Most Virginia schools are billing Medicaid for other services. Behavioral health services should be something schools can bill for. They should have the option to hire an LMHP clinical coordinator at the division-level and then form a team of CPST providers in the school, especially when the service is required by the IEP. 

Similar to ABA today, Therapeutic School Based Mental/Behavioral Health services in the late 90's and early 2000's originally used daily Data Collections tools to track-analyze and determine effectiveness of goals, objectives, strategies and progress toward level/tier progress. This data also drove weekly supervision and "all" changes related to ISP's, formulation of quarterly reports and discharge determinations, which often reduced length of stay in services and improved outcomes both short and long-term for students. 

With the enhanced clinical structure being outlined in this document, returning back to data collection tools (now-software) would allow for better empirical daily data collection, treatment discussion and outcomes. The use of data collection software will also better align with the new billing format outlined in this document.    

With limited number of units available in each tier, and with a CPST team sharing the units and treatment planning for a client, providing Outpatient in schools would seem to fit better (and remain) under the existing psychiatric services regulations vs. inclusion into CPST.  It would be difficult to discern the differences between tranditional OP services and CPST OP services.  Would it be easier to continue with existing regulation that CPST services must include OP?  If not, additional guidance is needed in regulations to establish these service differences.  What if I have an OP client that needs CPST in schools, and make a referral for CPST.  Can I continue seeing my client in my OP setting?  Can the two services coexist and overlap?  

How is CANS scoring going to correlate to LEVEL of Need to justify the Tier and service level placement.  

I wanted to offer some initial responses to the Draft policies for CPST - School. I do appreciate the efforts to increase use of evidence-based practices and to improve the quality of services for our clients! I can see that the intentions for the services are good and show a desire to serve our communities and improve mental health functioning. However, I do have some concerns with policies that I believe will have several unintended consequences.

• I can understand the reasoning for not having CPST - Community overlap with some of the EBPs that are also in the home/community setting. However, if CPST - School is denied due to the client qualifying for an EBP or different service, it seems like there will not be any other available services for the school setting specifically. MFT, FFT, CSC… it doesn’t seem like any of these would provide the level of support needed in the school setting, especially for Tier 2 clients. 

  • This would move the responsibility for treatment onto schools, FAPT teams, and other funding sources which would likely lead to increased out-of-school placement into alternative settings. In my local community specifically, alternative schools fill up very quickly. I have seen many clients forced into homebound instruction due to no alternative school placement being available. I think the referral requirement, specifically for CPST - School, could have a significant impact on highest needs clients who would lose access to needed education. I would ask that this requirement be reconsidered in view of the other services not be appropriate for the school setting.

• Requiring Clinical Supervisors to be part of face-to-face 90 day reviews for every client will pose a challenge with both time requirements and scheduling. In theory, they could be supervising 9 clinicians who could have up to 20 clients. That’s up to 180 clients they would need to personally be available to meet with over a 3 month period. While most staff will not be maxed out on caseloads to that degree, this requirement along with the extensive supervision requirements seems like too high of a demand for the amount of time needed in addition to requirements such as providing psychotherapy, reviewing and guiding staff through critical incidents, reviewing documentation every 30 days, crisis response, and more that they may be asked to do. Please consider altering this requirement for clinical supervisors to sign, but not necessarily be a part of, the 90 day reviews.

• Another related concern is the amount of administration and supervision required of LMHPs. I would like to offer caution about the difference between “capability” and “capacity.” An LMHP is likely capable of doing all of these activities (supervision, paperwork review, attending ISP review meetings, weekly team meetings, etc.) at a high level, but when all of those things are one person’s responsibility, the quality of the services are more likely to go down due to diminished capacity.
  • I would request that QMHP and LMHP-eligible staff’s supervision requirements be decreased AND that the list of who can provide supervision be expanded. The board of counseling has approved for QMHPs with experience and training to act as supervisors - this could actually improve quality of services as experienced QMHPs can speak to the service being provided and would have greater capacity for discussing client cases than a LMHP with numerous other administrative tasks.
  • Other ideas such as allowing supervisory QMHPs to sign paperwork for QMHP-level services and not requiring Clinical supervisors to be present for face-to-face ISP reviews every 90 days would decrease the administrative requirements while still allowing for LMHP oversight through occasional supervision and some document review. Please consider how the amount of work required impacts service quality as much if not more than the capability or professional level of a staff.

• I have some concerns with the 24/7 crisis response for school-based clients. A school-based service should be predominantly responsible for the school setting (which is also acknowledged in the draft in section 5.2, point 9). Occasional home interventions, such as with parents/guardians, may be appropriate (as noted in the draft policies), but generally, clients should be receiving the support in the school environment. If a client is experiencing crises in the community/home setting, there needs to be services provided specifically in that setting and referrals for other services such as CPST-Community. Requiring school-based staff to be available 24/7 significantly alters the purpose of this service, will impact availability of the workforce, and will create additional challenges with staffing, particularly for rural agencies.

  • For example, Staff who drive 15 minutes to a school may be asked to drive 30+ minutes to a client’s house in the middle of the night, something school staff have not previously been asked to do and something that does not appear to be built into rates. Please reconsider this component and think of how this need could be addressed in a different way.

• I would like to request allowing QMHP-Ts to provide Care Coordination since they can be directly involved in the Restorative Life Skills Training. Collaboration with other providers can and should be practiced by trainees.

• I would also like to request that Restorative Life Skills Practice be able to be done in group settings. Practicing skills with a clinician is great! But in the school setting specifically, practicing with peers is a valuable opportunity, especially when that practice is facilitated by a trained adult. In my experiences, peer conflict is one of the most common reasons that children are referred to services by schools. Clients need a safe place to practice the skills they are learning during training with peers, not just their MH providers.

• I can foresee potential challenges with guardian participation requirements for the school setting such as guardians who work, are unable to join, may not have consistent Wi-Fi access or transportation, may not trust mental health providers, etc. I would request for there to be more specific guidelines on what “participation” looks like. 

  • Additionally, can there be exceptions made for guardians who are unable or unwilling to participate in services? While I highly value and would prefer guardian participation, and I agree that it does improve outcomes, it can take several weeks or months to build rapport with guardians who have had poor experiences with mental health services or are less trusting. This requirement will prevent clients with less involved guardians from accessing needed services. These clients are often those with the highest needs and would be significantly impacted by the loss of service access due to actions of their guardian, something which is beyond the client’s control.

Thank you for your time and consideration on these points and the feedback from other providers!

As with regulation for adult CPST services there continues to be a conflict between the requirements to provide 24/7 crisis supports for individuals receiving CPST and Appendix G services that are often accessed through 988 Contact Centers.  A requirement for CPST providers to limit access to the Statewide Crisis Service continuum may violate the rights of citizens enrolled in these services and place undue pressure in diverting individuals from essential care during the time of a crisis.  There is no mechanism to determine if a caller to 988 has access to a CPST provider and verification of the same could prove costly for services that are designed to meet critical safety needs. 

Additionally, proposed rates and service limits do not support the required availability and capacity to respond in a timely fashion to such crises.  

The requirements for broad MAP training are concerning with less than 8 months until the proposed launch of services.  To ensure system capacity a broader network of training and support must be launched prior to inclusion in regulation.  Additionally, an initial round of training prohibited the participation in training for agencies that were not currently providing IIH and TDT services, further delaying statewide capacity building to ensure that providers were prepared to deliver care during service transition.

The CANS Lifetime is not yet available for review, training, or planned implementation.  A required assessment tool that must be broadly applied to Medicaid recipients in less than 8 months should not only be already developed, but should also have presented evidence base available for review, and training capacity within the system to support implementation.  Not only are providers ill prepared to implement this assessment tool, the interpretation and use of the tool by MCOs is not yet understood and could cause significant delays and potential inappropriate denials of necessary treatment.

Proposed rates and service limits do not support the required availability and capacity to respond to crisis appropriately.

I am going to list several concerns or questions below around the CPST School regulations.

Can we please have a definition for Clinical Director.  In a CSB setting the Clinical Director can manage multiple programs so the regulation of only being over 9 staff pretty much knocks a CSB out of the possibility of providing this service.  If we look at this as what at our CSB is the Assist Director of school based services and her staff is just the people that report directly to her then that would be acceptable.  In our catchment area we serve over 30 schools and would love to offer this service to the students but because of our size we would not be able to provide the service.  

The regulations state that we should collaborate with the IEP team.  Has this been discussed with Department of Education because at some schools, providers are not invited to the IEP meeting in general.

Why is the DLA-20 not an acceptable assessment tool when the adult version is for adult CPST?

This redesign was supposed to be budget neutral but you have created a service that requires staff to be on call 24/7 to their clients.  That is not budget neutral.  It is not reasonable to expect that from staff without additional compensation.  We also have spent the last couple of years building a crisis continuum.  Why would we not utilize those services for these individuals.  This is provider choice.

We also spend an enormous amount of time training crisis staff to appropriate handle crisis situations.  It would be a better service for trained crisis staff to provide crisis services.

The supervision requirements are also excessive.  Appropriate clinical supervision is important and you have to balance the needs of the staff along with the needs of the students and the needs of the school.  

The CANS assessment has not been released.  8 months is not an appropriate length of time to get all of this set and everyone appropriately trained.  We are going to have many individuals that are going to lose very important services IIH, TDT and MHSB and we need to be ready as a CSB to take care of those individuals.

Thank you for your time to read this.

Parental involvement is vital to the success of services for children but that doesn't mean that parents are willing to be involved.  If the parent isn't involved in the weekly meetings due to work, caring for other children, or lack of willingness will we need to discharge the client.

What if the individual has capacity to seek services on their own.  We have teenagers that want to seek services on their own and do not want parental involvement.  Will they be allowed to have this service.

Applied Behavior Analysis (ABA) has been effectively implemented within Therapeutic Consultation services to support a wide range of individuals, including those with psychological impairments.

