The Virginia Association of Community-Based Providers (VACBP) thanks DMAS for the opportunity to comment on the draft CANS Lifetime Policy Appendix. These comments reflect input from VACBP's Member's Advisory Council.

We support a single standardized assessment that follows the individual, the phased rollout of conditional modules, and the appendix's emphasis on trauma-informed, culturally responsive, family-involved assessment.

1. ADD AN EFFECTIVE DATE AND TRANSITION RULES

The appendix has no effective date and does not address the Comprehensive Needs Assessment (CNA). Please:
- State the date the CANS Lifetime becomes required. Confirm that the CNA remains valid until then, including for new CPST and CSC admissions.
- Clarify whether MH-IOP, MH-PHP, ACT, MST, FFT, and Clubhouse will require the CANS Lifetime. Attachments A and B include these services, but Section 1.2 does not.
- Resolve the H0031 overlap. H0031 is currently the IIH assessment code, and this appendix limits H0031 to one per individual per calendar year.

2. PUBLISH THE LEVEL OF NEED ALGORITHM AT LEAST SIX MONTHS IN ADVANCE, AND KEEP CLINICAL JUDGMENT CENTRAL

The scoring algorithm will directly inform service tiers, staffing models, compensation, and financial projections, so it is foundational to the entire CPST restructuring. Providers need time to evaluate their existing populations, develop financially sustainable operating models, and implement the workforce and operational changes that follow. A 90-day window would not be sufficient. Please:
- Publish the final algorithm, the interim spreadsheet, and practice cases no less than six months before the CANS Lifetime is required.
- Confirm that the algorithm is decision support only (Section 7.1). CANS ratings involve real clinical judgment, and certified clinicians can reasonably rate the same need differently.
- Require MCO reviewers to be qualified, CANS-certified behavioral health clinicians.
- Do not allow a reviewer to change a rating without a peer-to-peer review with the assessing clinician.

3. FUND CERTIFICATION AND PUBLISH A TRAINING PLAN

An agency may need to certify dozens of staff every year. Please:
- Confirm that initial training and annual recertification will be provided at no cost to providers, and publish the timeline.
- Name the certification contact (Section 10.2).
- Allow a short grace period for renewals.
- Publish a single calendar of all Behavioral Health Redesign training requirements, since these requirements are accumulating for providers.

4. MAKE EVENT-BASED REASSESSMENTS NOTIFICATION-ONLY

If prior authorization is retained, please allow retroactive approval and pause the 30-day timeframe while the request is pending (Sections 5.1.4 and 7.3.3).

5. CLARIFY BILLING ACROSS PROVIDERS

Please:
- Explain billing when an individual changes lead providers mid-year, or already has an authorization with another provider.
- Confirm that periodic-update work is reflected in service rates.
- Publish the H0031 rate.

6. PROVIDE CONSENT GUIDANCE AND PROTECT AGAINST MISREADING CHANGES IN THE LEVEL OF NEED

Please:
- Explain what happens when a member does not want their CANS shared.
- Explain how sharing fits within treatment, payment, and operations rules and 42 CFR Part 2 for the SUD module.
- Provide a standard release.
- State that a higher Level of Need on reassessment, which often reflects new disclosure as trust develops, is not by itself evidence that a service has failed.

7. STANDARDIZE MCO REQUIREMENTS

Please establish one set of submission requirements, forms, and turnaround times for all MCOs and fee-for-service, and publish direct MCO contact information (Section 7.4).

8. USE CORRECTIVE ACTION INSTEAD OF RECOUPMENT DURING START-UP

For the first 12 months, please address good-faith documentation errors through technical assistance and corrective action plans rather than recoupment (Section 9.3).

9. CLARIFY WHO SETS THE AUTHORIZED LEVEL OF NEED

Please clarify that the provider recommends and the MCO or Acentra authorizes. Require that a properly documented deviation be honored, or that any denial be explained in writing (Attachment A, Section A.3).

10. INTERPRETER ACCESS AND NEUTRAL LANGUAGE

Please:
- Explain how the qualified interpreters required by Section 5.2.3 will be funded and located.
- Replace "treatment based on financial interest of providers" in Section A.1(6) with neutral language about matching service intensity to need.

11. TECHNICAL CORRECTIONS

- Section 3.4: replace the "Section [X]" placeholder.
- Section 4.3: correct "ADMAS."
- Section 4.4: complete the VAC reference placeholder, and reconcile "elements 14 and 15" with Section 6.1, where diagnosis and formulation are numbered 13 and 14.
- Sections 7.3.2 and 7.3.3: correct the step numbering.
- Section A.1: the reference to "A.4" should be A.3.
- Use "Safety Plan" and "Crisis Mitigation Plan" consistently (Sections 3.3, 3.4, 6.1, 8.4, 11.2), or define how they differ.
- Section 11.2: reconcile "signed and dated by the certified LMHP" with Section 4.4, which allows a certified QMHP to complete the ratings.

VACBP appreciates DMAS's work on this appendix and is glad to support provider readiness and training outreach.