WORKFORCE FEASIBILITY AND LMHP OVER-RELIANCE
In their feedback, our members raised concerns that redesign places an unrealistic burden on LMHPs by requiring 24/7/365 availability, limiting supervision to a maximum of nine staff, mandating in-person supervision, demanding monthly documentation sign-offs, and assigning extensive assessment and ISP duties. Virginia already faces critical LMHP shortages, and they struggle to find and retain fully licensed clinicians who are willing to work in community-based programs despite low pay, safety concerns, and the heavy travel demands associated with these roles. By excluding residents, QMHPs, and QMHP-Ts from meaningful supervisory or service responsibilities, there is concern the new CPST service as proposed will lead to bottlenecks in capacity and make recruitment extremely challenging for small and mid-sized agencies in particular. They want to see regulations that recognize the workforce realities, are flexible where possible, and are tied to reimbursement levels that make recruitment sustainable—for example, by allowing QMHP-Ts and LMHP-types to take on greater responsibilities.
SERVICE DESIGN, DURATION, AND UNIT CAPS
The feedback provided by our members included concerns that the proposed tier structure is based on staffing rather than client symptomology, potentially creating confusion and disconnecting services from actual consumer needs. The input received indicates the unit limits are far too low to meet needs, with Tier 1 capped at 32 units per month (about 8 hours) and Tier 2 capped at 112 units per month (about 28 hours). By comparison, legacy services such as IIH and MHSS provided 8–15 hours per week, meaning these reductions will leave clients without the level of support they require. In addition, our members expressed concern that CPST duration is limited to 4–12 months, which they do not believe is sufficient for individuals with serious mental illness and chronic needs who require long-term stability. Without emergency flex allowances or transition overlaps, providers are concerned they will be forced to deny care once caps are reached, even in situations of crisis. Providers would like to see changes that allow service intensity and duration to reflect real-world needs, incorporate flexibility, and avoid arbitrary cutoffs that undermine patient care.
ADMINISTRATIVE, DOCUMENTATION AND TRAINING BURDEN
VACBP members also expressed concerns about what they believe to be an unsustainable level of unpaid administrative work by requiring assessments, ISPs, SARs, and quarterly reviews to be completed before services begin, and mandating LMHP review or co-signature of all non-licensed staff notes every 30 days, holding weekly team meetings, and providing four hours of supervision per staff member each month. They noted non-billable but required activities such as scheduling, documentation, and coordination continue to grow, placing further strain on agencies. Training requirements — including MAP, CBT, Adult Rehab Supports, and CEUs — were also raised as areas of concern, noting training will be costly, time-consuming, and difficult to sustain in a field already experiencing high turnover. While oversight is important, our members believe administrative and training mandates should be simplified, streamlined, and adequately funded in order to be workable.
CRISIS SERVICES AND EXCLUSIONS
Providers expressed concerns about the requirement that CPST providers deliver 24/7 crisis response, even though the service is neither designed nor reimbursed as a crisis program. At the same time, referrals to 988 or Mobile Crisis are prohibited, a restriction that is they fear could be unsafe and impractical, particularly in rural areas where in-person crisis coverage is limited. The draft also prohibits CPST from overlapping with other critical services such as ACT, PSR/Clubhouse, CSC, IOP, Partial Hospitalization, and Community Stabilization, which was very concerning. They would like DMAS to consider where there can clinical value with appropriate concurrent supports—such as combining CPST with Clubhouse—and how unnecessary risks of service gaps during transitions can be minimized. They do not believe CPST should be treated as a crisis service, and would like to see exclusion and transition rules be flexible enough to ensure continuity of care.
ACCREDITATION, LICENSING AND REIMBURSEMENT
The feedback received included concern that national accreditation requirements will impose high costs and create delays, with unrealistic timelines to comply. Some shared that they believe that accreditation is prohibitively expensive for a Medicaid service provider, particularly when paired with the ongoing oversight of DBHDS, creating duplicative and in some cases unnecessary burdens that don’t contribute to the health and safety of those being treated. The draft outlines billing codes and staff modifiers but does not include clarity with respect to reimbursement rates. There is also concern that when higher-level staff deliver lower-level tasks, they will only be reimbursed at the lowest rate, which devalues LMHPs. Providers would like more realistic accreditation timelines, financial assistance to help with accreditation costs, relief from duplicative licensing requirements and reimbursement rates that are better aligned with the actual workload required by the level of professional required to do the work.
OVERALL SYSTEM IMPACT
While we understand the mandate to implement redesign in a revenue-neutral manner, providers are very concerned that the draft policy is complicated, duplicative, and resource-intensive, with no corresponding reductions in requirements to offset the added burdens. Smaller agencies are particularly concerned, as it is more difficult for them to absorb the increased costs and staffing mandates, which may force closures or reduce capacity. Rather than expanding access, there is concern that the changes could shrink the provider network and leave consumers with fewer options for care. While providers support the intent to make services more clinical, accountable, and outcomes-driven, they would like to work with DMAS to help ensure the policy framework can strike a balance between accountability and feasibility.
PHẦN KẾT LUẬN
VACBP strongly recommends that DMAS: