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I respectfully submit this public comment on the Department of Medical Assistance Services (DMAS) proposal to add Community Psychiatric Support and Treatment (CPST) as a Medicaid-covered service under Virginia’s Behavioral Health Services Redesign initiative, Right Help, Right Now.

The purpose of this letter is not to oppose the intent of CPST. The goals of expanding access, using trauma-informed practices, and offering flexible supports are commendable. However, based on review of the CPST draft service description, Appendix G (Comprehensive Crisis Services, revised November 15, 2024), Appendix H (Community Mental Health Rehabilitative Services, revised June 14, 2023), the Behavioral Health Service Rate Updates effective January 1, 2024, and the controlling statutory framework including 12VAC35-105, 12VAC30-50-130, 12VAC30-50-226, 12VAC30-80-30, 42 CFR §440.130(c), 42 CFR §438.12, and 42 U.S.C. §1396a(a)(30)(A), it is clear that CPST, as written, presents major risks.

This comment expands upon those risks in depth. It addresses duplication of existing services, workforce exclusion, financial impact on providers and staff, potential noncompliance with state and federal law, and the risk of destabilizing the behavioral health continuum of care. Specific recommendations are also provided.

Background and Legislative Context

The Right Help, Right Now initiative was launched by Governor Youngkin and the General Assembly in 2022 following multiple public tragedies and a recognition that Virginia’s behavioral health system was fragmented and underfunded. The initiative emphasized a three-part strategy: crisis response, workforce expansion, and redesign of Medicaid services.

The Medicaid redesign has already introduced or strengthened several services, including Mobile Crisis Response (H2011), Community Stabilization (S9482), 23-Hour Crisis Stabilization, Residential Crisis Stabilization Units (RCSU), and Peer Recovery Services. In addition, long-standing services such as Mental Health Skill-Building (MHSS, H0046), Intensive In-Home (IIH, H2012), and Psychosocial Rehabilitation (PSR, H2017) continue to form the backbone of rehabilitative care.

The General Assembly also took fiscal action. Through the 2023 Appropriation Act, Item 304.VVVV.1 and Item 304.VVVV.2, DMAS was directed to increase reimbursement rates by ten percent for a defined set of behavioral health services. Item 304.WWWW provided further targeted increases. These increases were implemented January 1, 2024.

Within this legislative framework, CPST is now being introduced. The draft description frames CPST as a flexible, team-based, trauma-informed service that includes assessment, counseling, care coordination, crisis supports, and functional skill-building. While this sounds promising, DMAS’s own manuals already contain services covering these functions. Without careful revision, CPST will create duplication, conflict, and financial instability.

1. Conflict with Crisis Services

The CPST draft defines the service as including “crisis and functional supports.” At the same time, Appendix G of the Mental Health Services Manual defines crisis services as interventions for “a behavioral health crisis…in which an individual is at risk of hurting themselves or others and/or the symptoms prevent the individual from being able to care for themselves or function effectively in the community.”

Crisis services in Virginia include:

Mobile Crisis Response (H2011).

Community Stabilization (S9482).

23-Hour Crisis Stabilization.

Residential Crisis Stabilization Units (RCSU).

Each of these already requires assessment, crisis planning, therapeutic support, safety planning, and linkage to resources. DBHDS licensing regulations at 12VAC35-105-1860 through 12VAC35-105-1870 require safety plans, Crisis ISPs, and documentation standards for all crisis providers.

By placing “crisis supports” inside CPST, DMAS creates duplication that will:

Cause Managed Care Organizations to deny claims when CPST is billed for a crisis episode that could have been authorized under Community Stabilization.

Create regulatory ambiguity for DBHDS surveyors, who will not know whether crisis documentation standards apply to CPST.

Risk conflict with statutory language assigning Community Services Boards responsibility for crisis under Virginia Code §37.2-500 and §37.2-601.

This is not an academic concern. If CPST and crisis services overlap, providers will experience inconsistent authorizations, denials, and compliance risk. Families will be confused about what service to access during a behavioral health crisis. The result will be fragmented care at the exact moment continuity is most critical.

