17 comments
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.
3.2.2 This comment has been made on earlier versions:
4.2 Related to this and similar requirements for staffing
5.3.2 Crisis Support
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
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.
Please define and provide detailed descriptions for all required modifiers within the policy.
There is a concern that the Medicaid Conduent claims system may not currently be able to accommodate the adjudication of claims submitted for the same date of service when different modifier combinations are applied. This limitation is already evident with mobile crisis response H2011 claims.
Conduent will need to ensure that its system can effectively manage the complexity of processing claims with identical dates of service but varying modifier combinations, in order to support accurate adjudication and ensure providers are reimbursed appropriately.
Medicaid cannot be trusted. It should not exist, period! Because it cannot be trusted, unfortunately.
Section 12. CPST Billing Requirements
Section 12 should be revised to include clear Place of Service (POS) billing guidance for CPST. The proposed regs expand services into natural, community-based settings (which is a positive change!). But they do not explain how providers should determine the correct POS when services occur in multiple settings during the same encounter or when billable activities, such as treatment planning or care coordination, occur from the provider's office.
Without clear guidance, providers and MCOs will interpret POS requirements differently. This creates unnecessary audit risk, recoupments, and administrative burden; even when services are delivered appropriately.
A standard DMAS POS billing policy should be established and applied consistently across FFS + MCOs, so providers have one billing standard to follow, and we’re not left guessing.
I appreciate the opportunity to provide feedback on the proposed Community Psychiatric Support and Treatment (CPST) regulations. As a provider of school-based mental health services, I am deeply concerned about the feasibility and impact of several provisions on access to care for youth and families. While the intent of the regulations is clear, the cumulative effect of these requirements will significantly limit service delivery in community and school settings.
In conclusion, without meaningful revisions to increase flexibility, reduce administrative burden, and account for the realities of school-based service delivery, these proposed regulations will significantly reduce access to care for youth and families. I strongly encourage DMAS to further engage providers and incorporate practical adjustments to ensure these regulations are both clinically sound and operationally feasible.
Section 12. CPST Billing Requirements
The proposed regulations are very prescriptive about how CPST should be delivered. However, the billing structure does not reflect that same level of specificity. The draft identifies separate required service components, but most share the same procedure code and modifier combination, with billing differentiated only by provider type rather than the service performed.
By assigning the same billing code and modifier combination to multiple required service components, DMAS and the MCOs cannot determine from claims data which required services are actually being delivered. The only way to determine whether providers are complying with these requirements is to perform a chart audit. That seems like a missed opportunity when claims data could provide this information in real time through distinct service component modifiers.
The current billing structure also creates a claims processing issue. The draft regulations permit simultaneous billing for assessment and treatment planning when clinically appropriate, yet both services share the same billing code and modifier combination used for psychotherapy, care coordination, crisis support, and other CPST service components. Without a way to distinguish these services at the claim level, claims systems may identify legitimate simultaneous billing as duplicate or overlapping services.
Suggestion: Section 12 should be revised to include distinct billing modifiers for each CPST service component. This would allow DMAS and Medicaid MCOs to monitor utilization, spending, required service frequencies, and compliance through claims data instead of relying on what was proposed during the authorization process and waiting for a chart audit to determine what actually occurred.
Right now, claims only tell DMAS that a service was billed. They don't tell DMAS which required component of the CPST model was actually delivered, just that a claim was billed.
Distinct service component modifiers would change that. This would give DMAS and the MCOs real-time visibility into how CPST services are being delivered, identify utilization trends much sooner, and confirm that required service components are occurring. This would allow earlier intervention when service delivery does not align with the intended model.
7.4 It appears that the planned “methodology” for documenting staff qualifications (i.e., completion of the “required training”) is to require that providers “submit information pertaining to the qualification of each staff person providing CPST to an external entity (CEBP at VCU) and keep information “current and active.” In addition to maintaining internally a record of staff qualifications and training for examination by DBHDS Office of Licensure and submitting, as required, the same information to all of the contracted MCOs for the purpose of supporting the billing/credentialing as needed, this appears to be either duplicative (and therefore and uncompensated cost for providers), or an attempt to add an additional layer in an attempt to compensate for systemic failure of the existing system of oversight to be effective.
If the service is provided by a staff member who is qualified, the fact the an external entity does or does not have their name on a list is irrelevant.
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?
