Rather than try to continue the modality of commenting on the specifics of the requirements as outlined in the preliminary draft of the manual, perhaps describing the “big picture” is a better use of this space.  The following should, at this point, be clear:

• Neither the Commonwealth, nor the Managed Care Organizations, nor the provider community (public or private) are adequately prepared to eliminate the “legacy CMHRS services” on July 1, 2026.  And the time between now and when providers, MCOs and state agencies must be actively engaged, “qualified,” administratively prepared and staffed to provide or oversee new services is simply not sufficient.
• A scan of the DBHDS funded “Virginia EBP Service Provider Finder reveals that only 13 different providers (public and private) are providing one of three of the currently recommended services using EBP (ACT, MST or FFT) in only 27 locations and are actually funded by Medicaid.  This does not speak to the number of providers who attempted one of the services and had to step away because they could not consistently meet staffing requirements, the administrative costs which were not reimbursed were unreasonably high, and/or they could not carry high enough caseloads to make the service a viable option.  This either should signal that it will be a very difficult lift to meet the needs across the Commonwealth with the proposed service array, or that the intended goal is “streamlining” the services system by dramatically reducing the number of providers able to meet the requirements clinically, administratively  and financially.
• One of the targeted services – psycho-social rehab – needs special attention; a look at one portion of the medical necessity criteria shows that to be eligible for the service now one of the following must be met:

1) Have experienced long-term or repeated psychiatric hospitalizations;

2) Experience difficulty in activities of daily living and interpersonal skills; or

3) Have a limited or non-existent support system; or

4) Be unable to function in the community without intensive intervention;

5) Require long-term services to be maintained in the community

The apparent intended design for the “new” Clubhouse Model which would be required to meet one very proscriptive accreditation standard does not appear to address the needs which would be demonstrated by those meeting the criteria above.  The question remains – where are those individuals who meet the criteria above to get the support and resources they require? 

While DMAS staff seem very willing to continue discussions and “tweak” the regulations (within some fairly narrow boundaries), they are committed to making the system of care based on “Evidenced Based Practices” and are required by virtue of the existing budget language to do that in a budget neutral way (which significantly impacts both rates which were established well below the mid-point of the range and the number of “units” per week).  It is an interesting side note that few providers are talking about the “rates” at this point, they simply do not see the services as described as a viable or manageable option, and certainly not within the timeframe required.