2. Duplication with Mental Health Skill-Building (MHSS, H0046)

The CPST draft emphasizes “restoring functional skills of daily living, building natural supports, and achieving identified person-centered goals.” Appendix H defines MHSS as “training in functional skills and appropriate behavior related to the individual’s health and safety, activities of daily living, and use of community resources.”

The overlap is word-for-word in some cases. Both CPST and MHSS target functional rehabilitation. Both emphasize daily living skills, safety, and independence. Both are strengths-based and person-centered.

MHSS is authorized under 12VAC30-50-130 and 12VAC30-50-226. Federal regulations at 42 CFR §440.130(c) require optional rehabilitative services to be distinct. If CPST is implemented with identical language, Virginia risks federal disallowance during CMS audit.

For providers, the consequences are financial. MHSS employs hundreds of QMHP staff across the state. If payers prefer CPST over MHSS, agencies will lose revenue and be forced to downsize or close MHSS programs. Clients who benefit from long-term MHSS will lose access, replaced by a new service that has not yet been tested in Virginia.

3. Duplication with Intensive In-Home (IIH, H2012)

For youth, CPST states: “The goal of CPST services for youth is restoration to a youth’s best level of functioning by restoring the youth to their best developmental trajectory…with the ability to function in a developmentally appropriate home, school, vocational and community setting.”

Appendix H defines IIH as “intensive therapeutic interventions provided in the youth’s residence (or other community settings as medically necessary) to improve family functioning, prevent an out-of-home placement, stabilize the youth, and gradually transition the youth to less restrictive levels of care.”

The similarities are undeniable: both emphasize family involvement, home and community settings, stabilization, and developmental progress. IIH is recognized under 12VAC30-50-226. Introducing CPST with similar language risks redundancy that violates federal requirements and creates confusion for families.

If CPST and IIH compete, IIH providers may lose referrals and revenue. This would destabilize a service that has successfully prevented out-of-home placements for thousands of youth.

4. Exclusion of PRS and CSAC Workforce

The CPST draft requires LMHP and QMHP staff, but excludes PRS and CSAC. This is inconsistent with Appendix G, which explicitly authorizes “telemedicine assisted assessment by a QMHP-A, QMHP-C, CSAC with synchronous audio and visual support from a remote LMHP.”

Virginia law at 12VAC35-105-20 recognizes PRS, and DBHDS requires PRS supervisors to complete training. PRS and CSACs have been integrated into Medicaid through services like H0024, T1012, and ARTS programs.

Excluding PRS and CSAC contradicts legislative intent and may violate 42 CFR §438.12, which requires Medicaid managed care to allow “any willing provider” who meets requirements.

Financially, this exclusion means:

Agencies that invested in PRS/CSAC staff cannot use them under CPST.

PRS and CSAC staff face job loss.

Providers are forced to hire more expensive LMHPs, raising payroll costs.

This is inequitable and destabilizing to the workforce.

5. Reimbursement and Rate Conflicts

The CPST draft requires “two or more members of a team consisting of professional and paraprofessional staff.” This LMHP-driven model costs significantly more than MHSS or IIH.

The 2023 Appropriation Act directed DMAS to raise rates by ten percent for certain services. But CPST is new and has no appropriation. Current rates for MHSS and IIH already fail to cover LMHP salaries. Requiring LMHP-driven CPST teams without new funding violates 12VAC30-80-30 and 42 U.S.C. §1396a(a)(30)(A), which require rates sufficient to ensure provider participation.

If CPST is rolled out without rate adjustments:

Providers will lose money on every unit billed.

Smaller agencies will be forced out of business.

Access to care will shrink, especially in rural areas.

6. Expanded Financial Impact on Providers and Staff

Higher Labor Costs: LMHP salaries average $80,000–$90,000 with benefits. QMHPs average $45,000–$55,000. PRS and CSACs average $35,000–$45,000. CPST excludes PRS/CSAC and requires LMHP teams, instantly doubling labor costs per service hour.

Workforce Displacement: Hundreds of PRS and CSAC staff across Virginia will be displaced, despite state investment in training and certification.

Destabilization: Agencies that rely on MHSS and IIH billing will lose revenue if CPST becomes the default service.