4.1.2 Changes to this section reflect that DMAS heard providers' concerns about operating CPST with only fully-licensed supervisors, as was the case in V2. Allowing LMHP-types to supervise within the scope granted to them by the Board of Counseling is much appreciated. However, the suggested June 30, 2029 sunset date raises an obvious question: Why plan for failure before giving the policy a chance to succeed? If the flexibility works, let it work. If it doesn't, DMAS already has the authority to revise the regulations. An arbitrary expiration date seems unnecessary when the regulations can be updated if experience demonstrates a change is needed. Also, how will the supervisees' supervision hours be tracked and reported for accountability? Who will be following up and how? If no plan for this, this seems an easy target for potential dishonesty. If there is a plan for accountability, please consider the many new reporting requirements for providers already in place in V3. Perhaps simply a requirement that supervisees' completed hours data be made available to licensure upon request?
While we support the goals of improving access, quality, and outcomes, we believe the proposal remains sufficiently complex and lacks the critical operational, fiscal, and implementation details needed to fully assess its impact on individuals receiving services, providers, workforce capacity, and long-term sustainability. At this stage, several key elements remain unclear, including:
The current draft significantly expands provider responsibilities through new requirements for implementing evidence-based practices, managing referrals, coordinating crises, measuring outcomes, communicating with MCOs, training and supervising the workforce, and providing administrative oversight. However, stakeholders have not yet received sufficient information about the assumptions underlying the proposed rates or how the expanded service expectations are intended to be operationalized. Additional transparency regarding these assumptions is necessary to evaluate implementation feasibility, workforce implications, financial sustainability, and the overall impact on the client experience. We remain concerned that the policy requirements and reimbursement structure may not yet be sufficiently aligned to support successful statewide implementation.
Before final implementation, we encourage DMAS to provide greater transparency into rate-development assumptions and to assess the redesign's cumulative impact on client access, provider capacity, workforce sustainability, and the overall client journey. The ultimate measure of success should be a system that is clinically effective, operationally feasible, financially sustainable, and easier for individuals and families to navigate.
Impact on the Client Journey: The redesigned model introduces several new decision points, including specialty service screening, referral requirements, crisis planning, treatment planning, reassessments, and transition evaluations. While each requirement may be appropriate on its own, the cumulative effect may create a more complex pathway to care than currently exists. We encourage DMAS to evaluate the redesign from the perspective of individuals and families seeking services and to ensure that implementation simplifies, rather than complicates, access to care. Success should ultimately be measured by whether individuals can access services more quickly, more easily, and more effectively.
Expansion of CPST Responsibilities: The revised draft substantially expands CPST's scope beyond traditional rehabilitative interventions. As proposed, CPST providers are expected to deliver treatment, coordinate care, manage referrals, participate in crisis planning and response, communicate with MCOs, monitor outcomes, and meet fidelity requirements. Collectively, these responsibilities encompass psychosocial rehabilitation, mental health skill-building, case management, care coordination, crisis prevention, and treatment planning. We encourage DMAS to clearly define CPST's intended role within the continuum and to ensure that reimbursement, staffing assumptions, and productivity expectations align with these responsibilities.
Crisis Response Responsibilities: We support proactive crisis planning and coordination. However, several provisions appear to expand CPST responsibilities into areas traditionally managed by Virginia's established crisis system, including 988, Mobile Crisis Response, CSB Emergency Services, Crisis Stabilization Units, and hospital-based emergency services. We recommend clarifying that CPST providers coordinate with existing crisis resources rather than serve as a primary crisis response entity, thereby reducing duplication and role confusion.
Continued Stay and Long-Term Recovery: We support measurement-based care and outcome monitoring. However, many individuals receiving CPST have serious and persistent mental illnesses that require long-term support to maintain stability and prevent deterioration. The policy should explicitly recognize outcomes such as avoiding hospitalization, maintaining housing, sustaining employment, remaining engaged in treatment, and preventing relapse as meaningful indicators of success. Individuals should not be required to demonstrate continuous functional improvement to retain medically necessary services.
Administrative Burden: The revised draft significantly expands requirements for documentation, reporting, referral tracking, crisis planning, MCO communication, and treatment planning. While accountability is important, excessive administrative requirements may reduce direct service time, contribute to workforce burnout, and divert resources from clinical care. We encourage DMAS to streamline documentation expectations and eliminate duplication wherever possible.