In accordance with BACB Ethics Code 1.05 – Practicing Within Scope of Competence, behavior analysts practice only within their identified scope of competence. They engage in new professional areas (e.g., with new populations or procedures) only after obtaining and documenting appropriate study, training, supervised experience, consultation, and/or co-treatment from competent professionals. Otherwise, they refer or transition services to an appropriate professional.

Given this, here are some of the recommendations we would propose to strengthen behavioral supports and align with evidence-based practices within Community Psychiatric Support and Treatment (CPST)

• Section 3.1.2: Include Functional Behavior Assessment (FBA) as an explicitly recognized evidence-based practice within assessment, service planning and implementation.

• Section 3.2: Add language supporting referral for Applied Behavior Analysis services for individuals whose needs would be best met through behavior analytic intervention and programming.

• Section 3.3.1: Expand service delivery training to include DBHDS-approved behavior analytic training focused on function-based treatment, Applied Behavior Analysis, and Positive Behavior Support planning, ensuring continuity of appropriate and effective services as individuals transition into the adult system, where Therapeutic Consultation remains a primary mode of support.

• Section 3.3.2: Incorporate Trauma-Informed Clinical Behavior Analysis as a recommended framework to ensure compassionate, contextually sensitive, and evidence-based service delivery.

• Section 4.5: Revise supervision guidelines to include the Behavior Analyst Certification Board (BACB) standards for supervision of behavior analysts, ensuring ethical and high-quality oversight of applied practice.

The requirement to provide 24/7 crisis support is unreasonable for this service. First, CSBs already have emergency services staff that are trained pre-screeners and are already providing crisis support for our clients after-hours. I can respect wanting someone familiar with the case to be able to respond to a crisis, but that is not feasible to continuously be available outside of the school hours. This would also create an increased cost burden to have the CPST staff available outside of school hours. 

CPST School based will sharply reduce our students' mental health access (1-7hr/week cap, implementation barriers for providers- at a time when it is already hard to get providers to come back to schools) These changes will leave students without on-the-day support and push crises to teachers.

I appreciate DMAS’s continued efforts under Right Help, Right Now to expand access to behavioral health care for youth and families within educational settings. Integrating community psychiatric supports into schools can strengthen prevention, early intervention, and care coordination. However, the proposed CPST – School Setting model raises several implementation and compliance concerns that must be addressed before adoption.

1. Service Duplication and Licensing Clarity

The CPST–School Setting draft overlaps with existing Medicaid and DBHDS-licensed services, including Intensive In-Home (H2012), Therapeutic Day Treatment (TDT), and School-Based Mental Health Supports funded under the Virginia Department of Education’s Tiered Systems of Support (VTSS).
Under 12VAC30-50-226 and Appendix H of the Mental Health Services Manual, these programs already authorize in-school interventions targeting the same youth population and functional outcomes.
DMAS should clearly define how CPST-School differs from TDT or IIH to avoid duplication and potential CMS disallowance under 42 CFR §440.130(c).

2. Workforce Readiness and Training Burden

The draft requires extensive credentialing: LMHP-led teams, MAP certification, trauma-informed and crisis skills, and CANS Lifetime training through CEP-VA.
While clinically appropriate, these expectations will impose significant cost and time burdens on community providers already facing workforce shortages.
DMAS should phase in these training requirements with financial support, CEU reimbursements, or grants, and allow cross-credit for staff who already completed equivalent MHSS, IIH, or Crisis service trainings under Appendix G & H.

Agencies must also receive clear guidance on which training platforms are approved—such as VCU CEP-VA, DBHDS Workforce Development, and TCOM/Praed Foundation for CANS—to ensure compliance and audit readiness.

3. PRS and CSAC Role Inclusion

The draft limits CPST-School staffing to LMHPs, QMHPs, and Behavioral Health Technicians. This exclusion of Peer Recovery Specialists (PRS) and Certified Substance Abuse Counselors (CSAC) conflicts with the state’s current investment in peer integration and substance-use navigation within youth programs.
Under 12VAC35-105-20 and 42 CFR §438.12 (Any Willing Provider), qualified PRS and CSAC professionals should be recognized contributors to the CPST-School team under LMHP supervision. Their presence is particularly important for school-based prevention and recovery initiatives.

4. Reimbursement and Rate Structure

The CPST–School model includes LMHP supervision, MAP fidelity monitoring, and coordination with educational staff—all of which increase administrative costs.
Current behavioral-health rates, even after the 10 percent increase mandated by Appropriation Act Item 304.VVVV, will not sustain this structure.
DMAS should publish the proposed rate methodology under 12VAC30-80-30 and confirm that it accounts for supervision, travel between schools, and non-billable collaboration time with teachers and counselors.

Without a sustainable rate, small and mid-size agencies—especially minority-owned providers—will be unable to participate, reducing network adequacy and violating 42 U.S.C. §1396a(a)(30)(A) access standards.

5. School Collaboration and Parental Consent

Section 4.5 of the draft requires collaboration with schools and families, yet lacks detail on FERPA and HIPAA coordination.
DMAS should issue joint guidance with VDOE and DBHDS to clarify consent procedures, data-sharing agreements, and privacy safeguards so that providers can remain compliant with both HIPAA and FERPA while coordinating care within school settings.

6. Accreditation and Implementation Timeline

The requirement for agencies to obtain CARF, COA, DNV, or Joint Commission accreditation within 18 months of July 2026 is commendable but unrealistic for new or small agencies.
DMAS should consider a tiered compliance timeline—for example, allowing provisional participation for 24 months with documented progress toward accreditation—consistent with 12VAC35-105-50(B) flexibility standards.

7. Recommendations

Clarify the CPST-School service definition to distinguish it from IIH and TDT.

Explicitly include PRS and CSAC under LMHP supervision.

Publish rate methodology ensuring cost neutrality and sustainability.

Approve statewide training vendors and offer tuition assistance or CEU reimbursement.

Issue joint DMAS-DBHDS-VDOE guidance on confidentiality, parental consent, and data-sharing.

Implement a phased accreditation timeline to protect smaller providers and maintain access.

Phần kết luận

The concept of CPST within school settings has strong potential to close service gaps and support youth mental-health recovery.
However, successful implementation requires clear service differentiation, equitable workforce inclusion, sustainable reimbursement, and coordinated regulatory guidance.
DMAS should revise the CPST-School draft accordingly to ensure compliance with 12VAC35-105, 12VAC30-50-226, 12VAC30-80-30, and federal standards at 42 CFR §440.130(c) and 42 U.S.C. §1396a(a)(30)(A).

I am excited about some of the information I see in the draft documents.  But I am concerned about the ability to successfully manage the heavy lift of the credentially processes.  It is complicated because I do agree with the need for the training but I do not see how agencies/providers will be able to manage the financial burden of this process.  I am also still unclear as to what CPST will actually look like.   I would hope with being so close to implementation we would have a better idea of what this services looks like and does on a daily basis.  

Proposed Regulations continue to be unclear it regards to what actual service implementation will look like.

The requirement for 24/7 in-person crisis support by CPST team is likely to impact service delivery overall.  You can't expect a provider to be responding to crisis all hours of the day and night and continue to provide scheduled care to other recipients of the service. Why the limitation on utilizing Comprehensive Crisis and Transition Services? These providers literally specialize in crisis support. If a continuum of care already exists - use it. Additionally, the reimbursement rate for these services is not adequate for the expectation of the CPST providers. 

The Team/Tier structure provided is confusing. Does each agency decide what team/tier they offer? 

The availability of MAP training is completely insufficient this close to implementation. 

When will the CANS Lifetime be available? 

Will the requirement of caregiver participation be waived for an adolescent seeking services on their own? What clarity can be provided on "the caregiver must commit to participating in 30 min of SPST covered services components a week"?

What clarity can be given on "active participation by school team in treatment planning and implementation"?

1. Crisis Response: Per the manual, crisis services should be available 24/7.

This service is specifically provided by the CSBs and crisis response services. It will be difficult to cross train staff for crisis response, MAP and evidenced based programming. In addition, with a shortage of LMHPs in Virginia, there are many other jobs that pay more than the reimbursement of this service will allow providers to pay that do not require being available for crisis response 24/7. Currently, for most of our licensed staff in TDT, the benefit of a daytime, school calendar schedule balances the lower salary compared to other positions. Adding a 24/7 availability requirement without a significant salary increase will outweigh the schedule benefit, and we anticipate losing them to private practice and other jobs.

Most providers will need to implement a rotating on-call system so that staff can schedule their evening/overnight/early morning hours to allow for crisis calls that will require privacy and potential access to the client’s electronic medical record (e.g. NOT running errands, watching children’s sports events, dropping them at daycare,  or eating out with friends in a restaurant). This then defeats the purpose of having the client’s regular service provider available in a crisis – odds are they won’t be connected to the regular service provider but be speaking with someone they are unfamiliar.

2. The 9:1 ratio of LMHP to QMHP while requiring a team response teams means that the LMHP may be responsible for providing services for 180 clients as QMHP max caseload is 20. This is an issue on several fronts.

1.      LMHP-E staff could be utilized in a similar role to assist in providing the team services

2.      The LMHP is billing for time under the CPST program that could otherwise be billed as outpatient taking away from CPST services

3.      The lack of LMHPs across the state places burdens on agencies that are already facing hiring and retention obstacles

3. There is not a long term plan for providers to access MAP. Once staff have been trained and completed the required hours, how do they maintain access to the online program? Providers should know the long term costs that may be required for this program.
4. The billing system is complicated and micromanaged. There is a limit on caseload, number of units per month, etc. while not accounting for multiple billers, crisis intervention, etc. Why is CPST unable to adopt a billing system similar to outpatient services to simplify things?
5. The program encourages a person-centered and trauma informed approach, however, restricts children and adolescents if the family is not involved. This could make the service restrictive to those populations (incarcerated parents, caregivers with substance abuse concerns, etc.) most in need.
6. While this program is presented as a school-based service, some of the clinical requirements focus on intensive therapy that should not take place at school. For example, family therapy, EMDR and other traumas (sexual abuse, physical abuse, etc.) are best addressed in an outpatient setting and clients should be able to receive support at school and through outpatient services. Recovery should be able to take place in multiple settings.
7. The CANS Lifetime Assessment is still under development. Providers will need to know what, if any, costs will be associated with the initial training to use the assessment, the annual retraining cost, and the time for these trainings as the cost to pay staff for training hours (which likely will not be billable) and any training fees will need to be factored into a provider’s assessment of the cost to provide the service versus payment rates.