Administrative Costs: CPST requires CANS Lifetime every 12 months, standardized tools, and measurement-based care. These are valuable but uncompensated tasks, adding 10–15% to provider overhead.

Staff Retention: QMHPs, PRS, and CSACs will see reduced billable roles. Many will leave the field. Providers will be unable to recruit LMHPs in rural areas, worsening shortages.

7. Detailed Financial Modeling

Consider a mid-sized provider serving 100 clients. Under MHSS/IIH:

1 LMHP, 10 QMHPs, 5 PRS/CSACs.

Payroll: $1,200,000.

Overhead: $300,000.

Revenue at current rates: $1,600,000.

Net: +$100,000 (sustainable).

Under CPST model:

3 LMHPs, 10 QMHPs, 0 PRS/CSACs.

Payroll: $1,500,000.

Overhead (with new compliance costs): $350,000.

Revenue at current rates: $1,600,000.

Net: -$250,000 (deficit).

This deficit cannot be absorbed. Providers will close or reduce services.

8. Staffing Shortages and Access Barriers

Virginia already faces LMHP shortages, especially in rural regions. DBHDS workforce data show vacancies in LMHP roles exceed 20 percent in some areas. CPST requires LMHP-driven teams, which cannot be recruited at scale.

By excluding PRS and CSACs, CPST removes lower-cost, more available staff. The result will be service bottlenecks, waitlists, and reduced access, violating 42 U.S.C. §1396a(a)(30)(A).

9. Risks to Continuum of Care

If implemented as drafted, CPST will:

Eliminate MHSS by duplicating its scope.

Undermine IIH by overlapping youth stabilization functions.

Destabilize crisis services by including “crisis supports.”

Exclude PRS and CSAC staff, wasting state workforce investments.

Bankrupt small providers with LMHP mandates and no rate increase.

This contradicts the goals of Right Help, Right Now, which sought to strengthen, not weaken, Virginia’s continuum.

10. Recommendations

Revise CPST to exclude crisis stabilization functions already covered by Appendix G and DBHDS crisis regulations.

Clarify CPST’s role as distinct from MHSS and IIH, in compliance with 42 CFR §440.130(c).

Amend staff qualifications to include PRS and CSAC under LMHP/QMHP supervision.

Adjust reimbursement rates under 12VAC30-80-30 and align with 2023 Appropriation Act requirements.

Ensure compliance with 42 U.S.C. §1396a(a)(30)(A) by setting sustainable rates.

Submit CPST to CMS with explicit boundaries to avoid disallowance.

11. Legal Authority Appendix

12VAC35-105-1860 through 12VAC35-105-1870: Crisis requirements.

12VAC35-105-20: Definition of Peer Recovery Specialist.

12VAC30-50-130: Rehabilitative services.

12VAC30-50-226: Children’s mental health services.

12VAC30-80-30: Rate-setting requirements.

42 CFR §440.130(c): Rehabilitation services must be distinct.

42 CFR §438.12: Any Willing Provider.

42 U.S.C. §1396a(a)(30)(A): Access and sufficiency of rates.

Virginia Code §37.2-500 and §37.2-601: Crisis responsibilities of CSBs.

2023 Appropriation Act Items 304.VVVV.1, 304.VVVV.2, 304.WWWW: Rate increases.

Phần kết luận

The proposed CPST service, while well-intentioned, conflicts with existing services, duplicates MHSS and IIH, destabilizes crisis services, excludes PRS and CSAC staff, and imposes LMHP staffing mandates without funding. These issues violate state and federal requirements and will financially destabilize providers, displace staff, and reduce access to care.

DMAS should revise CPST before implementation to:

Clarify service boundaries.

Include PRS and CSAC roles.

Adjust rates for LMHP-driven costs.

Ensure compliance with 12VAC35-105, 12VAC30-50-226, 12VAC30-80-30, 42 CFR §440.130(c), 42 CFR §438.12, and 42 U.S.C. §1396a(a)(30)(A).

Only with these revisions can CPST strengthen Virginia’s behavioral health continuum and achieve the goals of Right Help, Right Now.