hour day, Virginia recognizes 120 hours in holidays for this calendar year. 

CARF or Other Accreditation: 

These accreditations add substantial upfront and on-going cost.  While having this accreditation sounds good, as someone who works in an agency that previously had CARF accreditation it does little to nothing to enhance service delivery.  

Supervision limits-

While the agency I work for operates at close to the 9 staff person limit for LMHP supervision, we will have to recruit and hire for additional positions, adding $90,000 to $100,000 in annual cost per FTE for salary, benefits, and overhead.  If an LMHP provides 2 hours of supervision weekly to 9 staff, this accounts for 18 hours of their time.  This seems very inconsistent with the CPST, rate assumption that for each FTE you have more than 32 hours of available time weekly.  Virginia is also struggling to maintain a workforce of mental professionals which does not appear to have been considered. 

Service limits and requirements for parental involvement:

Currently many children in our schools get 20 hours of service weekly which is critical to their ability to function in the school setting and avoid residential or psychiatric placement.  The service limits of the proposed regulations will cut these services by as much as 75%,  CSA and localities will inevitably end up having to cover these costs as the needs are not going to change.  The requirements for parental involvement also consumes some of the very limited service units.  On many occasions it is an absolute struggle to get parents engaged even for treatment planning.  Many children only have access to behavioral healthcare because the services are delivered in the school setting, otherwise the would get no service at all.  This appears to be an example of applying middle class values to families who live different lives and face very different circumstances.  The children who services most will be most impacted by these requirements. 

EBPs: 

This requirement does nothing but pass individuals back and forth between agencies.  It  will limiti provider choice,and force individuals into services they do not want to participate in.  What if the individual refuses the referral to another provider services?  What if they refuse to allow the initial provider to share their information with the EBP providers in the area?  It's really hard to maintain staff to provide services when you cannot rely on having a sufficient caseload to support the cost, and having providers farm their clients to multiple other providers will make it nearly impossible to predict staffing needs and pay for positions.