8. What is the definition of specialized services? Section 8, p 21

Our organization has been very impressed with the roll out of MAP and the state facilitated trainings. We are very excited about moving away from the unit system and the current authorization process with the MCOs. We appreciate your time in hearing our questions and concerns regarding the daily implementation of the services.

I wanted to ask for clarification on caseloads. A team can consist of multiple non-licensed staff. For example, an LMHP-E and a QMHP could be on a team. However, would that client then count towards caseload limits for both of these staff, or would the client be assigned a “primary” clinician? If the client counts towards both caseloads, then a team of QMHP and LMHP-E would be severely limited on the number of clients that could be seen. Specifically, Tier 2 clients would max out at 8, severely limiting the number of billable hours and reimbursement a staff could have.

Please offer some clarification on whether a client is on the caseload of everyone on a team or if each client is assigned to 1 caseload.

Thank you for the information provided in the Open Office Hours today. Based on that conversation, I wanted to compile some of my thoughts on the supervision requirements and possibly some suggestions. I also want to ensure that my reading/understanding of the regulations is correct.

My understanding of supervision requirements:

Based on my reading of the requirements, here is what I see being asked of LMHPs for supervision. 

1. There is 1 Clinical Director, the LMHP who is over the whole program. This director must at-minimum provide 1 hour of supervision to each other LMHP involved in CPST. They may or may not supervise direct care staff depending on factors like the size of the agency/number of staff.

2. Underneath the clinical director are clinical supervisors, also LMHPs, who can supervise LMHP-Es/QMHPs/BHTs. They can supervise up to 9 staff.

3. Each week, team meetings must occur. These can count towards group supervision hours. Though a minimum time is not established, there has to be enough time to allow for brief discussion of each client as needed (is it required to discuss each client, or are staff able to select the clients they need to staff?)

4. At least 1 hour per month must be individual supervision for all non-licensed staff.

5. At least half of the supervision hours must be in-person for all non-licensed staff.

6. This means that at-minimum, 1 team meeting is in-person each week, and clinical directors are meeting in-person for 1 hour per month with each staff member they supervise.

Supervision Implications: 

1. Clinical directors who have a full 9 staff will spend at least 3-4 hours in supervision each week, not including travel time for in-person supervisions, research, and preparation (i.e. planning a topic for skill-building and researching the information for that topic). That is

   • 1 hour per week for team meetings (if more time is not necessary, which it could be if multiple clients need to be discussed);

   • 2-3 hours per week for individual supervisions to see all 9 staff throughout the month;

   • And 1 hour of individual supervision with the clinical director each month. 

   • Plus any required research, planning, preparation, travel, etc.

2. Staff will likely be receiving closer to 5 hours of supervision each month at minimum (4 hours in team meetings + 1 hour of individual supervision). 

3. Staff must meet in-person for at least 1 team meeting, or must plan for additional supervision, in order to meet the in-person requirements. Travel will be either put onto the staff to go to the clinical supervisor or the supervisor to go to the staff, further increasing time devoted to supervision.

Supervision Questions:

1. What happens if staff are on PTO for a week? Is the supervision required to be made-up at some point in the month. That would add additional hours of supervision requirements for Clinical supervisors and further decrease flexibility in their schedule.

2. What provisions are made if a Clinical Supervisor is on PTO for a week and a team meeting must occur?

Supervision Ideas/Suggestions:

1. I fully support LMHP oversight and understand the intentions behind that! However, I have some ideas on how the demand on LMHPs could be decreased while still allowing for clinical integrity.

2. One idea is to differentiate between some of the clinical supervision hours, which could occur during team meetings, versus other areas of supervision.

   1. For example, team meetings can specifically focus on clinical improvement such as teaching skills/strategies/tools to staff, ensuring clinical interventions are being applied appropriately, reviewing ISPs and progress/lack of progress, staffing major client concerns, etc. 

   2. Other forms of supervision such as administrative (overseeing paperwork, reviewing documentation, etc.) and restorative supervision (checking on staff well-being, job satisfaction, preventing burnout) could be done by LMHP-Es and qualified QMHPs. Having LMHPs involved in weekly team meetings while individual supervision is done by other staff members would significantly decrease the amount of time LMHPs have to spend in supervision and would increase availability for other clinical oversight such as staff who need to discuss a specific client in more detail or when crises arise. 

   3. Additionally, if LMHP-Es and QMHPs are providing supervision, this could streamline treatment questions to LMHPs. Rather than having 9 staff trying to discuss various clients and personal needs, some of these questions can be resolved by the LMHP-Es and QMHPs. Then, any significant client issues or staff needs could be taken to the LMHP directly through one source rather than each staff member going to the LMHP. Considering that LMHPs could have extremely high numbers of clients that they are responsible for, this again is more likely to improve services as LMHPs could focus more on the biggest clinical needs rather than spending time in supervision or traveling around to each staff individually.

   4. If this were the case, there could be site supervisors directly available on-site to staff for supervision. This could decrease travel time and increase in-person availability. For example, an LMHP-E or qualified QMHP could serve as the supervisor traveling to different sites to meet with their staff. They resolve certain issues (can't get in touch with guardian, staff is struggling with paperwork, unsure of how to support client with specific problem, conflict with a teacher, etc.). Then team meetings would allow LMHPs to focus on bigger client needs (crises, lack of progress, needed changes to ISP, etc.) and still provide direct LMHP oversight.

Ultimately, I believe that the biggest concerns for the current draft supervision structure are the following:

• There are concerns about being able to staff enough LMHPs to sustain the amount of services needed in our area. Many LMHPs do not want to spend that much time in supervision if they want to work in community-based services at all. The high level of administrative burden has the chance to decrease the amount of Licensed staff available even further.

• Similarly, although the supervision is stated to have been included in the rate reimbursements, I have seen many comments questioning if those rates will be competitive enough for LMHPs to be retained. In addition to the supervision, there are other nonreimbursable activities such as likely being on-call at times (as part of the crisis requirements), attending every quarterly ISP review for each client they are supervising (per the regs), and traveling to various school sites. How many LMHPs will be willing to do this instead of the outpatient side with more flexibility and likely more money?

• The administrative requirements also require a lot of scheduling and planning, including relying on guardians to respond to requests and keep appointments (i.e. intakes, reassessments, 90-day reviews, etc.)

I am hoping that some adjustments can be made to make better use of licensed staffs’ time and skills. I think there are several areas where LMHP-Es and QMHPs are capable of high-level services, so allowing their involvement would be an improvement to quality rather than a detriment. Thank you for your consideration and request for ideas on this matter.

• Restore flexibility for school-based CPST to meet students’ individual needs by allowing for more service time and less control of that time dictated by MCOs;
  
  
• Modify the 24/7 on call regulation  so schools can retain qualified mental-health providers and
  
  
• Allow more realistic supervision ratios, greater than 1:9
  
  
• Devise a plan for Summer treatment (this is intended to replace legacy services, yet there is no mention of summer)

I think we agree our youth in VA deserve better than widening the gap.

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:

• Unclear and sometimes conflicting requirements;
• Feasibility concerns tied to workforce capacity, especially LMHP availability and supervision rules; and
• Administrative and billing mechanics that are misaligned with school operations and clinical need.

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.

The following summarizes feedback regarding the "Definitions" section received from our members since the draft policy was released:

• CANS Lifetime Assessment Clarity: Need explicit guidance on which evidence-based practices (EBPs) are required or allowed; uncertainty over whether providers can use alternative EBPs.

• Terminology and Compliance Ambiguity: Terms like “affiliated” and “school setting” are unclear, as are expectations for MOUs and their alignment with FERPA/HIPAA.

• Supervision Standards: Request clarification on what it means to “address the spiritual needs” of individuals within supervision requirements.

• Tele-Supervision and Confidentiality: Recommend updating “face-to-face” and “supervision” definitions to reflect modern tele-supervision practices while ensuring confidentiality safeguards.

• Transparency on CANS Lifetime Tool: Stakeholders want to see the actual CANS Lifetime tool and question why it hasn’t been shared publicly.

The following summarizes feedback regarding the "Service Definitions/Critical Features" section received from our members since the draft policy was released:

Staffing Flexibility and Cost Concerns

• Overemphasis on clinicians (LMHPs) for team composition; many activities could be performed by QMHPs.
• Requiring LMHPs for all supervision (and limiting supervisees to nine) is cost-prohibitive and limits workforce capacity.

IEP and Funding Barriers

• Current IEP-related language conflicts with education rules and funding structures
• Providers cannot be written into IEPs without triggering funding obligations for schools.

Service Delivery Practicality

• The 24/7 crisis support requirement is unrealistic in school-based settings.
• Limits on office-based hours reduce flexibility during closures or testing.

Reimbursement and Workload Balance

• Expectations for extensive family and school collaboration exceed what current unit structures and reimbursement rates can reasonably support.

LMHP Workforce Shortage

• The scarcity of LMHPs, especially for in-person, school-based work, makes the supervision and staffing model unsustainable.
• Broader LMHP-type supervision should be permitted.

Implementation and Role Clarity

• Confusion around how the team model functions, how BHTs fit within it, and how coordination with IEP/school teams is expected.

