Mental health providers across Virginia have partnered with the Department of Medical Assistance Services (DMAS), the Department of Behavioral Health and Developmental Services (DBHDS), the Department of Health Professions (DHP), members of the General Assembly, and administrations of both political parties to strengthen Virginia's community behavioral health system. Throughout this time, providers have consistently shared practical recommendations based on direct experience delivering services to Medicaid recipients, supervising clinical staff, and navigating managed care requirements.
The current draft of the Community Psychiatric Support and Treatment (CPST): Community Services Manual does not appear to reflect many of the concerns repeatedly raised by front-line providers. As written, several proposed requirements have the potential to increase administrative burden, reduce workforce capacity, and limit access to care, particularly for Medicaid recipients served by small and mid-sized community providers. The limited volume of public comments submitted on this draft should not be interpreted as broad agreement with its provisions. Rather, many providers have lost hope in the regulatory revision process.
This feedback focuses on three areas that are likely to have the greatest impact on behavioral health services throughout the Commonwealth: clinical supervision requirements, workforce development and training requirements, and operational requirements affecting provider sustainability and employee retention.
The draft CPST Community Services Manual introduces several supervision requirements that, while intended to strengthen oversight, may unintentionally reduce the availability and effectiveness of qualified clinical supervisors. Several provisions appear to conflict with established supervision practices recognized by the Department of Health Professions (DHP) and National credentialing standards for Advanced Clinical Supervisors, and do not reflect the operational realities of community-based behavioral health services.
One of the most significant concerns is the elimination of tele-supervision as an acceptable method of providing clinical oversight. Clinical supervisors have successfully utilized secure tele-supervision for well over a decade, long before its widespread adoption during the COVID-19 public health emergency. The Department of Health Professions permits licensed clinical supervisors to provide supervision through secure technology when consistent with professional standards, and nationally recognized Advanced Clinical Supervisors similarly recognize tele-supervision as an appropriate modality when implemented responsibly. Many clinical supervisors also hold the Board-Certified Tele-mental Health credential. We know tele-supervision is effective in rural and underserved communities with limited access to licensed supervisors; organizations operating across multiple service locations; agencies employing hybrid or mobile clinical staff; immediate consultation during clinical crises; post-incident debriefing and risk management; and maintaining continuity of supervision when travel is impractical or would delay clinical consultation. Removing tele-supervision from the manual may inadvertently reduce access to experienced supervisors, increase travel requirements, delay clinical consultation, and create additional workforce barriers without evidence that these restrictions improve client safety or clinical outcomes.
Section 3.4 references compliance with the "higher standard" when DHP and DMAS requirements differ. Clinical supervisors are already regulated extensively by the Department of Health Professions through statutes, regulations, continuing education requirements, supervision standards, and disciplinary oversight. Introducing additional Medicaid-specific supervision requirements that differ from DHP standards creates unnecessary regulatory complexity and increases the potential for inconsistent interpretation during audits by MCOs.
Section 4.2 requires Clinical Directors to be able to provide in-person services and travel to an individual's location when clinically necessary. While timely access to clinical leadership is an appropriate objective, the proposed language may unintentionally restrict organizations serving geographically large or rural regions. Many Clinical Directors oversee multiple schools or districts, and increasingly reside outside the communities they supervise because of workforce shortages, housing availability, or regional cost-of-living considerations. The current language may also limit agencies' ability to utilize telehealth and other evidence-based methods of consultation that have become integrated into modern behavioral healthcare delivery. A more flexible standard that requires agencies to demonstrate timely access to clinical leadership—rather than requiring routine physical proximity—would better accommodate the realities of workforce distribution while preserving high standards of clinical oversight. The role of the clinical director in providing oversight of clinical supervisors and staff in client care is confused with direct care interventions in this section and does not reflect the work of clinical directors.
Clinical supervisors already carry substantial professional liability. They are responsible for ensuring that supervisees practice within their scope of competence, monitoring clinical documentation, overseeing ethical practice, responding to high-risk situations, and maintaining compliance with DHP regulations. Additional restrictions that do not clearly improve clinical outcomes risk reducing supervisory capacity while increasing provider attrition. Effective supervision requires an environment in which supervisees can openly discuss clinical decision-making, ethical concerns, professional impairment, secondary traumatic stress, burnout, and challenges that may affect the delivery of care. These conversations strengthen client safety by allowing supervisors to identify risks early and provide appropriate guidance. The draft manual does not clearly define how supervision records will be maintained, who may access those records, or the extent to which supervision documentation may be reviewed during audits or by managed care organizations. If supervision documentation becomes subject to routine external review without clear safeguards, supervisees may become less willing to engage in candid discussions regarding professional challenges, mistakes, or emerging impairment. Such an outcome could unintentionally weaken one of the profession's most effective quality assurance mechanisms.