Workforce Capacity: We appreciate DMAS' recognition of workforce challenges and its temporary flexibility regarding Clinical Director and Clinical Supervisor qualifications. However, the redesigned model requires more supervision, training, documentation, care coordination, and clinical oversight, even as behavioral health workforce shortages remain significant. We encourage DMAS to closely monitor workforce impacts, provider capacity, network adequacy, and access-to-care indicators throughout implementation.
Coordinated Specialty Care and First Episode Psychosis: We strongly support Virginia's continued investment in Coordinated Specialty Care (CSC) and in developing a sustainable, Medicaid-funded service for individuals experiencing First-Episode Psychosis. As implementation progresses, we encourage DMAS to maintain flexibility in engagement strategies, family participation, telehealth use, transition planning, and fidelity expectations. Successful early psychosis intervention often requires individualized approaches that cannot always be captured by rigid service thresholds.
The following comments are submitted by the Virginia Coalition of Private Provider Associations (VCOPPA) in response to the Draft V4 CPST Provider Manual released for public comment on June 8, 2026.
We appreciate the significant work that has gone into this policy and acknowledge several improvements made between the prior draft and the current version. We submit these comments in the spirit of constructive engagement and with the goal of ensuring this service can be operationalized effectively by private providers seeking to participate in Virginia’s Medicaid behavioral health system on behalf of the Medicaid members in need of these critical services. We respectfully request DMAS consider each issue before finalizing the policy.
Section 3 requires all CPST providers to incorporate evidence-based principles, practices, protocols, and policies into treatment planning and service delivery, and to document in their SOPs which elements they are incorporating and how staff are trained. While V4 reformatted these categories — an improvement — the definitions remain functionally unclear. Specifically:
The V4 requirement that providers “clearly identify” which EBP elements they are incorporating cannot be met if the underlying categories remain poorly defined.
Section 3.2 of Draft V4 was reorganized into three subsections and now includes specific documentation requirements when a standalone EBP is unavailable at the time of authorization — an improvement over Draft V3. However, a separate and ongoing obligation relating to youth service delivery during active CPST services remains unclear.
The policy states that for youth presenting with a disorder that aligns with an EBP that cannot be provided directly through CPST, providers shall ensure EBP options are coordinated through the care coordination component. We acknowledge that Section 3.2.3 addresses the steps a provider must take when seeking authorization in lieu of a standalone EBP — documenting the barrier, notifying the MCO, recording referral efforts, and including a transition plan in the ISP. However, Section 3.2.3 addresses the authorization scenario only. The care coordination language creates a continuing duty throughout the service period, and it is not clear what active steps are required of the provider once services are underway. Specifically:
CPST is a new service type with substantial training requirements. Depending on credential type, providers must ensure staff complete: the Foundational Skills Curriculum (FSC); MAP credentialing for all youth-serving LMHPs and LMHP-types; CANS Lifetime certification for all assessment staff; the CPST Intermediate Skills (IS) Curriculum for QMHPs, QMHP-Ts, and BHTs (added in V4); and documented EBP training for all adult-track LMHPs and LMHP-types. This is a significant, largely unfunded investment. Draft V4 does not indicate whether training costs were considered in the rate study, whether any training is reimbursable, or whether accommodation exists for providers who must train staff before rendering billable services.
This training burden risks creating a landscape where only large, well-resourced agencies can enter this market. Smaller providers — including group practices and community-based organizations — may be unable to absorb training costs before generating revenue, threatening network sufficiency particularly in rural and underserved areas.
Attachment 1, Section 1 requires all youth-serving LMHPs and LMHP-types to achieve MAP Credentialed Therapist status within 18 months of enrollment or hire, and requires at least one MAP-credentialed therapist on staff at all times. This creates significant operational challenges:
Attachment 1, Section 3 requires weekly supervision contact for non-licensed staff, with monthly minimums of two hours including at least one hour of individual supervision. While robust supervision is essential, prescribing the exact split between individual and group formats within a monthly hour minimum does not allow for clinical discretion and does not reflect how supervision is typically structured in community-based settings. Supervision needs vary based on supervisee experience, caseload complexity, and the Clinical Director’s professional judgment.