Service Definition Inconsistencies

• Questions remain about overlap between CPST-School and home-based CPST services, and about the roles of non-LMHP team members in coordination and care delivery.

The following summarizes feedback regarding the "Required EBPs" section received from our members since the draft policy was released:

Training and Capacity Concerns

• MAP Training Access and Cost: Many LMHPs have been denied access to MAP training due to limited capacity at CEP-VA. Agencies need clarity on timelines, funding, and whether the state or agencies will bear training costs.
• Training Duplication and Burden: MAP may duplicate existing EBP credentials. Intensive, mandatory trainings (MAP and foundational modules) could strain smaller providers’ staffing, cost, and scheduling capacity.
• Implementation Timeline: Agencies need advance notice (by March 1, 2026) of training requirements to budget and plan before the July 1, 2026, rollout.
• Credentialing and Flexibility: Clarify timeframes, costs, and flexibility for MAP certification (which may exceed $700 per clinician). Consider “train-the-trainer” options or financial support.

Evidence-Based Practice (EBP) Processes

• CANS Lifetime Notification: Clarify who within each MCO should be notified when CANS results indicate a fit for a standalone EBP.
• Referral Burden: CPST providers shouldn’t be expected to assess for EBPs they’re not trained in; MCOs are better equipped to make those determinations.
• Billing and Documentation: Agencies need to know whether EBP assessments, coordination, or attempts to link clients to EBPs are billable and what proof of effort will be required.
• Duplication of Services: CPST psychotherapy requirements overlap with existing outpatient services.

Rate and Reimbursement Questions

• Measurement-Based Care: Unclear whether using optional assessment tools will increase reimbursement or simply use existing authorized units.
• Reimbursement for Coordination: Agencies ask if coordination efforts beyond standard time limits can be billed.

Service Delivery and Operational Limits

• Supervision Cap: The rule limiting each LMHP to nine supervisees is impractical, especially for small or rural agencies that depend on part-time or flexible staffing models.
• Overlapping Service Definitions: Need examples showing how the new CANS and Comprehensive Needs Assessment integrate, including estimated completion time and confidentiality safeguards.

The following summarizes feedback regarding the "Required Service Oversight and Supervision" section received from our members since the draft policy was released:

Supervision Intensity and Feasibility

• The required four hours of monthly supervision for LMHP-Rs, LMHP-RPs, and LMHP-Ss is viewed as excessive.
• Weekly supervision for non-licensed staff and monthly documentation reviews add heavy administrative burden.
• The 1:9 supervision ratio restricts staffing flexibility, especially for agencies relying on part-time or relief staff.
• Smaller agencies question how a single LMHP who also serves as Clinical Director/Supervisor can receive required supervision.
• The combined supervision and documentation expectations make it difficult for agencies to remain compliant and operational.

Workforce Shortages and Structural Strain

• There is a statewide shortage of LMHPs, particularly in rural and school-based settings, making compliance nearly impossible as proposed.
• The requirements could intensify competition for LMHPs, increasing costs and destabilizing the provider network.
• The rules disregard the established supervisory capabilities of LMHP-types and QMHPs, creating barriers for licensed-eligible staff to advance.
• Agencies report current hiring pressure across regions as organizations compete for the limited pool of licensed clinicians.

Tele-Supervision Limitations

• The requirement that 50% of supervision be in-person (face-to-face) is impractical given travel distances and dispersed service areas.
• Restricting tele-supervision contradicts current DMAS definitions of “face-to-face” and ignores proven telehealth effectiveness.
• Agencies conducting services across large geographic regions (1,000–2,000+ square miles) say travel demands make these requirements unworkable.
• Concerns about confidentiality protocols for tele-supervision documentation remain unresolved.

Regulatory and Policy Conflicts

• The proposed standards conflict with Board of Counseling regulations that permit LMHP-types and some QMHPs to supervise others.
• Supervision and oversight requirements diverge from state licensing board standards and recognized national tele-supervision certifications.
• Unclear definitions of “clinical director” and “supervision” create confusion about roles and responsibilities.
• The requirement for licensed practitioner oversight undermines existing regulatory structures and workforce development pathways.

Operational Burdens and Compliance Risks

• Agencies question the evidence base for the in-person supervision mandate.
• Staff unit limits (504/month) constrain scheduling flexibility and coverage for school-based programs.
• 24/7 crisis coverage expectations are incompatible with labor law and lack compensation mechanisms.
• Overlapping roles (LMHPs required to provide both administrative and clinical oversight) add to workload strain.

The following summarizes feedback regarding the "Required Service Components" section received from our members since the draft policy was released:

In-Person and Crisis Support Requirements

• Ambiguity around in-person crisis support: It’s unclear whether an LMHP must always be physically present or only when clinically necessary.
• Unrealistic 24/7 crisis expectations: Round-the-clock availability is incompatible with staffing limits, labor laws, and non-billable demands.
• Conflicting telehealth guidance: Some sections allow telehealth, while others require in-person intervention, creating compliance confusion, especially in rural areas or during public-health restrictions (i.e., quarantine).
• Crisis referral contradiction: Requiring in-person crisis support before referral to CATS conflicts with language permitting telehealth or client-preference options.
• Lack of clarity on billing: It’s unclear whether crisis time has a separate billing code or is drawn from a client’s authorized monthly units.

Service Delivery and Scope Issues

• CPST encompasses numerous activities, including assessment, planning, crisis response, psychotherapy, care coordination, and restorative skills, creating heavy workload and documentation requirements, much of which is non-billable.
• The mix of psychotherapy and rehabilitative services blurs boundaries with other programs, raising duplication concerns when clients already receive outpatient therapy.
• In school settings, limited instructional time and rigid schedules restrict the ability to provide all required service components, especially for lower-tier clients.
• QMHP-T involvement is marginalized, even though many agencies rely on them; proposed limits on their service hours significantly reduce capacity.
• The 504-unit monthly staff cap further constrains flexibility and coverage for school programs.

Psychotherapy and Level-of-Care Conflicts

• Requiring psychotherapy within CPST duplicates existing outpatient services and may lead to denials from insurers when clients are already engaged in therapy.
• For many high-risk clients, outpatient psychotherapy is not clinically appropriate; forcing its inclusion delays access to needed care and wastes resources.
• Lack of clarity on whether psychotherapy within CPST must be billed separately or included in authorized units adds operational risk.

Telehealth and Restorative Skill Practice

• The prohibition on conducting restorative skills training via telehealth appears inconsistent and limits flexibility for families and staff.
• Telehealth restrictions reduce the ability to adapt services to public-health or geographic constraints.

Administrative and Oversight Burdens

• Supervisors face unsustainable documentation and oversight loads, including review of hundreds of progress notes weekly, compliance with multiple oversight bodies (DMAS, DHP, accreditation), and 24/7 staff supervision.
• Combined supervision, administrative, and direct-care expectations are unmanageable for agencies with limited LMHP staff.
• The structure will divert staff time away from client services toward paperwork, compliance, and insurance appeals.

Workforce and Systemic Strain

• The new requirements reverse recent DHP efforts to address workforce shortages and make hiring and retention of qualified clinicians even harder.
• The overall design of supervision, service delivery, and crisis expectations discourages provider participation, particularly in school-based and rural settings.

The following summarizes feedback regarding the "Provider Qualification Requirements" section received from our members since the draft policy was released:

Memoranda of Understanding (MOUs) and Data-Sharing Concerns

• Conflict of Interest: Concern that MOUs could be managed by organizations that also provide the same services, creating potential conflicts and inequity.
• Undefined Content and Boundaries: MOU requirements are vague with no clear guidance on content, responsible parties, or oversight.
• Privacy and Compliance Risks: Ambiguity around FERPA vs. HIPAA standards, parental consent, and data-sharing protocols could expose providers and schools to compliance violations.
• Role Confusion: The regulations require collaboration with schools but fail to define limits on provider responsibilities, leading to potential role overlap with school staff.

Licensing, Enrollment, and Accreditation Challenges

• Providers must secure DBHDS licensure, DMAS enrollment, and accreditation within 18 months, which is viewed as unrealistic, especially for small or rural agencies.
• Accreditation costs and timelines are prohibitive; some accrediting bodies require agencies to operate the service for 18 months before applying, creating a catch-22.
• Unclear licensure and specialty categories (still “to be determined”) prevent agencies from preparing effectively.
• Agencies already accredited (e.g., through CARF) are concerned about redundant or conflicting requirements.
• No clear transition process for providers who already hold DBHDS licenses or accreditations.

Service and Billing Clarifications

• Restorative Skills Training: Need clarity on why telehealth cannot be used when other skill-building activities can occur virtually.
• Psychotherapy: Unclear whether it is included within CPST or must be billed as a separate service.

Eligibility and Functional Criteria Issues

• The Functional Impairment Criteria section is confusing and contradictory, language around “two domains at level 2” vs. “three at level 3” needs simplification to ensure consistent interpretation.

System Readiness and Implementation Timing

• CPST is a new service model for both providers and accrediting organizations, meaning there is no established standard for review.
• The 18-month compliance timeline does not align with accreditation processes, training readiness, or operational startup realities.

The following summarizes feedback regarding the "CPST Medical Necessity Criteria" section received from our members since the draft policy was released:

IEP/504 Plan Integration and Documentation

• Unclear whether IEP or 504 plans must include CPST goals or be submitted with service authorization requests.
• Providers are uncertain how IEP-related documentation will affect eligibility, unit allocation, and tier assignment.
• Concern that the process could create additional administrative burdens and confusion between education and Medicaid systems.

