Thank you for the opportunity to review this draft policy. We will be submitting public comment from our members that reflects on-the-ground operational realities across urban, suburban, and rural settings. Across submissions, providers consistently flagged three primary issues:
A summary of the feedback provided by our members since the draft policy was released is provided below.
DEFINITIONS AND TERMINOLOGY
First and foremost, providers shared that the definitions and terminology throughout the draft create confusion and risk inconsistent implementation. Providers highlighted uncertainty around terms such as “affiliated,” “school setting,” “face-to-face,” and “supervision.” There is also strong concern that the new CANS Lifetime tool has not been developed or shared and that required or allowable evidence-based practices (EBPs) remain undefined. Transparency and clear operational guidance are viewed as essential to successful rollout.
WORKFORCE AND SUPERVISION REQUIREMENTS
The most significant concern overall relates to workforce and supervision requirements. The proposed limits, such as a 1:9 LMHP-to-staff ratio, four hours of required supervision per month (half of it in person), and the exclusion of LMHP-types and QMHPs from supervisory roles, are widely viewed as unworkable as proposed. Providers believe these provisions conflict with Virginia Board of Counseling rules and with established clinical practice, especially in rural areas where licensed staff are scarce. Providers also warn that these requirements could create a bidding war for LMHPs, drive consolidation, constrain access to services and client choice, and undermine the licensed-eligible pipeline.
TRAINING AND CAPACITY
Closely tied to this are concerns about training and capacity. The requirement for Managing and Adapting Practice (MAP) certification and other state-mandated trainings poses significant cost, scheduling, and access challenges. Many LMHPs have already been denied entry into MAP courses due to limited capacity at CEP-VA. Agencies are seeking clarity on whether the state or providers will bear the cost, how long certification takes, and whether “train-the-trainer” options or provisional compliance pathways will be available.
DESIGN AND PRACTICALITY OF COMPONENTS OF THE SERVICE MODEL
Providers also questioned the design and practicality of components of the service model, particularly the expectation of 24/7 crisis coverage in a school-based program. Around-the-clock availability is incompatible with labor law and the realities of school schedules, and the requirement that crisis response occur in person contradicts with situations where telehealth or client-preferred modalities are allowed. Agencies further noted confusion about whether crisis hours are billed separately or drawn from monthly unit limits.
INTEGRATION WITH SCHOOLS AND RELATED DOCUMENTATION
Another major area of concern involves integration with schools and related documentation. Providers are uncertain whether CPST must be written into students’ IEPs or 504 plans and whether those plans must be submitted with service authorizations. Requirements for Memoranda of Understanding (MOUs) between providers and schools are vague and raise compliance risks under FERPA and HIPAA. Questions also remain about who is responsible for parental consent, what information can be shared, and how to avoid role conflicts between school personnel and providers.
TIERING, AUTHORIZATION AND UNIT STRUCTURES
The tiering, authorization, and unit structures are viewed as overly complex and open to carrying interpretations by the Medicaid managed care organizations (MCOs). Providers fear that the lack of concrete criteria will result in inconsistent determinations and that MCOs will default to lower tiers and fewer units, regardless of client need, to reduce costs. The proposed one-day submission window for service authorization, along with requirements to include a signed individualized service plan at the time of request, is seen as unworkable, especially for agencies still determining EBP fit.
ADMINISTRATIVE BURDEN AND DOCUMENTATION EXPECTATIONS
Administrative burden and documentation expectations were cited throughout the feedback as excessive. LMHPs would be required to review and sign off on all notes across the agency, complete monthly documentation reviews, and participate in multiple layers of oversight, all of which are non-billable. Agencies warn that these tasks will consume more staff time than direct service delivery. Similar concerns extend to billing logistics, as the provider type/specialty designations and related billing guidance have not yet been finalized by DMAS, preventing agencies from building EHR templates or testing claim scenarios.
INEQUITIES ACROSS COMMUNITIES
Participants also emphasized the inequities these policies would create across communities. Rural and under-resourced areas would face the steepest barriers due to workforce shortages, geographic travel demands, and limited technology infrastructure. Moreover, the 24/7 expectations and rigid supervision rules would disproportionately impact women clinicians, who represent the majority of Virginia’s behavioral health workforce and often have caregiving responsibilities, raising serious concerns about worker retention and equity.
IMPLEMENTATION TIMELINE
Finally, providers underscored that the timeline for implementation is far too short to address these issues and otherwise prepare. Between new training requirements, accreditation mandates, MOU development, and workforce recruitment, agencies need a phased rollout and clear, final guidance to avoid service disruption for children and families.