Youth Services Council

September 18, 2026

Syreeta Stewart

Regulatory Coordinator

Department of Medical Assistance Services (DMAS)

600 E. Broad St., Suite 1300

Richmond, VA 23219

 

On behalf of the Virginia Association of Community Based Providers (VACBP) Youth Services Council, thank you for the opportunity to comment on the draft Community Psychiatric Support and Treatment (CPST) — School Setting policy manual, Version 2, dated August 31, 2026. These comments reflect input gathered from Council members who provide, supervise, and bill for community-based behavioral health services in Virginia’s public schools, discussed during our September 15, 2026 Council meeting.

 

We appreciate the substantive revisions DMAS has already incorporated in response to earlier stakeholder feedback. The comments below identify the areas where Council members believe additional clarity, flexibility, or DMAS action would materially improve the manual’s workability and protect continuity of care for the youth this service is designed to support. Each comment is organized by manual section, with a specific requested action and supporting rationale.

 

Issue: The manual’s rolling six-month average of 750 units relies on individual staff and provider agencies to self-report and track units across employers. Council members noted that staff working for multiple agencies have no reliable, shared mechanism to confirm they have not exceeded the cap in the aggregate, making the current self-report approach difficult to enforce consistently.

Requested Action: Clarify who bears responsibility for cross-agency tracking, and explore a payer-level (MCO or DMAS) tracking mechanism rather than placing the full compliance burden on individual provider organizations.

Rationale: A self-report-only system creates inconsistent compliance and audit risk that providers cannot fully control on their own. We caution, however, that any DMAS-level tracking solution should be structured to preserve existing group billing arrangements; a solution that inadvertently requires individual QMHP credentialing to enable centralized tracking would create new administrative burden without resolving the underlying problem.

Issue: Attachment 1 establishes specific caseload/hour caps for QMHP- and BHT-heavy staffing configurations (100/120/75 client-hour thresholds), but the manual does not establish comparable caseload or oversight guardrails for licensed (LMHP) staff delivering the same services.

Requested Action: Establish caseload or oversight benchmarks for licensed staff that are proportionate to those already defined for QMHP/BHT staff, or clarify the basis for excluding licensed staff from a comparable standard.

Rationale: Without parity, programs may be incentivized to lean on licensed staff to avoid the QMHP/BHT caps, without a corresponding safeguard against overextension of licensed clinicians.

 

Issue: The manual requires CANS Lifetime as the standardized assessment tool for medical necessity and level-of-need determinations, but CANS Lifetime is not validated for children six and under — a population the school-based service is intended to serve.

Requested Action: Identify or approve an age-appropriate, validated alternative assessment for children six and under, or specify an alternative review pathway for this age group.

Rationale: Applying an assessment tool outside its validated age range risks inaccurate level-of-need and medical necessity determinations for the youngest children served.

Issue: CANS Lifetime uses the same underlying instrument as the original CANS (Praed Foundation) without substantive revision to the assessment content itself. A provider survey circulated the week of September 8, 2026 found that our members frequently report the pilot’s assigned Level of Need does not match their own clinical judgment of the youth’s needs.

Requested Action: Before finalizing reliance on CANS Lifetime for authorization decisions, review the pilot survey data referenced above and establish a clinical override or appeal mechanism for cases where a treating provider’s clinical judgment diverges materially from the CANS-assigned Level of Need.

Rationale: An assessment tool that treating clinicians do not perceive as reliable risks driving authorization decisions that do not reflect a youth’s actual clinical presentation.

 

Issue: The manual’s ISP/IEP coordination language could be read to require LMHP attendance at IEP meetings. Under IDEA, a parent or guardian may decline to have outside providers, including CPST staff, attend an IEP meeting — a right the manual should not inadvertently override. In practice, schools frequently schedule all IEP meetings for a given day or time block, making simultaneous attendance across an LMHP’s full caseload logistically impossible.