Tier Criteria and Functional Impairment Confusion

• The Tier 1 and Tier 2 criteria tied to CANS scores, diagnoses, and caregiver/school engagement are overly complex and open to interpretation by MCO reviewers.
• The Functional Impairment Criteria language is inconsistent (i.e., “must meet a and b plus one or two domains”) and needs clearer definitions for how levels determine tier eligibility.
• Lack of alignment between required family engagement (30 minutes per week) and the authorized minimum service units makes implementation impractical.
• Unclear how IEP status or impairment severity will impact tier placement and service intensity.

Family and School Engagement Requirements

• The 30-minute weekly caregiver engagement expectation may be unrealistic for many families with limited availability or competing obligations.
• School team participation is required but not well defined with unclear expectations for frequency, format, and accountability.
• The two-hour caregiver response rule for crisis consultation conflicts with the 24/7 crisis coverage expectation and may be unmanageable for families.

Service Limitations and Seasonal Gaps

• Excluding summer camp or structured summer therapy programs removes valuable continuity of care for children who rely on those supports.
• In-office service restrictions (one hour per week) are too limited to accommodate comprehensive assessments or intake needs.

Implementation and Interpretation Risks

• Ambiguous criteria for impairment, engagement, and documentation create room for inconsistent application across MCOs.
• The overall structure risks reducing service access due to administrative complexity and conflicting requirements.

Complex Terminology: The use of numerous specialized terms (e.g., LMHP-type, CANS Lifetime, CPST) may be confusing for providers unfamiliar with the updated language. This could necessitate additional training and administrative support to ensure proper understanding and implementation.

• Concerns with the CANS Assessment Tool:
• Lack of Standardization: The CANS tool exists in multiple versions, often customized by local agencies. This variability undermines consistency and comparability across providers and regions.
• Limited Validity and Reliability: There is a scarcity of peer-reviewed research confirming the tool’s validity and reliability. A 2024 study examining its internal structure revealed inconsistent findings, raising concerns about its psychometric soundness.
• Changing Rating Scales: The evolution from severity-based to action-based rating scales complicates longitudinal comparisons and may obscure clinical progress.
• Ambiguity in Outcome Measurement: CANS ratings reflect a child’s functioning without treatment, not their current status with interventions in place. This can result in persistently high scores even when a child is improving, making it difficult to demonstrate treatment effectiveness.

Section 2: Service Definition / Critical Features

• Mandatory Family/Caregiver Involvement: Requiring caregiver participation may pose challenges for families facing barriers such as limited availability, transportation issues, or engagement difficulties.

Section 2.2: CPST Teams

• Rigid Team Composition: The mandated tiered structure requiring specific combinations of licensed and paraprofessional staff may be difficult to maintain, especially amid workforce shortages.
• Supervision Demands: Requiring LMHP Clinical Supervisors to oversee all licensed service components significantly increases their workload and will likely impact service delivery in regard to timeliness of start/delays in treatment.

Section 3: Required Evidence-Based Practices

• Yêu cầu đào tạo: Mandating MAP and other evidence-based trainings for all staff could impose significant time and financial burden on agencies.
• Referral Protocols: Requiring providers to assess and refer individuals to standalone EBPs prior to CPST authorization—even when such services are unavailable within the agency—adds complexity and will delay care.

Section 3.3: Service Delivery Requirements

• Dual Training for Transition-Age Youth Providers: Agencies serving youth aged 16–25 must complete both youth and adult training modules, increasing the training burden.
• Mandatory Statewide Training: Requiring all staff to complete foundational modules may be difficult to coordinate, track, and execute, particularly for part-time or newly hired employees and within the implementation target dates.

Section 4: Service Oversight and Supervision

• Supervision Ratios: Limiting LMHP Clinical Supervisors to overseeing only nine staff will hinder staffing flexibility and necessitate additional hires, resulting in limited access to treatment .
• In-Person Supervision Mandate: Requiring at least 50% of supervision to be conducted in person presents logistical challenges, especially for agencies with rural, remote,  or part-time staff.
• 24/7 LMHP Availability: Mandating continuous LMHP availability for consultation may be unsustainable without substantial staffing resources.

Section 5: Required Service Components

• Group Size Limitations: Capping group services at a 1:6 ratio may reduce operational efficiency, increase staffing demands, and will limit access to services.

Section 6: Provider Qualification Requirements

• Accreditation Mandate: Requiring agencies to obtain accreditation within 18 months may be financially and administratively burdensome.
• Annual MOUs with Schools: The requirement to maintain and renew MOUs with each school division or private school annually adds to administrative complexity and burden.

Section 7: Medical Necessity Criteria

• 1. Misalignment with School Staff Expectations

School personnel often operate under the assumption that mental health providers embedded in schools are available to support all students, regardless of diagnosis or level of need. However, the proposed criteria strictly limit CPST services to youth who meet specific diagnostic and functional impairment thresholds, as determined by the CANS Lifetime assessment and other clinical documentation. This creates a disconnect between what school staff expect and what providers are permitted to deliver under Medicaid guidelines.

Without adequate training and education on the complexities of CPST services, school staff may inadvertently refer students who do not meet the stringent admission criteria. This can lead to frustration, miscommunication, and a breakdown in collaboration between schools and mental health providers. It may also result in delays in care for students who need support but do not qualify for CPST, leaving school staff feeling unsupported and mental health providers burdened with managing expectations beyond their scope.

• 2. Complexity of Service Eligibility and Documentation

The criteria outlined in Section 7 are highly complex and require nuanced clinical judgment, extensive documentation, and ongoing reassessment. School staff, who are not trained in behavioral health diagnostics or Medicaid service authorization processes, may struggle to understand why certain students are not eligible for services or why services must be discontinued. This complexity can hinder the collaborative treatment planning and implementation that the regulations themselves emphasize as essential.

• 3. Risk of Undermining School-Based Mental Health Integration

By narrowly defining eligibility and requiring multiple layers of documentation and service intensity, the regulations may inadvertently discourage providers from engaging in school-based work. The administrative burden and risk of non-reimbursement for services provided outside strict criteria could lead to reduced provider participation in schools, undermining efforts to integrate mental health supports into educational environments.

• High Admission Thresholds: Requiring multiple criteria across functional domains for Tier One and Tier Two services may exclude youth with moderate needs who could still benefit from CPST.
• Caregiver Participation Requirement: Weekly caregiver engagement may not be feasible for families facing socioeconomic or logistical challenges.

Recommendations for Section 7 – CPST-School Setting Medical Necessity Criteria

To ensure the successful implementation of CPST services in school settings, the following recommendations are proposed:

1. Increase Flexibility in Service Delivery

The current criteria are highly prescriptive and may unintentionally exclude students who could benefit from mental health support. DMAS should consider allowing greater flexibility in service delivery to accommodate the diverse needs of students across school environments. This includes:

• Allowing all students who meet the medical necessity criteria to receive CPST services within the school setting on a daily basis, if clinically appropriate and supported by their Individual Service Plan (ISP).
• Permitting providers to tailor service frequency and intensity based on the student's evolving needs, rather than rigid unit limits tied to Level of Need scores alone.

2. Tiered Support Based on Clinical Complexity

Students with more complex and clinically significant needs should have access to enhanced services delivered by highly trained professionals, such as LMHPs and LMHP-types with specialized training in trauma, mood disorders, and crisis intervention. This tiered approach would:

• Ensure that students with serious emotional disturbances or early serious mental illness receive intensive, evidence-based interventions.
• Promote clinical matching, where the provider’s expertise aligns with the students’ presenting concerns, improving outcomes and reducing provider burnout.

3. Clarify Roles and Expectations for School Staff

Given the complexity of CPST eligibility and service structure, DMAS should develop clear guidance and training for school personnel to help them understand:

• The scope and limitations of CPST services.
• The distinction between mental health support and educational responsibilities.
• How to collaborate effectively with CPST providers without assuming they can serve all students or fulfill school staff duties.

4. Strengthen Collaboration and Communication

To bridge the gap between clinical providers and school teams, DMAS should encourage:

• Regular joint meetings between CPST teams and school staff to align goals and expectations.
• Shared documentation tools that allow for transparent communication while maintaining confidentiality and compliance.

Section 8: Exclusions and Service Limitations

• • Restrictions on Service Overlap: Prohibiting CPST for individuals eligible for other EBPs (e.g., MST, ACT) limits flexibility in treatment planning and may hinder continuity of care.
• Billing Limitations: Capping non-licensed staff at 504 CPST units per month across all agencies will constrain service delivery and impact quality of care, as it is not person-centered and doesn’t take into account individual acuity.

Section 9: Service Authorization

• • Stringent Authorization Timelines: Requiring preservice authorization within one business day of admission may be difficult to consistently meet, especially during high-volume periods.
• Complex Authorization Criteria: Mandating multiple documentation elements (CANS, ISP, engagement metrics) for service requests increases administrative burden and will delay service initiation.

Section 10: Documentation and Utilization Review

• LMHP Documentation Review: Mandating LMHP review of non-licensed staff documentation every 30 days increases supervisory demands.

Section 11: Billing Requirements

Complex Modifier Use: The requirement for precise procedure codes and modifiers based on staff type and service component increases the risk of billing errors and administrative challenges.

The following summarizes feedback regarding the "Exclusions and Service Limitations" section received from our members since the draft policy was released:

Exclusion and Service Eligibility Concerns

• Concurrent service restrictions (e.g., MST, FFT, ACT, CSC, crisis) could leave youth without necessary support, particularly those with developmental disabilities but no co-occurring mental illness.
• Affiliate service bans discourage collaboration and integrated care models, undermining continuity across programs.
• The exclusion rules appear to apply outside school settings, which could mean students receiving school-based CPST are barred from other community services (e.g., IOP or ABA), an unintended and restrictive outcome.
• Sections C and D of the exclusions are internally inconsistent and confusing; the intent and boundaries are unclear.
• Section I (24/7 availability) seems contradictory; requiring around-the-clock access sounds like a crisis service even though crisis services are excluded.

Documentation and Reimbursement

• The volume of required documentation and measurement tools creates significant non-billable workload; providers question why this time isn’t reimbursable.

