The Virginia Association of Community Services Boards (VACSB) appreciates the opportunity to provide feedback on the proposed CANS Lifetime Assessment. VACSB supports efforts to promote consistent, person-centered assessments and improve coordination of care. However, several areas of the proposed policy require clarification or revision to ensure consistent implementation, minimize administrative burden, and avoid unnecessary barriers to accessing services.
1. Limit Initial Implementation to CPST and Coordinated Specialty Care
VACSB strongly recommends that DMAS limit the initial implementation and required use of the CANS Lifetime Assessment to Community Psychiatric Support and Treatment (CPST) and Coordinated Specialty Care (CSC), rather than applying the requirement broadly across Medicaid behavioral health services.
Section 1.2 of the proposed policy states that it applies to all Medicaid-enrolled behavioral health providers, "including but not limited to" CPST and CSC. Section 5.1.1 further indicates that a comprehensive CANS is required when an individual first accesses Medicaid behavioral health services or does not have a current valid assessment on file. This language creates uncertainty regarding whether the assessment is required only for designated services or more broadly across Medicaid behavioral health services.
Requiring a comprehensive CANS for individuals entering any Medicaid behavioral health service would create a significant administrative burden for CSBs, strain already limited workforce capacity, and potentially delay access to needed services. The operational requirements associated with completing, maintaining, and updating these assessments across multiple programs and providers would be substantial.
A phased implementation, initially limited to CPST and CSC, would allow DMAS and providers to evaluate assessment workflows, staffing requirements, information-sharing capabilities, and the impact on service delivery before considering expansion to additional behavioral health services.
VACSB requests that DMAS explicitly limit the initial requirement to complete and maintain the CANS Lifetime to individuals receiving CPST or CSC. The policy should clarify that the CANS is not a universal intake requirement for individuals accessing other Medicaid behavioral health services and that referring providers are not responsible for completing the assessment solely because they initiate a referral.
2. Assessment Responsibility and Coordination
While Section 5.1.1.A establishes a hierarchy for designating a lead provider responsible for maintaining the CANS Lifetime and addresses transfers of responsibility when services end, additional operational guidance is needed to ensure consistent coordination across programs and providers.
DMAS should clarify how the responsibilities of the designated CANS lead provider align with the care coordination and transition responsibilities outlined in the Member Transition Plan, particularly when individuals receive services from multiple providers.
Additional guidance should establish procedures for notifying and acknowledging transfers of assessment responsibility, ensuring receiving providers have timely access to the existing assessment, and identifying who assumes responsibility when the designated lead provider or qualified assessor becomes unavailable. The policy should also clarify the process for designating or reassigning responsibility when service arrangements change and the established hierarchy does not clearly identify a lead provider.
These procedures should ensure that receiving providers can rely on an existing valid assessment without unnecessary duplication or disruption in services.
3. Assessment Access and Information Sharing
VACSB requests additional guidance regarding where CANS Lifetime assessments will be maintained, which providers and staff will have access, and how information will be shared across agencies and managed care organizations.
Although Section 5.1.1.A directs receiving providers to use an existing valid assessment, and Section 6.3 outlines the initial use of a documentation template and spreadsheet while an electronic system is developed, the process for locating, accessing, and transferring assessments requires further clarification.
DMAS should establish a consistent process for verifying whether a current assessment exists and ensuring timely access when individuals transition between providers or programs.
As DMAS develops the electronic CANS system described in Section 6.3, VACSB recommends incorporating functionality to track periodic updates and annual reassessment deadlines and notify responsible providers when assessments are due. Because the CANS follows the individual rather than the agency, this functionality would be particularly important when individuals receive services from multiple providers or transition between programs.
DMAS should also provide guidance on how providers are expected to track these requirements during the initial implementation period before the electronic system becomes available.
4. Reassessment Requirements and Service Authorization
Sections 5.1.2 through 5.1.4 establish periodic updates, annual comprehensive reassessments, and qualifying events and timeframes for event-based reassessments. Section 7.3.1 also distinguishes which assessment types require separate service authorization.
However, additional guidance is needed regarding how these requirements interact in practice, particularly when an event-based reassessment occurs near a scheduled periodic update or annual reassessment. DMAS should clarify whether an event-based reassessment resets or otherwise affects subsequent assessment deadlines and how overlapping requirements should be documented and billed.
Additionally, Sections 7.2.1 and 7.3.1 describe authorization as required before billing for an event-based reassessment, while Section 7.3.3 requires providers to obtain approval before completing the reassessment. These provisions should be reconciled to clearly establish whether authorization must be obtained before the assessment is performed or before the claim is submitted.
Because Section 5.1.4 establishes specific deadlines for completing event-based reassessments, DMAS should also clarify how providers are expected to meet these deadlines when authorization is delayed, including whether extensions or exceptions will be permitted.
While Section 7.3.3 provides that underlying services continue under their existing authorization when an event-based reassessment request is denied, additional guidance is needed regarding whether the reassessment must still be completed and how providers should proceed in those circumstances.
VACSB recommends practical examples illustrating how assessment timelines, authorization requirements, and billing procedures interact to promote consistent implementation and prevent disruptions in care.