Requested Action: Frame LMHP participation in IEP meetings as a recommended best practice rather than a mandatory requirement, and state explicitly that non-attendance — whether due to a parent/guardian’s preference or a scheduling conflict — cannot be grounds to deny, delay, or discharge services. Retain and emphasize the existing option for written provider input as the default coordination mechanism rather than treating it as an exception.

Rationale: A mandatory-attendance standard conflicts with parental rights under IDEA and is not operationally achievable given typical school scheduling practices. Duplication of services can be avoided through the SAR and treatment plan without requiring in-person IEP attendance.

Issue: Council members are concerned that schools may be moving toward training in-house staff to bill Medicaid directly for school-based behavioral health services, without a clearly defined billing pathway for QMHP-delivered services under this manual. Existing school-based Medicaid billing infrastructure is built primarily around related-service providers (e.g., occupational therapy, speech, nursing) rather than community-based behavioral health providers.

Requested Action: Explicitly define and publish the Medicaid billing pathway for QMHP-delivered CPST-School services, and clarify DMAS’s intent regarding the respective roles of school-employed staff and external community-based providers going forward.

Rationale: Ambiguity here creates business-planning risk for community-based providers who have historically delivered this service, and could disrupt continuity of care for youth currently served by external providers.

 

Issue: The manual continues to require a written statement documenting a family’s refusal of, or inability to access, an evidence-based practice (EBP) before a youth can access CPST. While Version 2 softened this requirement relative to the prior draft, it remains an additional procedural step beyond standard clinical documentation.

Requested Action: Allow a standard clinical progress note or treatment plan entry documenting EBP inaccessibility or family preference to satisfy this requirement, rather than requiring a separate written statement.

Rationale: The underlying clinical determination is already captured in standard documentation; a duplicative written-statement requirement adds administrative burden without a corresponding clinical benefit.

Issue: The manual does not define what constitutes clinical "progress" or "stability" for medical necessity and continued-stay determinations in a school context, where outcome indicators (e.g., reduced in-school suspensions, increased instructional time, improved classroom functioning) differ from community-based settings and vary by school division.

Requested Action: Define operational, functionally-oriented examples of progress and stability specific to the school setting, while preserving flexibility to account for variation across school divisions, and clarify how progress in a single area of functioning should be weighed in continued-stay determinations.

Rationale: Without a shared operational definition, MCOs are likely to apply inconsistent standards in utilization review, creating unpredictable authorization outcomes for providers and unnecessary appeals.

Issue: Provider experience with other Medicaid behavioral health services shows that MCOs often adopt SAR tools and authorization criteria inconsistently even when DMAS publishes a standard template.

Requested Action: Finalize and publish the promised uniform SAR tool for CPST-School prior to implementation, paired with an enforceable compliance mechanism to ensure consistent adoption across all contracted MCOs.

Rationale: Inconsistent SAR and authorization practices across MCOs create unpredictable administrative burden and access barriers for youth, regardless of how well-designed the underlying tool is.

 

Issue: It remains unclear whether the manual reinstates a requirement — similar to a prior TDT-era requirement — for providers to individually register or pre-approve each specific school site under DBHDS licensure before initiating services there. DBHDS’s own public presentations reportedly grouped CPST-School with all CPST generally, without directly addressing this school-site-specific question, creating a possible inconsistency between DBHDS guidance and the DMAS manual.

Requested Action: Clarify, in coordination with DBHDS, whether individual school-site pre-registration is required and, if so, streamline that process to avoid the service-initiation delays providers experienced under the prior TDT model. Also clarify whether executed MOUs must be actively submitted with each SAR or simply retained on file for audit.

Rationale: Ambiguity between DBHDS regulatory requirements and the DMAS manual creates compliance risk for providers and could delay service delivery to youth awaiting a new placement.

Issue: Section 9.4 requires providers to notify the MCO within five business days of a youth’s transfer to a school in a different division, or to a school not covered by an existing MOU, and to execute a new MOU or coordinate a transfer within that window.

Requested Action: Extend the notification and MOU-execution timeline, or establish a phased compliance grace period, informed by input from local school divisions regarding realistic administrative turnaround times for new MOU execution.

