Thank you for the opportunity to provide feedback on the draft regulations. While the intent to improve accountability and quality is understood and much needed, the current draft contains provisions that create serious risks for agencies, staff, and most importantly, the population who depend on Medicaid services.

Main Concerns

1. Supervision and Workforce Burden

The limits on LMHP supervisors (nine staff maximum), the mandate of four hours of monthly supervision with 50% delivered in person, and the requirement for 24/7 on-call availability create an unworkable burden. These requirements intensify workforce shortages, drive unsustainable salary competition, and push LMHPs into administrative duties such as note reviews and timesheet approvals rather than clinical oversight.

Further, requiring staff to be on call 24/7 raises compliance issues with Virginia labor laws. How are providers expected to pay employees under these conditions, and has DMAS considered the legal implications of these requirements? Small and rural agencies simply cannot recruit or fund the number of LMHPs these rules assume.

2. Assessment and Service Continuity Risks

Tying service eligibility too rigidly to assessment scores risks abrupt transitions between services without adequate clinical judgment. This creates instability for youth and families, particularly where EBPs like FFT or MST are not available in rural areas.

DMAS has moved away from CMHRS and does not want to revert to past models, but it remains responsible to ensure that Medicaid members do not experience disruptions so severe that they cause harm. We are very concerned that there is not a transition time where both services are occurring while providers work to transition clients to the new services. Who will be accountable for client suicidal or homicidal emergencies if service gaps occur due to lack of transition time?

3. Service Hour Allocations and MCO Discretion

The proposed Tier 1 allocation of 1–1.5 hours per week is not practical when factoring in travel, documentation, and clinical needs. Additionally, leaving service hours in ranges (e.g., 1–2 hours) gives each MCO the discretion to dictate how many hours are approved for every authorization request. This continues to place clients and providers in a vulnerable position, with inevitable inconsistencies and inequities across the system. With so many different entities and individuals involved in authorization decisions, variability is unavoidable. 

Fixed, clearly defined service allocations are the only way to ensure consistent access statewide.

4. Hour Caps vs. Real-Life Crises

Each client only gets a set number of hours per month (for example, Tier 1 = about 4–8 hours a month).

But crises don’t follow a schedule. If a client has already used their hours and then has a crisis, the provider must still respond — but it doesn’t look like there is any billing that can occur?

Multiply that by several clients, and staff quickly run out of their own monthly limit of hours.

The hours on paper don’t match the unpredictable nature of real-life crises especially with individuals diagnosed with SMI.

You cannot require staff to be “on-call 24/7” and ready to respond in person, but then not pay them for that time. Federal labor law (which Virginia follows) makes clear that when employees must stay available, drop personal plans, or respond right away, that time counts as work and must be paid. The proposed CPST rules require constant availability but do not provide the resources or funding necessary for agencies to meet those requirements, leaving providers in an impossible position.

Thank you for considering these concerns. We want to be part of the solution so that providers can keep doing what matters most- serving our communities, supporting our schools, and protecting the wellbeing of children and families across Virginia.