Seasonal and Setting Limitations

• Section G (summer services) lacks clarity: if school is not in session, it’s unclear what types of services can continue and how coverage should be structured.
• Excluding summer camp or school-break programs eliminates important continuity for youth who rely on consistent behavioral supports.

Systemic and Practical Impacts

• Restrictions on concurrent services and classroom-based programming represent a regression from past models (e.g., TDT, IIH) that allowed more flexible, integrated support in schools.
• The overall structure risks reducing access to services, discouraging collaboration, and fragmenting care for students with complex needs.

The following summarizes feedback regarding the "Service Authorization" section received from our members since the draft policy was released:

Authorized Units and Service Intensity

• The proposed maximum units and hours per week/month for both Tier 1 and Tier 2 are far too low to meet the needs of the target population, given their ongoing emotional and behavioral challenges.
• Providers are unclear how authorized units will be divided among different staff roles, raising operational and billing uncertainty.
• The limited authorized time does not align with the complexity of the cases or the intensity of support required.

Authorization Process and Timing

• The requirement for preservice and concurrent authorizations with short turnaround times (i.e., submission within one day) is unrealistic, especially when providers must evaluate for potential EBPs before authorization.
• Concern that initial assessments may not be reimbursed if the authorization is delayed beyond the narrow window.
• The requirement to include a signed ISP at the time of authorization submission adds administrative burden and could delay service initiation.
• Unclear how retroactive requests will be handled under these new timelines.

Tiering Criteria and MCO Discretion

• The tier and level system (Tier 1–2; Levels 2–6) is overly complex and subjective, leaving room for inconsistent MCO interpretation.
• Providers fear MCOs will default to the lowest unit tiers to minimize cost, even for high-need clients.
• Requests for clear examples of what distinguishes Tier 1 vs. Tier 2 and how Level 2–6 criteria differ in practical terms.
• These tiering ambiguities directly affect staffing models, service planning, and reimbursement predictability.

Summer Programming Restrictions

• Requiring discharge at the end of the school year eliminates summer continuity of care and undermines clinical progress.
• Loss of summer services may lead insurers to deny reauthorization in the fall, claiming lack of medical necessity since services lapsed.
• Summer programming is also viewed as clinically valuable for observing peer interactions and community functioning that can’t be assessed during the school year.

The following summarizes feedback regarding the "Additional Documentation Requirements and Utilization Review" section received from our members since the draft policy was released:

Excessive LMHP Documentation Requirements

• LMHPs must review and sign off on all client documentation across the agency, including progress notes and treatment records, which is viewed as excessive and unmanageable.
• The expectation that LMHPs handle both supervision and documentation review for every client drastically increases workload and limits their availability for direct care and oversight.

High Administrative and Non-Billable Burden

• The draft requires extensive administrative tasks, including detailed progress notes for every service, monthly LMHP reviews of all non-licensed staff documentation, ISP signatures from youth/guardian, the entire CPST team, and the LMHP Supervisor, and 90-day face-to-face ISP reviews and annual CEP-VA reporting. These expectations create a significant amount of non-billable time that many agencies cannot absorb.

Workforce Utilization Constraints

• By requiring LMHPs to review and sign all documentation, the policy eliminates the ability to delegate routine paperwork review to trained QMHPs.
• This restriction reduces efficiency and undermines the role of QMHPs and other paraprofessionals in team-based care.

Practical Implementation Challenges

• School schedules make it difficult to coordinate required synchronous ISP meetings and signature collection.
• The overall documentation and review process is unclear and likely to create compliance risks due to unrealistic expectations.

The following summarizes feedback regarding the "Billing Requirements" section received from our members since the draft policy was released:

Monthly Unit Cap Concerns

• The 504-unit monthly cap for non-licensed staff is viewed as too restrictive and will limit service delivery capacity, especially in programs with high client needs.
• This cap could shift excessive workload to LMHPs, increasing their caseload burden and reducing supervision quality.

Tracking and Enforcement Challenges

• It is unclear how the 504-unit cap will be monitored or enforced, particularly since staff often work for multiple agencies.
• Agencies have no mechanism to know when an employee’s total units across employers exceed the cap, creating compliance and audit risks.

Implementation and Readiness Issues

• Providers cannot build electronic health record (EHR) templates or prepare billing processes until DMAS finalizes provider type/specialty codes and DBHDS completes the service definition.
• The lack of finalized guidance delays operational readiness; providers request billing guides and test-claim scenarios to ensure correct implementation.

The following outlines other feedback received by our members on the draft CPST-School Setting policy:

Implementation Timeline

• The timeline for implementing the new requirements is too short, leaving agencies insufficient time to prepare, train, and staff appropriately.

Workforce and Supervision Requirements

• LMHP On-Call and 1:9 supervision ratios are unrealistic, particularly for school-based or rural programs, and will intensify workforce shortages.
• The expectation for 24/7 availability contradicts the nature of school-based services and would make staffing unsustainable.
• The licensed-practitioner requirement is impractical given Virginia’s shortage of LMHPs; it risks creating a competitive “bidding war” for scarce clinicians and driving consolidation among providers which will reduce client choice and access to care.
• The rules exclude LMHP-types and QMHPs from supervisory roles, despite existing Board of Counseling regulations allowing certain supervision functions.
• Stakeholders argue for allowing licensed-eligible staff to supervise, as they already provide outpatient care, and note that excluding them undermines workforce development.

Misalignment Between Agencies and Boards

• DMAS and the Virginia Board of Counseling appear out of sync: the Board has expanded QMHP roles, while DMAS policy reverses this progress.
• The resulting inconsistency and confusion make compliance and staffing planning difficult.

Gender and Workforce Sustainability

• The expectations for 24/7 coverage disproportionately impact women in the workforce, especially younger LPCs who make up a large share of Virginia’s mental health clinicians and who often have caregiving responsibilities.
• These requirements create equity and retention concerns and threaten workforce stability.

Training and Capacity

• MAP training access remains a problem; many LMHPs have applied and been denied due to limited capacity at CEP-VA.
• Without prompt, expanded access, providers will be unable to meet required training standards before the policy’s implementation date.

Service Delivery Realities

• Office-based caps (one hour/week) and reliance on telehealth disadvantage small and rural providers and families with limited internet access.
• The policy’s expectations for year-round, in-person service and documentation add cost and workload burdens that small or rural agencies cannot absorb.

Comparative Policy Perspective

• Other states implementing CPST do not impose such restrictive, prescriptive staff requirements, highlighting Virginia’s divergence and the need for more flexibility.

The following provides a summary of the top concerns shared by our members:

LMHP Requirements and Workforce Impact

• Overly burdensome LMHP expectations (on-call, supervision, documentation, and training) will make staffing unsustainable, particularly with LMHP-types excluded from supervisory roles.
• The shortage of licensed staff will limit access, drive up costs, and reduce the ability to meet community needs.
• Training access, cost, and timeline (especially MAP) remain unclear and unrealistic.

Lack of Clarity and Transparency

• Providers need clear, consistent guidance on service tiers, authorization processes, IEP integration, and crisis expectations.
• Ambiguity invites inconsistent MCO interpretation and compliance risk.

Service Design and Practicality

• 24/7 crisis coverage and other in-school service expectations are not feasible in school-based settings.
• Low unit caps and strict ratios hinder service flexibility and access.
• Policies must better align with school operations and coordination protocols to ensure realistic implementation.

Overall:  The draft manual has a significant level of complexity related to medical necessity criteria, team composition, heavy administrative burden, heavy supervision requirements and heavy emphasis on LMHP to engage in non clinical functions such as signing off on LMHP-types assessments, frequent supervision sessions for qualified LMHP-types and QMHP staff and the 24/7 availability of LMHP and other staff for crisis supports.  Given the workforce shortages that Virginia continues to experience, it is recommended that the aforementioned is reconsidered and associated requirements are reduced.

Additionally, the requirement that in-person crisis support must be provided before any referral to a crisis continuum service is impossible to ensure.  First responders and other crisis service providers will not know who is currently receiving CPST services and how to contact the provider.  This requirement will cause significant access issues for individuals experience a crisis who are in immediate need.  Please remove this requirement.

Supervision of LMHPs:  The requirement of the Clinical director to provide one hour of supervision to LMHP staff is a heavy administrative burden and highly impossible for CSBs with a high number of LMHPs in the CPST service.  For example, we have 7 LMHPs in the school-based service who would need to receive supervision from our clinical director although they report to the Program Manager who is a licensed, tenured and heavily experienced.  It is recommended that this requirement be removed.

Supervision of LMHP-types and QMHPs – LMHP-types and QMHPs have had a sufficient number of work hours where they do not require weekly, or four hours per month, supervision.  This requirement is excessive, adds administrative burden and gives no regard to the level of experience that the LMHP or QMHP may have.  It is recommended that this requirement be removed.

Crisis Support: The prohibition of individuals utilizing Comprehensive Crisis and Transition Services denies access to potentially appropriate and needed services during a crisis.  Crisis support is not the same as crisis intervention.  Individuals’ crises may be acute to the point of needing a more intense and prolonged crisis intervention that is community-based.  This requirement may lead to more ED visits and more utilization of first responders.  Additionally, the requirement that the program be operational 24/7 adds costs as LMHP and QMHP have to be paid to work while responding to after-hours, weekend and holiday calls.  This will also be confusing for school staff and confuse policies, practices as much of this service is intended to be school-based.  It is recommended that the aforementioned requirements be removed.

Psychotherapy:  There are some youth who receive therapy outside of the service provider as this is a current allowance within the TDT service.  Some youth are referred to TDT and currently receiving therapy.  It is recommended that the CPST allow outside providers to provider therapy simultaneously to the CPST-school based service.

Accreditation:  Please consider other licensing or certification to suffice in lieu of CARF or other accreditations.  Examples could be CCBHC or existing CARF, etc.  Please consider removing this requirement as it is heavy on administrative burden.