Rationale: Five business days is often insufficient for a receiving school division to execute a new MOU. A more realistic timeline reduces the risk of service gaps for transferring youth while still supporting continuity of care.

Issue: Section 7.4 requires a minimum 60-calendar-day notice period before terminating an MOU. In practice, this can require a provider to continue funding an embedded LMHP or QMHP in a school with a declining or inactive caseload for up to 60 days without corresponding billable service volume.

Requested Action: Either shorten the required notice period or establish a mechanism for cost recovery or transition support (e.g., a defined transition billing code) during the notice window.

Rationale: The current provision may create a financial disincentive for providers to enter school-based partnerships, particularly for smaller or rural providers with thinner margins.

Issue: DMAS has previously cited a viability benchmark of approximately 40–50 cases for community-based CPST, but no comparable published benchmark exists for CPST — School Setting.

Requested Action: Study and publish a viability caseload benchmark specific to the school-based service model.

Rationale: A published benchmark supports responsible provider business planning and helps DMAS and providers jointly assess whether the school-based model is being implemented at a sustainable scale.

 

Issue: The manual’s crisis response time standards (approximately 15 minutes in-school / 30 minutes outside of school) do not account for scenarios where a single LMHP is responsible for multiple simultaneous crises, or for rural areas where travel time alone may exceed these windows. Council members noted that Community Services Boards (CSBs) are largely not active in this market, leaving community-based and private providers as the primary source of rural school-based crisis coverage.

Requested Action: Allow telehealth-based crisis response to satisfy the response-time standard as an equally valid first response, particularly in rural areas or when multiple crises occur simultaneously, rather than requiring in-person response within the stated windows.

Rationale: A rigid in-person response standard is not achievable for a single on-call clinician managing multiple simultaneous crises, and disproportionately disadvantages rural youth if providers cannot reliably meet the standard and decline to serve those areas as a result.

Issue: Strict on-call response-time requirements likely trigger federal and state labor-law obligations for on-call compensation. Council members do not believe this cost is fully reflected in the Mercer rate-setting study underlying the FY2027 rates, which members also believe already understate current market clinician salaries given recent wage inflation.

Requested Action: Confirm whether on-call labor cost was factored into the FY2027 rate-setting methodology and, if not, revisit the rate assumptions accordingly.

Rationale: Rates that do not reflect the true cost of mandated on-call coverage create a structural financial gap that could reduce provider willingness to offer crisis response coverage, particularly in rural areas.

Issue: There is no published, service-component-level matrix specifying which parts of the CPST-School service may be delivered and billed via telehealth.

Requested Action: Publish a telehealth billing matrix by service component and modality for CPST-School.

Rationale: A published matrix would standardize billing practices across providers and give DMAS a clear, enforceable standard to hold MCOs accountable to consistent telehealth reimbursement decisions.

 

Issue: Providers are currently being asked to submit DBHDS licensure policies ahead of the CPST-School manual’s finalization, creating a sequencing mismatch, compounded by the DBHDS/DMAS inconsistency noted in Section V.1 above.

Requested Action: Align DBHDS licensure submission deadlines with the final publication of the DMAS manual, or explicitly permit provisional policy submissions pending the final rule.

Rationale: Requiring providers to finalize licensure policies before the underlying service manual is final creates unnecessary rework and compliance risk.

Issue: Successful implementation of this redesigned service depends on shared understanding among DMAS, providers, and local school divisions.

Requested Action: Host a school-facing webinar or training prior to implementation, with provider representatives included in that engagement, to align expectations across all three stakeholder groups.

Rationale: Proactive, shared training reduces early implementation friction and inconsistent application of the manual at the school-division level.

We appreciate DMAS’s continued engagement with providers throughout this redesign process and welcome the opportunity for further dialogue before the manual is finalized. Please do not hesitate to contact us with any questions regarding these comments.

 

Respectfully submitted on behalf of the VACBP Youth Services Council.