Requiring a face to face visit in the community while ideal does not acknowledge the client's rights and say in treatment. Clients might have a mistrust of the system, don't want workers at their home, or to be seen with workers in the community. This does not allow for that option therefore affecting their rights, their access to treatment, and their say in their own treatment. There is plenty of work and help case management can provide in office, via phone, or virtually to help clients gain skills and independence within the community. Additionally taking the building of the ISP out of the hands of the clinician providing the direct service only further complicates things and puts more barriers in place for clients to receive services. These clients need individualized support from a trusted clinician they have built a relationship with not more strangers faces they see once a year/quarter and the more boxes that need to be checked effectively putting more "fingers in the pot" directing treatment only makes providing that individualized care more difficult to achieve and will negatively impact the client. Clients who have historical trust issues and documented paranoia, delusions, and trauma that are not being accounted for with these changes in regulations. 

• Page 14 - If the individual continues to make limited or no progress (remaining at the
  same Level of Need for 18 months), the LMHP Clinical Supervisor shall
  evaluate whether a referral to a different service may better support
  progress.      - what other services would be recommended?  Part of the intake process is to refer out to other suitable services that would be available and only approve for CPST if they are not available or the individual does not qualify?     Services such as MHSB and CPST fill a gap in service and provide a lifeline to a lot of individuals.  Sometimes progress is just simply the fact that with support the individual follows through with their care better.  MCOs do not see it that way however and deny for "not making progress"  Also, who helps these individuals during this time of bureaucratic red tape? will authorization be continued for CPST while linkage to "another service" occurs?  MHSB currently is a safety net for individuals who need help but do not fit boxes for other services.  
• Feedback - tiers continue to seem super difficult to decipher with so many moving parts.  It's like reading one huge flow chart and difficult
• Paperwork/Documentation is excluded for payment.  Providers shall only bill for time spent face to face with individual or individual's family/caregiver.  Can a face to face session completely devoted to treatment plan creation/updating be billed?  ISP creation is a lengthy process, particularly when constant updates or changes are required and a significant unpaid burden if there is no allowance for payment for that.
• There are several mentions of provider expectations to contact the MCO or MCO care coordinator and directives regarding provider's expectations regarding answering calls/queries from the MCO in an expedient manner.  Is there a similar guidance document that be provided that outlines the MCO's expectations in their interactions with providers, expectations of them, policies they are to follow, etc.?  Currently MCOs create their own processes, and each is different.  There are times when a call is received demanding a call back within a few hours - which is unrealistic and a burden on front line individuals who are in the community providing service/care and attending to the multiple duties required to keep a program running and clients being served.
• Have any other providers observed increased oversight and scrutiny from MCOs regarding current authorizations for MHSB? For instance, declining to approve anyone (no matter the case made for medical necessity) to individuals who have ever had the service for a length of time in the past and frequent requests for time draining peer reviews regarding current continue stay requests?  This seems to have increased since the sunsetting of MHSB was announced.

3.2.2    This comment has been made on earlier versions:

• By creating the foundational service (CPST) as an option only if other services are “inappropriate” or “unavailable”
• The expectation that a provider who meets the requirements for providing CPST also meets the requirements to conduct the needed assessment for ACT, CSC, FFT or MST (several of which are proprietary and require nationally recognized specialized training) or that the time/effort required (and uncompensated) will be beneficial for the individual is unrealistic.
• Identification of the most appropriate service accessible and available is the responsibility of the referring agent or, in the case of self referral the provider’s assessment of their ability to meet the needs.

4.2        Related to this and similar requirements for staffing

• While it is clear that part of the intent is to assure qualified staffing and supervision, and it is an intent that we can support, it is also clear that there is a significant bias against smaller provider entities which do not have “deep benches” of licensed professionals. 
• The termination of the option for a variance on a date certain (6/30/2029) suggests that past that date, staffing (recruitment & retention) will no longer be an issue.  We see no reason to assume that clinical staffing will be more readily available in three years!

5.3.2    Crisis Support

• References in B & D to MCOs are intentionally misleading; MCOs are bound by their contract not by a DMAS Manual and:
  • All operate differently
  • None operate consistently
  • “Contact the MCO” has no functional meaning so can neither be monitored nor relevant
  • Section D implies “real-time” involvement which is not a functional concept in the current environment

5.5        Care Coordination – see comment to 3.3.2 above

12.1 (#5)           While it is understood that staff who work an excessive number of hours may not be providing their best service.  And we would all like to be able to pay staff a sufficient wage to allow them to support themselves and their families without working multiple jobs, the rates paid for these services do not necessarily support a “living wage.”  If staff are struggling they work additional hours (either for another provider or at the local WaWa) and that is not a discussion any employer can reasonably have! 

This particular requirement is specifically troublesome

• There is no way “other than self report” to obtain the information
• There is no clear consequence stated or implied – do you plan to have an MCO retract payment?  If so, for which individual and from which provider? 
• How would the MCO know that billing exceeded 750 (15 minute units) in any given week?   How would the provider know?

              Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply. Adding a requirement (which will also require monitoring by an entity with authority to do so) will not make a material difference for any provider inclined to skirt the edges of the rules, but will add an additional burden for all providers who make every attempt to comply.  How will you know, and how will you monitor, and what are the consequences for non-compliance?

To whom it may concern,

I would like to recommend organizing an advisory/work group/commission etc. comprised of those knowledgeable/experienced in EBP services to assist with the EBP aspect of this proposal. EBP services in Virginia have been a niche service, and this design outlines a significant market shift for consumers as well as providers. Over the last several years I've spent a lot of time learning certain EBP models and becoming an advocate for these types of empirical evidenced based services that historically produce better patient outcomes and control cost. However, I do have concerns with several key areas; to include scalability and sustainability for providers (which impacts patient access to care), provider startup capital requirements and EBP model requirements being able to fully align with Federal and State regulatory requirements under CMS, DMAS and DBHDS. I also have concerns with our human capital resources as it relates to how our workforce in Virginia has shifted since Phase 1 of redesign and Covid, and if there needs to be clinical and regulatory adjustments to better reflect our current workforce market. These programs can be labor intensive.

-This group for example would assist with understanding what a new provider financial profile should consist of and if current requirements for new provider applicants are a realistic barometer based on the carrying cost associated with EBP service models. Or if EBP companies can adjust model requirements to assist with lowering cost for new provider applicants in year 1. Also evaluate areas of adjustments for agencies/companies beyond year 1. 

-This group for example would evaluate current Federal and State regulatory requirements and work to see where adjustments can be made to fully align all regulations and EBP clinical models. Also work to align EBP model language with regulatory language or vice versa. This may result in developing completely different provider manuals (all chapters) and or how they are formatted (structurally, terminology/language, utilization etc.) for EBP services.

-This group for example would assist with developing a strategic EBP Statewide development plan based on market analysis and business impact studies (to include small businesses) and subsequent transition plans designed to insure long term sustainability and growth of EBP services in Virginia. This would include evaluating all existing statewide EBP data/outcomes.