Medical Necessity Criteria:  The criteria is very complex and nuanced.  Please consider simplifying the criteria to make it accessible to children who would benefit from the service.  For example, please consider removing the Intensity of Service section.  The hours of allowable service are extremely limited and do not allow staff to be available to the individual throughout the school day to provide intervention, support, reinforcement of coping strategies or to teach new skills.  The service is very prescriptive and does not allow flexibility to meet kids’ nuanced and specific needs.  It is recommended that number of hours be removed or significantly increased so that staff can be available throughout the school day.  Possibly consider a per diem for this service that covers all service components, administrative requirements and supervision requirements.

Please allow referrals to come from other partners in the school.  For example, Communities in Schools may make a referral to the CPST provider

Discharge Criteria:  Given the significant life experiences of many youth served including poverty, community violence, parental-supervision issues, in-home or community trauma and other social determinants of health, it is going to be highly unlikely that a child’s behavior and/or symptoms will be resolved within four months.  Many times, youth need additional support to manage at school because of the chronic factors aforementioned.  It is recommended that CPST be allow for at least one to two years.  If not, our children will fall through the cracks.

Thank you for reviewing and taking into consideration the comments below, related to the recently released draft policies for CPST-School Setting.

Screening Tool/Assessment & Training Requirements:

• The “CANS Lifetime” has not been publicly released and seemingly not tested for validity and cross-rater reliability, but yet continues to be cited as the mandated screening tool for CPST services.  To date, there is no screening tool and there are no training plans for CANS Lifetime.    
• Planned MAP training is limited in capacity; as such, CPST service providers will have to bear the financial burden for independently training staff.
• All CPST youth providers are required to complete a new "foundational, state-wide Youth Mental Health Rehabilitative Supports & Services training". Like for CANS Lifetime, a training plan is also needed for this component and preferably will include timeline, location(s), and entity(ies) responsible for/available to provide this training.
• Mandates to annually submit documentation to CEP-VA which substantiates staff-mandated training, puts additional administrative burden on CPST service providers.     

Service Delivery & Coordination Requirements:

• The requirement for youth to be referred to and offered a “Standalone EBP” prior to CPST authorization will significantly delay treatment and cause substantial frustration and confusion for families.
•  Excluding youth from CPST Services-School Setting who meet criteria and/or are receiving MST or FFT services is not reflective of person-centered, individualized treatment planning or service delivery.  MST & FFT are prescriptive EBPs that do not provide daily services & supports within a school setting.  
• Regarding the exclusion of crisis response services delivered under the state-wide “Right Help, Right Now” model and within the regional crisis continuum for a youth receiving CPST services, this prohibition is not reflective of person-centered, individualized treatment planning or service delivery either.  With those services delivered under the crisis continuum, it is the expectation for service delivery to be immediate, clinically responsive to the highest acuity level of need, and provided regardless of other existing services.  It is simply not feasible (nor clinically appropriate) for crisis continuum service providers to ‘screen out’ those youth and families currently receiving CPST services.  Furthermore, it is duplicative and fiscally irresponsible to replicate a second system of care with 24/7/365 crisis response.
• Consideration should be given for QMHPs also being permitted to devise/write ISPs, under the review of the LMHP/LMHP-E Type.          
• The requirement for caregivers to receive 30 minutes or greater of CPST services per week does not take into consideration valid time constraints for a family (caring for other siblings, parent employment, transportation barriers).  It also does not take into account older adolescents who are permitted to receive treatment services without parental consent, according to VA Code.         

Supervision & Oversight Requirements:

• Under the proposed CPST Team structure, QMHP staff are categorized as “paraprofessionals”; this categorization diminishes the knowledge/education, skills, and abilities of many experienced, highly qualified professionals who have four-year, human services-related degrees and have been providing within scope-of-practice and clinically appropriate interventions to youth & families, for years and in some cases even decades.  Differentiation between QMHP staff and BHT staff should be taken into consideration with regard to not only supervision requirements, but also in reimbursement rates for the various Tier-Level “Teams”.  Of particular note, there are already set standards for training and supervision of QMHP-Ts, as established by the Board of Counseling.    
• The restriction of an LMHP Clinical Supervisor supervising only nine (9) CPST employees is too limiting, from a staffing perspective and in the midst of the behavioral healthcare workforce shortage. 
• Likewise, the restriction of an LMHP Clinical Supervisor only being permitted nine (9) CPST employees in a Group Supervision setting is too limiting, from a staffing perspective and in the midst of the behavioral healthcare workforce shortage. 
• Clarification is needed regarding the definition of and expectations for the “Clinical Director”, and the required supervision of “Licensed” LMHPs by the CPST agency’s Clinical Director.  If an agency, regardless of size, only has one named “Clinical Director”, is that Clinical Director required to provide the indicated supervision to “Licensed” LMHPs?   
• The requirement for senior, experienced LMHPs to be available to provide 24/7/365 consultation to employees is a sizable financial and staffing burden for CPST providers, as these senior, experienced LMHPs will have to be paid accordingly and at a differential rate.   
• For those LMHP-E Types in Clinical Supervision for Licensure outside of the CPST agency, it will create administrative burden to negotiate and collect “official documentation of supervision sessions” from outside-of-agency Clinical Supervisors.  This requirement could also greatly restrict or even eliminate the LMHP-E’s choice of Clinical Supervisor.        

Accreditation & Implementation Timeline:

• Accreditation is a weighty administrative and financial burden on the CPST agency.  In reaching out to a number of the recommended accreditation agencies , it was reported that they do not currently have enough surveyors/reviewers and already have a sizable list equating to over a one (1) year wait to begin the process.     
• The allowable time is inadequate for providers to re-configure and build out electronic health records (EHR) for entirely new 1) services/service codes and 2) billing structures, neither of which have been clearly/formally defined or solidified.
• The state-wide capacity and allowable time are inadequate, for training related to CANS Lifetime and MAP, both cited as mandates for CPST authorization and service delivery.

In closing, the most concerning potential consequence of rushing this implementation will be the detrimental impact it has on Virginia’s young people and their families who are currently receiving these “Legacy” services.  Most providers embrace EBPs and the desire to achieve better clinical outcomes for those they serve … but if not executed in a planful manner, the effects could be particularly devastating to those most in need of our support.  Thank you again for taking your time and giving your attention to review these comments.

Trân trọng gửi,

Paulette Skapars

Harvest Outreach Center Public Comment on Proposed CPST–School Based Regulations

Thank you for the opportunity to share feedback on the draft manual for the new school-based service that will replace Therapeutic Day Treatment (TDT). While we appreciate DMAS’s goal to strengthen quality and accountability, the current manual contains numerous contradictions and impractical expectations that make the model unworkable for school-based mental health programs,particularly for rural providers.

The following overview reflects our agency’s feedback as an active provider of school-based mental health services that has remained committed to supporting students and families while adapting to the many challenges of implementation and sustainability.

1. Supervision and Oversight Requirements

The manual’s definition of supervision fails to recognize the effectiveness and safety of tele-supervision. It excludes live observation opportunities, shared video reviews, and other secure online methods that have been in use successfully for years. “Face-to-face” supervision should include HIPAA-compliant virtual options to ensure equitable access, especially for rural providers who cannot be physically present at all times.

The proposed 1:9 LMHP supervision ratio and requirement for 24/7 on-call availability are unrealistic and damaging to the workforce. This rule means that one Licensed Professional Counselor (LPC) can only supervise nine staff members total,whether they are full-time, part-time, or relief workers. That restriction makes it nearly impossible to employ part-time Behavioral Health Technicians (BHTs) who fill in or help during peak needs, because even a part-time worker still counts toward the total of nine supervisees. It also prevents agencies from having additional staff available to provide backup coverage or support when needed. It is unclear whether this cap applies strictly to the same nine staff members on an ongoing basis, or if supervisors can temporarily adjust supervision assignments when staff are out for vacation, illness, or other absences.

Without clarification, this rule creates confusion and potential compliance risk. For example, if one of the nine supervised staff takes a week of leave, can another employee temporarily provide services under that supervisor, or would that violate the 9-person limit? In real-world practice, agencies frequently need to adjust staffing to ensure continuity of care for clients.

If the rule is interpreted rigidly, it would make it extremely difficult to manage normal staff turnover, coverage, and schedule changes, particularly in smaller or rural programs. DMAS should clarify whether flexibility will be allowed for temporary substitutions and provide guidance on how agencies can remain compliant while still meeting client needs when staff are unavailable.

Oversight of staff caseloads with this model would include supervision tasks, approving a range of 126-180 daily progress notes a week (this is just referencing 1 form) in addition to oversight of all other clinical and enrollment documentation, direct client care, and 24/7 oversight of staff and client support.

One thing that we really appreciate about this service model is its design to have multiple people supporting each client, allowing for a team approach that blends the strengths of different professionals. However, if each staff member is capped at a strict maximum caseload, this team model becomes impossible. Once every staff member reaches their caseload limit, no one else can join a case,even to provide minimal or short-term support.

The 504 monthly billing unit limit already prevents any one person from being overloaded, so these additional caps only restrict flexibility without improving quality. LPC-Residents (LPC-Rs) and Behavioral Health Technicians (BHTs) could meaningfully support more clients by taking smaller roles,yet under the current draft, they cannot participate at all unless they act as the primary Qualified Mental Health Professional (QMHP). This undercuts the team-based structure that CPST is supposed to rely on.

The combination of limited supervision ratios, inflexible caseload caps, and around-the-clock availability requirements will make it virtually impossible for agencies to staff programs adequately.

Currently, one in three Licensed Professional Counselors (LPCs) in Virginia is under the age of 40, and nearly 90% of those under 40 are women. Requiring 24/7 availability places an unmanageable burden on working parents,primarily women,and threatens to drive clinicians out of the workforce altogether.