5. Documentation, Ratings, and Treatment Planning
The draft recognizes that individuals and families may decline to discuss certain topics and that providers must document unavailable information. However, additional guidance is needed to ensure consistent documentation and interpretation of assessment ratings.
Specifically, DMAS should establish a clear method for distinguishing information that could not be obtained, declined responses, and nonapplicable items from needs or strengths that have been assessed and determined to be absent. This is particularly important for the Strengths Domain, where Section 3.2 permits a rating of 3 when information remains unavailable after reasonable efforts.
Additionally, Section 3.1 identifies ratings of 2 or 3 as actionable needs that generally must be addressed in the Individual Service Plan (ISP). For individuals with multiple complex needs, addressing every actionable indicator simultaneously may not be clinically appropriate or realistic.
Although the documentation template references prioritized actionable items, DMAS should clarify throughout the policy and supporting materials that treatment planning may prioritize identified needs based on clinical judgment, safety, individual and family preferences, and available resources. Guidance should explain how providers document actionable needs that cannot reasonably be addressed simultaneously.
6. Age-Specific Requirements and Assessment Modules
VACSB recommends that DMAS develop a consolidated age- and circumstance-based crosswalk identifying applicable assessment domains, required and optional modules, and caregiver participation requirements.
While the draft identifies caregiver interview requirements and distinguishes modules required at launch from those that will become mandatory later, consolidating this information would support consistent administration and reduce the potential for errors.
DMAS should also reconcile inconsistencies across the policy, documentation template, and reference guide. For example, the documentation template places Independent Living Skills under the "Ages 6+" heading, while Section 8.1 of the policy and the reference guide identify Independent Living Skills as applicable beginning at age 14. The template should be revised to reflect the age 14 threshold.
Similarly, Section 3.4.2 identifies the Justice/Crime Module as optional during initial implementation, while Section 6.1 describes it as required when actionable. These provisions should be reconciled so providers clearly understand which modules are mandatory at launch and which will become required later.
Additionally, the policy should reinforce the importance of developmental considerations when assigning ratings, particularly for young children. For example, guidance addressing Oppositional Behavior should distinguish developmentally typical behaviors from clinically significant concerns. Although the draft recognizes developmental context, practical examples would assist assessors in applying ratings consistently.
VACSB also recommends incorporating clear reminders in the reference guide and documentation template that, while ratings generally reflect the preceding 30 days, certain indicators require consideration of different timeframes or relevant history.
Sections 3.3 and 5.2.2 already recognize exceptions to the standard 30-day window. However, the compliance checklist in Section 11.2 should be revised to explicitly acknowledge these exceptions rather than suggesting uniform application of the 30-day window across all indicators.
7. Provider Qualifications, Signatures, and Billing
VACSB requests that DMAS reconcile the requirements governing who may complete, sign, co-sign, and bill for the CANS Lifetime Assessment.
Section 4.4 permits a certified Qualified Mental Health Professional (QMHP) to complete CANS ratings and establishes additional requirements for diagnostic formulation and signatures when the assessor cannot independently diagnose. However, Section 11.2 indicates that the assessment must be signed by a certified Licensed Mental Health Professional (LMHP), creating uncertainty regarding the signature requirements for assessments completed by QMHPs and other qualified practitioners.
Section 6.1 and the documentation template also establish signature and certification requirements that should be reconciled with these provisions.
VACSB recommends that DMAS provide a credential-based workflow identifying who may complete the assessment, render and sign the diagnosis and clinical formulation, provide supervisory co-signatures when applicable, and support billing for the assessment.
This guidance should clearly distinguish the responsibilities of certified QMHPs, independently licensed LMHPs, and LMHPs practicing under supervision, consistent with applicable Medicaid regulations.
DMAS should also reconcile the documentation element references in Section 4.4 with the numbered documentation requirements in Section 6.1 to ensure that the diagnosis and clinical formulation requirements are consistently identified.
Ensuring consistency across these requirements would reduce confusion, support compliance, and prevent unnecessary delays in assessment completion and reimbursement.
8. Level of Need Determinations
Attachment A establishes the Level of Need (LON) framework and provides guidance for documenting deviations from the recommended Level of Need. However, additional information is needed regarding the methodology used to calculate the recommended level and how it informs authorization decisions.
Section 6.3 indicates that DMAS will initially use a spreadsheet to determine the Level of Need while the electronic system is developed. VACSB recommends that DMAS provide the methodology used by this spreadsheet, including the indicators, scoring criteria, and applicable decision rules used to generate the recommended Level of Need.
This information, along with practical examples, should be available to providers before implementation to ensure transparency and consistent application.
Additionally, while Attachment A establishes documentation requirements when the authorized Level of Need differs from the recommended level, practical examples would help providers understand how to support clinically justified deviations.
DMAS should also clarify the distinction between the provider's determination of the appropriate Level of Need and the authorization decision made by the MCO or DMAS service authorization contractor, including how disagreements or differing determinations should be documented and resolved.
Clear guidance will help ensure consistent application of the Level of Need model and support appropriate access to medically necessary services.
VACSB appreciates DMAS's consideration of these recommendations. Limiting initial implementation to CPST and CSC, accompanied by clear and consistent guidance regarding provider responsibilities, information sharing, reassessment timelines, documentation requirements, and service authorization, would support a more manageable and effective implementation while protecting timely access to behavioral health services.