Attachment 1, Section 3.4 requires DHP board-approved supervision documentation to be maintained in the employee’s employment (HR) record. This requirement is unworkable: personnel files are legally protected records. Clinical supervisors — including the CPST Clinical Director — do not have authorized access to an employee’s HR file, nor should they. These files are controlled exclusively by HR departments and subject to confidentiality protections. A clinical supervisor cannot add documentation to a protected personnel record, and an HR department cannot reasonably be expected to accept, organize, and maintain ongoing clinical supervision logs as part of its personnel file function.
This creates a difficult compliance situation for providers:
Supervision documentation is clinical and compliance-related in nature. It belongs in a location that clinical and compliance staff can access, maintain, and produce on request — such as a designated compliance file, a supervision log maintained by the program, or a staff credentialing file separate from the protected HR record. The policy also does not specify what form “official documentation” must take or how frequently it must be updated.
Section 8.4 requires Tier 2 youth caregivers to participate in at least one hour of CPST weekly, attend quarterly treatment planning meetings, and be available for crisis consultation within two hours during business days. We acknowledge the reduction from two to one hour weekly. However, the policy does not address what providers must do when caregivers consistently fail to meet these requirements during an active authorization period. The policy states that if a caregiver is not engaged following initial authorization, the ISP must be updated before reauthorization — addressing only the reauthorization scenario. Providers need guidance on what happens during the active authorization period:
Youth in Tier 2 have the greatest level of need and are most likely to have caregivers facing participation barriers. A policy that allows service discontinuation based on caregiver behavior without clinical discretion risks harming the youth it is designed to serve.
Section 12 billing tables specify that for Restorative Life Skills Training, “all professional levels of staff shall bill” using the HN modifier — the modifier associated with QMHP and QMHP-T staff — even when the service is delivered by an LMHP or LMHP-type. This means an LMHP delivering this service bills identically to a QMHP and is reimbursed at the same rate, which is inconsistent with every other clinical component in the billing table where LMHPs use the HO modifier at a higher rate.
If this is intentional — a flat-rate component regardless of credential — it should be explicitly stated so providers can plan accordingly. If unintentional, the table should be corrected. Restorative Life Skills Training is a high-volume component; billing LMHPs at the QMHP rate has direct revenue implications that affect provider financial viability and creates a disincentive to assign licensed clinicians to a service that may clinically warrant their involvement.
We appreciate the opportunity to submit these comments and strongly support expanding access to intensive community-based mental health services for Virginians with serious mental illness and serious emotional disturbance. These comments are intended to ensure the policy enables private providers to participate effectively, sustainably, and in compliance with clear and implementable standards. We respectfully request written responses to each comment and an opportunity to engage further with DMAS staff prior to finalization.
Nina Marino, Government Affairs Chair
Virginia Coalition of Private Provider Associations (VCOPPA)
The current billing structure indicated is likely to create operational challenges. While the draft permits simultaneous billing for assessment and treatment planning, these services share the same CPT codes as other CPST components. Without clear differentiation at the claim level, systems may incorrectly flag valid concurrent billing as duplicate or overlapping services.
Greater specificity in billing codes and/or modifiers is needed to clearly distinguish CPST service components. Without this clarity, both MCO and Medicaid claims systems may face implementation challenges, potentially disrupting claim adjudication and creating unnecessary administrative burden.
Ensuring sufficient billing detail is critical to support a seamless implementation and to avoid unintended negative impacts on provider reimbursement.
There continues to be concerns over crisis regulation as well as supervisory requirements. The clinical director role is more established but extremely prescriptive. The amount of supervision time will take away from the service delivery. Perhaps the regs should set a minimum amount of time particularly for clinicians that are seasoned and do not need the amount of supervision as a possible new hire. The crisis requirement still requires that staff work 24 hours. The reimbursement rate does not allow an agency to pay their staff at a rate that pays for 24 hours of availability. Why would we not allow the individuals with additional training and experitise in crisis handle crisis.
7.1 Communication of DBHDS-OL Corrective Action Plans to MCOs suggests that a CAP is relevant to one or more individuals who are associated with a particular MCO – obviously that will most likely not be true. Individuals are not (for HIPAA reasons) identified in a CAP. By having a secondary review by all six MCOs – using different formats, with different criteria when it is possible that none of their clients were involved will be an expensive, and time-consuming exercise for any provider months into the future!
Any of the MCOs will be entitled to use their own criteria for review, response, and for any requirements for “corrective action”, while possibly none of the specific citations are relevant to either an individual supported by the MCO or a service paid for by the MCO.
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?