Community-based and school-based services operate during business hours (7am-8pm time frame) to meet students’ needs in natural environments,schools, homes, and offices. Unlike emergency rooms or crisis response centers, they are not designed to deliver care 24 hours a day. Requiring them to do so would collapse already strained programs.

Oversight requirements are also inconsistent with state licensure boards and national certification standards. Limiting tele-supervision to half of total supervision hours conflicts with guidelines set by the Virginia Board of Counseling and national programs such as the Advanced Clinical Supervisor and Board Certified Telemental Health Provider credentials. Supervisors should have flexibility to meet requirements through individual and group telesupervision, live observation, consultation, and secure video review.

In practice, these new requirements would force LMHPs to approve hundreds of progress notes weekly, oversee documentation, handle insurance appeals, provide clinical care, and maintain constant on-call availability. These overlapping duties are unsustainable and risk major burnout among supervisors.

2. Workforce Shortages and Administrative Burden

The manual overburdens licensed staff by assigning both administrative and clinical oversight responsibilities without providing additional resources. By requiring LMHPs to sign off on all documentation for all clients across the agency, it prevents the effective use of trained QMHPs who are fully capable of reviewing non-clinical paperwork and supporting direct care staff.

Staffing caps (e.g., 504 units per month per staff) and rigid caseload rules make it impossible to maintain a team-based model of care. These limitations prevent multiple staff members from supporting the same client, even when shared care is clinically necessary. They also restrict part-time and relief staff who play a crucial role in rural and school-based settings.

The combined effect of supervision limits, 24/7 availability, and unit caps leaves agencies in an impossible situation,unable to comply with every rule at once. This will result in fewer available providers and ultimately harm access for children and families.

3. Crisis Coverage and Ethical Conflicts

The manual mandates that crisis support must be available 24 hours per day, 7 days a week, 365 days a year, and that in-person crisis response must be offered. Requiring on-call availability around the clock for non-crisis, school-based programs places agencies in conflict with federal labor laws regarding compensable on-call time and creates conditions that would lead to severe staff burnout.

Additionally, forcing clinicians into constant on-call roles blurs ethical boundaries. It requires counselors to move between therapeutic and evaluative functions without separation, increasing the risk of impairment, ethical violations, and emotional exhaustion. Staff need clear boundaries between their professional and personal lives to preserve their well-being and professional judgment.

Beyond the ethical and legal concerns, there are significant safety implications that the current language does not address. Even law enforcement officers do not enter a potential crisis situation without first assessing risk and determining whether conditions are safe for response. Is the expectation that a mental health provider would respond to a home at midnight or 2 a.m. to intervene with a client who is escalating—possibly to prevent a caregiver from taking the child to the emergency room? Would that provider be expected to call 911 and request law enforcement to accompany them to a private residence? Responding to a crisis in the middle of the night introduces serious safety risks. Family members may be impaired, aggressive, or irrational, and clinicians are not equipped or authorized to manage those situations alone. Where is the line between when a behavioral health provider is expected to respond versus when a situation warrants law enforcement or emergency medical intervention? If the situation is not a significant safety issue, then it is unclear why the situation could not wait until normal working hours when providers can safely and effectively respond. The expectation that school-based mental health providers deliver 24/7, in-person crisis support is not only impractical—it is dangerous. DMAS must clarify realistic crisis protocols that distinguish between clinical support and emergency response, and ensure the safety of both clients and staff.

4. Assessments, Documentation, and Service Definitions

The manual’s assessment requirements are overly complex and duplicative. It is unclear whether the CANS Lifetime replaces or supplements the Comprehensive Needs Assessment (CNA), and whether the two must be completed separately. Clarification is also needed on who can participate in assessments,particularly for young children who cannot complete the CANS independently.

The manual’s definition of progress and engagement is also vague. Terms like “no progress” and “lack of caregiver engagement” are undefined, leaving too much room for interpretation by Managed Care Organizations (MCOs). This could lead to inappropriate service terminations or denials of care. Barriers such as transportation, work schedules, or rural isolation often prevent families from attending frequent in-person meetings. These systemic realities must be recognized to prevent penalizing families for factors beyond their control.

5. Service Model Conflicts

There are several contradictions within the manual itself. For example, “crisis avoidance” language assumes clients can avoid triggers, even when the trigger is a family member or unavoidable environment. Similarly, requiring both “on-site” skill-building and allowing telehealth sessions creates confusion about when and how telehealth may be used.

The restorative skill-building and restorative life skills sections appear nearly identical, using different terms for the same type of intervention. The psychotherapy requirement creates further overlap and may lead to billing denials, particularly when clients already receive outpatient therapy from the same provider. Many students referred for school-based services are not appropriate for outpatient therapy due to the intensity of their needs. Requiring outpatient psychotherapy as a prerequisite wastes time and delays effective intervention.

6. Service Eligibility and Functional Criteria

The level-of-need criteria in the manual are unclear and inconsistent. Some sections require two lifetime domains at level three or higher, while others reference a level four threshold. These inconsistencies make it difficult to determine who qualifies for services and invite arbitrary interpretation by MCOs.

7. Summer Programming and Service Authorization

The new manual eliminates the ability to provide summer programming under CPST–School Based services. Under the current model, summer programming allows continued support through structured therapeutic groups, summer school sessions, and community-based interventions. Without this, students must be discharged at the end of the school year and then reapply for services in the fall,an interruption that insurers may use to deny care.

Summer programming plays a critical role in assessing functioning outside of school, building peer relationships, and maintaining clinical stability. Removing this option will disrupt continuity of care and increase regression among high-need students.  In addition, the absence of ongoing summer services will likely place added strain on other community systems—such as crisis response, juvenile justice, and hospital emergency services—as youth lose access to the preventive supports that help keep them stable and connected.

8. Exclusions and Contradictions

Sections C and D of the “Exclusions and Service Limitations” are written in conflict with each other and need clarification. Section G lacks guidance on what services may be offered during summer months when students are not in school. Section I contradicts itself by defining Tiered services as requiring 24/7 availability while simultaneously excluding crisis care from coverage.

9. Accreditation, Implementation, and Feasibility

Providers need realistic timelines to plan training, staffing, and compliance. The manual’s expectations for supervision hours (4–6 per month), documentation, and 24/7 crisis readiness far exceed available resources. Providers will not be able to maintain compliance without additional funding or flexibility.

Phần kết luận

In its current form, the proposed CPST–School Based service model is not operationally or financially sustainable. It introduces overlapping rules that conflict with one another, overextends clinical staff, and fails to consider the realities of school-based work.

If implemented as written, these regulations will cause severe workforce shortages, service interruptions, and barriers to access,especially for children in rural and underserved areas.

Harvest Outreach Center and other community-based partners stand ready to collaborate with DMAS to develop a framework that strengthens oversight without dismantling the workforce or reducing access to care.

Thank you for taking the time to consider this feedback. We share the same goal: ensuring Virginia’s children and families receive consistent, compassionate, and effective mental health support. We want to be part of the solution,please work with us to make this model both ethical and sustainable.

If the new CANS assessment is integrated into a platform that DMAS controls, there must be clear transparency around who will have access to client records, how that information will be stored, shared, and protected, and what safeguards will prevent unauthorized viewing or data misuse. These records include highly sensitive personal and clinical details about children and families, and shifting control of this data to a centralized DMAS platform could significantly alter how providers manage and share information. Providers need assurance that confidentiality standards will remain fully compliant with HIPAA and ethical practice, and that access will be limited strictly to authorized personnel directly involved in the client’s care. 

While CPST in the school setting is a great idea, it is not realistic for many communities, especially rural communities that do not have the resources, funding or means available to make the changes necessary to be able to meet those requirements. It would be helpful to allow for schools and communities to create natural partnerships with local organizations, CSBs, private providers, etc., to be able to meet those needs in more creative ways and allow for more resources and funding opportunities to go toward increasing those efforts and/or sustaining ones that have already begun instead of limiting access due to insufficient resources in order to establish a CPST. 

We appreciate the inclusion of more activities that can be completed by a QMHP-T than in the CPST Home/Community draft.

The CANS must be completed initially and every 12 months.  Will this replace the CNA and annual reassessments and the DLA-20?  Or is this adding another assessment to the list?  Of the 6 other recommended assessments for adults and 15 for youth, DBHDS already requires the Columbia.  This is a significant number of assessments for the individual to experience.  Recommend swapping the CANS for 1 or more other current assessments.  Also, it is problematic that we are commenting on an assessment that we have not seen, haven't assessed the validity, nor know the training requirements to conduct.

 

When completing the initial CANS, the clinician must be knowledgeable about the 4 listed EBPs whether or not they are offered at the CSB in order to refer the individual if appropriate and also be knowledgeable about the availability, waitlist status, and whether the individual's insurance is accepted at services in the geographic area.  This is an undue training and administrative burden.

 

The clinician must notify the individual's MCO about a potential fit w/ an EBP, coordinate that a CANS is not repeated if not necessary, and coordinate on assessments dates.  This is an undue administrative burden.  How and who at the MCO will be notified, and wouldn't most of this be the responsibility of the MCO Care Coordinator?

 

It's confusing to include 3.3.3 Coordinated Specialty Care when it cannot be provided with CPST as stated in 8.2.d Exclusions and Service Limitations.  Is it included because you mean to indicate that if an individual served in CPST experiences first episode psychosis that CPST should end and the individual transferred to CSC? Or do you mean that CSC should be folded into and billed as CPST as applicable?

 

Annual submission of documentation to CEP-VA is an undue administrative burden.  If this includes PHI, then the risk of breaches increases.

Specifying that supervision documentation must be kept in the personnel files is prescriptive, potentially mingles consumer PHI increasing the risk of breaches, and is an undue administrative burden versus simply requiring that supervision be documented which is typically how this is worded in regs.