We want to share important concerns about the state’s proposed changes to mental health services, particularly around Community Psychiatric Support and Treatment (CPST), Psychosocial Rehabilitation (PSR), and Targeted Case Management (TCM). These changes, as currently written, create serious challenges for providers, communities, and the people we serve.

We support innovation in behavioral health care; however, we have significant concerns about the feasibility and structure of the proposed redesign that will likely create gaps in care.  In addition, there is still a great deal of confusion about the new design.

Some of the most notable concerns are as follows:

• Rates: With rates falling below the midpoint of the rate study, the reimbursement rates proposed are too low to cover the cost of services. In particular, the new requirements for psychosocial rehabilitation will put those services at risk due to the increased cost and administrative requirements.
• Psychosocial Rehabilitation Services: Clubhouse model is costly, takes years to certify, and would prevent most providers from sustaining their programs.  We have experience with the Clubhouse model and moved away from it many years ago due to ongoing problems. We transitioned to a therapeutic, clinical model that has been very successful and would not want to return to the former model.  The alternative CPST option for day programs does not have rates that will sustain the current service capacity. The redesign of this service will increase cost and administrative burden without adding value. It is our hope that the current PSR model will remain, or that the redesign will be paused to take into account feedback from providers about the feasibility of a new structure. This is a critical service for the individuals we serve and we want to avoid any negative impact. 
• Targeted Case Management (TCM): The proposed changes to TCM, including caseload algorithms and new authorization requirements, are impractical and will not improve care. Instead, they add paperwork, increase costs, and risk reducing access. The tiered caseload model is unrealistic and does not reflect the dynamic needs of the individuals receiving the service. Without benefit, it will increase documentation requirements and take away from important service provision without actual clinical justification for the change.  At a time when we are trying to increase service capacity, this structure will reduce clinical staffing capacity by increasing administrative burden for providers – this will in turn increase cost and reduce quality of care. It is our hope that the changes to TCM will not take place.
• Accreditation: The requirement for all providers to meet new accreditation standards is burdensome and unrealistic, especially with backlogs at accrediting bodies like the Commission on Accreditation of Rehabilitation Facilities (CARF). Relying solely on Clubhouse International for PSR accreditation may prove risky and limits professional options.  Please eliminate the accreditation requirement for CPST and allow alternative, evidence-informed models for psychosocial rehabilitation.
• Implementation Timeline: In the current design structure, the proposed start date of July 1, 2026, is not realistic. Providers cannot adequately prepare critical details such as workflows, staffing models, billing processes, and training requirements for new services. Not to mention, there is far too much confusion and concern statewide to remain on this timeline. Delay implementation until providers, Medicaid Managed Care Organizations (MCOs), and the Department of Medical Assistance Services (DMAS) can work together to resolve concerns.

• Staffing and Administrative Burden: The new staffing standards rely heavily on licensed clinicians, yet Virginia already faces severe shortages. New requirements for assessments and data tracking will increase costs and overwhelm current workflows. Providers may not be able to meet the standards, which could limit access to care. We request elimination of unrealistic staffing ratios and supervisory structures, and that any new assessment tool be delayed until it can be fully developed, tested and integrated into systems.

In Summary:

• Delay implementation by at least one year until stakeholder input can be considered.
• Set sustainable reimbursement rates.
• Do not require Clubhouse International for psychosocial rehabilitation.
• Remove or reduce burdensome accreditation, staffing, and administrative requirements that do not ultimately improve care.
• Remove changes to Targeted Case Management.
• Preserve the existing therapeutic model for PSR.