The 2025 Healthcare Workforce Data Center report for the VA’s LPC Workforce held information that we see as significant to explaining why maintaining a healthy workforce is difficult, such as 1 out of every 3 LPCs is under the age of 40, 87% of LPCs are female, and 29% of LPCs currently have multiple work locations. By combining multiple services into the new CPST model and requiring 24-7 coverage, such as in hospitals or CSBs, small providers will be unable to maintain the personnel for coverage, which will lead to further burnout and a workplace shortage. Unlike large health systems or Community Services Boards, small agencies employ relatively small clinical teams. The draft manual does not consider provider demographics and overly restricts referrals to entities that manage crises that result in evaluation and hospitalization after hours.
Clinical supervisors assume significant professional liability when determining service recommendations and ensuring that services remain medically necessary. When licensed staff complete comprehensive assessments and recommend services based upon their professional judgment, they remain responsible for those recommendations regardless of whether services are ultimately authorized by a managed care organization. In practice, providers frequently encounter situations in which extensive clinical documentation supports the need for services, yet authorization decisions differ because of varying interpretations of Medicaid criteria or manual language. These situations create challenges not only for providers but also for individuals and families whose access to care may be delayed or interrupted. The draft manual places substantial emphasis on provider accountability but provides comparatively little discussion regarding how differences in interpretation between providers and managed care organizations should be resolved. Greater consistency in medical necessity standards and oversight of MCOs would improve predictability for providers while reducing unnecessary administrative appeals and delays in treatment.
Career longevity in behavioral health is built upon rigorous education, supervised clinical experience, continuing education, and professional licensure. Licensed clinical supervisors typically complete graduate education, supervised internships or practica, post-graduate residency requirements, and ongoing continuing education before the Department of Health Professions authorizes independent clinical practice. These existing licensure standards are specifically designed to ensure competence, public protection, and accountability. Despite these established professional requirements, the proposed Community Psychiatric Support and Treatment (CPST) model requires licensed clinical supervisors and clinical staff to complete additional Managing and Adapting Practice (MAP) training before serving Medicaid recipients. The required MAP training represents a significant financial investment, with reported costs reaching approximately $4,500 per staff member, in addition to the time required for months of training. For many small community-based providers, these expenses are not financially sustainable. Each requirement requires additional staff time, training, quality assurance activities, administrative oversight, and financial investment. These responsibilities are not directly reimbursable under the current Medicaid payment structure.
When the Qualified Mental Health Professional (QMHP) credential was established nearly a decade ago, licensed clinicians accepted responsibility for supervising QMHP staff despite concerns regarding increased professional liability. Many organizations invested substantial time and resources into developing internal training programs grounded in evidence-based practices while maintaining cost-effective service delivery. The proposed requirements would effectively require many of these experienced supervisors to complete expensive additional training in order to continue providing services they have successfully delivered for years. This creates a significant workforce burden without clear evidence that the additional certification requirements will improve clinical outcomes beyond existing professional licensure standards.
Additional concerns exist regarding implementation of the Child and Adolescent Needs and Strengths (CANS) Lifetime assessment. Use of the CANS requires additional training, certification, and ongoing costs. At present, providers have limited information regarding how CANS data will be stored, who will have access to assessment results, what privacy protections will be implemented, and how confidential client information will be managed. Given the sensitive nature of behavioral health records, greater transparency regarding data governance and confidentiality protections is essential prior to implementation.
Behavioral health providers consistently strive to improve client outcomes through evidence-based assessment, clinical judgment, supervision, and individualized treatment planning. Rather than requiring costly proprietary training programs, providers would benefit from clearly defined medical necessity criteria, consistent authorization standards across Managed Care Organizations (MCOs), and timely reimbursement for medically necessary services. These changes would strengthen service delivery while preserving resources that could otherwise be directed toward direct client care.
Finally, implementation concerns have also been raised regarding reliance on proprietary training and assessment systems. Providers have reported inconsistencies in guidance regarding required MAP training modules, resulting in providers being guided by PracticeWise to complete incorrect MAP training modules. Because implementation relies on proprietary assessment and training systems administered by external organizations (Praed Foundation/PracticeWise), providers would benefit from greater transparency regarding vendor selection, governance, costs, data stewardship, and ongoing financial obligations associated with these required tools.