Thank you for the opportunity to provide public comment on the proposed Medicaid service redesign, including the implementation of Community Psychiatric Support and Treatment (CPST). We want to express several concerns regarding feasibility, funding, and operational impact on CSBs, school systems, and the broader provider community.
The proposed July 1, 2026 implementation date is not feasible. Providers cannot begin preparing for CPST or other redesigned services until essential policy documents—such as service definitions, billing guidance, staffing expectations, and training requirements—are finalized. Without these details, CSBs cannot determine whether they can deliver the service effectively or sustainably.
This timeline also poses a serious risk to school systems, which rely heavily on day treatment services provided by CSBs. The redesign would eliminate these services without a clear replacement model in place. Schools depend on these programs to support students with behavioral health needs, and removing them without adequate planning will disrupt care coordination, increase strain on school staff, and leave vulnerable students without structured support.
Additionally, the proposed CPST model introduces a delayed access pathway for consumers. Individuals must first be found ineligible for other services before they can qualify for CPST. This creates unnecessary barriers and delays in care, particularly for those in urgent need of support. It also adds administrative complexity for providers and confusion for families navigating the system.
Local Impact: Premature implementation risks service disruption across CSBs and school systems, undermining continuity of care for children, families, and adults with behavioral health needs.
Proposed Solution: Delay implementation by at least one year to allow providers, school partners, and Medicaid Managed Care Organizations time to prepare—and to give DMAS additional time to address concerns about standards, requirements, and the loss of day treatment services.
Adjusting rates alone will not resolve the deeper structural challenges of the redesign. The proposed rates fall below the midpoint of the contractor’s recommended range and do not reflect the true cost of delivering CPST—especially when factoring in accreditation, proprietary assessments, staffing ratios, and service unit limits.
The requirement to use the Clubhouse International model for psychosocial rehabilitation is particularly concerning. This proprietary model demands extensive certification that can take up to four years and significantly increases staffing costs. Current providers will not be able to bill enough to sustain the program under the proposed rates and unit limits.
DMAS has acknowledged that Medicaid is not expected to fully fund Clubhouse programs, yet no alternative funding sources have been identified.
Remove the budget neutrality requirement and set rates above the midpoint of the contractor’s recommendations.
Revisit service unit limits and streamline authorization processes to avoid dual hurdles with DMAS and MCOs.
Do not mandate Clubhouse International as the sole model for psychosocial rehabilitation. The budget language does not require replacing the current model.
Local Impact: Without adequate reimbursement, CSBs may be forced to discontinue psychosocial rehab services, eliminating a vital source of structured engagement for individuals.
Remove the budget neutrality requirement and set rates above the midpoint of the contractor’s recommendations.
Revisit service unit limits and streamline authorization processes to avoid dual hurdles with DMAS and MCOs.
Do not mandate Clubhouse International as the sole model for psychosocial rehabilitation. The budget language does not require replacing the current model.
Remove the accreditation requirement for CPST and/or allow for CCBHC certification to take the place of the CARF accreditation requirement.
Allow flexibility in psychosocial rehab models rather than mandating Clubhouse International.
Eliminate rigid staffing ratios and reduce administrative data burdens.
Delay implementation of the level-of-need assessment until a validated tool with interrater reliability is available.
Do not require Clubhouse International as the only model for psychosocial rehabilitation.
The proposed accreditation standards present significant barriers. Many private providers may not be able to meet them, creating service gaps that CSBs may not be able to fill. CARF accreditation, for example, requires 18 months of service delivery before review, and the current backlog could worsen with increased demand.
Relying solely on Clubhouse International—a proprietary model with a sole-source accreditation—places the state in a vulnerable position, dependent on a single entity to support an entire service.
Remove the accreditation requirement for CPST and/or allow for CCBHC certification to take the place of the CARF accreditation requirement.
Allow flexibility in psychosocial rehab models rather than mandating Clubhouse International.
Local Impact: Accreditation delays and limitations could destabilize service availability statewide.
Proposed Solution: Table all proposed changes to Targeted Case Management at this time.
The proposed staffing ratios and administrative requirements are not feasible under current conditions. CPST relies heavily on licensed clinicians, yet most localities in Virginia are designated mental health provider shortage areas. Increasing staffing requirements does not increase workforce availability.
Additionally, DMAS has not provided clarity on key metrics—such as evidence-based practice delivery, caseloads, supervision ratios, and fidelity monitoring. The proposed assessment tool (CANS Lifetime) is still under development and not yet available for training or integration into CSB systems. Requiring a 3-hour assessment will severely disrupt workflows, especially in Same Day Access programs.
The Clubhouse International model also requires double the staffing of current programs, and the 1:9 supervisor-to-staff ratio for CPST is not achievable for many providers.
Eliminate rigid staffing ratios and reduce administrative data burdens.
Delay implementation of the level-of-need assessment until a validated tool with interrater reliability is available.
Do not require Clubhouse International as the only model for psychosocial rehabilitation.
Local Impact: These requirements will strain already limited resources and may lead to service reductions.
Recent draft guidance from DMAS outlining changes to the mental health Targeted Case Management (TCM) service raises significant concerns. The proposed modifications are not operationally feasible and are unlikely to improve the quality of care.
The tiered algorithm for determining caseload sizes does not reflect the realities of service delivery at CSBs. Individuals’ needs fluctuate frequently—sometimes daily—based on life circumstances and available supports. Attempting to categorize people into static levels of intensity oversimplifies their lived experience and creates a rigid framework that cannot be practically implemented.
Moreover, tracking and managing caseloads under this system would substantially increase administrative burden without any clear benefit to service quality. There is also concern that DMAS auditors and DBHDS licensing staff may lack the training and context needed to consistently evaluate how individuals move between intensity levels during audits and reviews.
The proposed in-person contact requirements are similarly problematic. Tying contact frequency to intensity levels assumes a level of predictability that does not exist in real-world practice. CSBs currently adjust contact frequency based on individual need, and formalizing a rigid schedule will only increase provider risk and administrative complexity.
Additionally, the draft guidance introduces conflicting requirements around assessments. While DMAS allows QMHPs to complete assessments for TCM, it also requires LMHP documentation of serious mental illness (SMI) or serious emotional disturbance (SED). This requirement should be removed, especially given the shortage of licensed staff and the fact that TCM is not a clinical service.
The introduction of “Continued Stay Criteria” is also concerning. TCM has historically been a registration-only service, and adding an authorization process could jeopardize access for individuals who are stable precisely because they receive TCM. Requiring improvement to justify continued access undermines the purpose of the service.
All of these changes are proposed alongside a modest rate increase that does not begin to cover the added administrative and staffing costs. Increasing staff time requirements without proportionate funding will strain CSBs and reduce their ability to provide high-quality care.
Local Impact: These changes will increase administrative burden, reduce flexibility, and risk destabilizing services for individuals who rely on TCM for continuity of care.
CSBs are committed to delivering high-quality, person-centered care. However, the proposed redesign must be grounded in operational reality. Without adjustments to the timeline, rates, accreditation, staffing requirements—and without a plan to preserve school-based day treatment services, prevent delays in access to care, and maintain the integrity of Targeted Case Management—the system risks losing critical supports and destabilizing care for vulnerable populations.
Moreover, these changes will likely increase costs for the Office of Comprehensive Supports and local CSA funds, as services previously covered through Medicaid will shift to other funding sources. This cost shift will place additional pressure on local governments and further complicate efforts to maintain a stable and equitable system of care.