Maryland COMAR Update Effective July 6, 2026: What CASII, ECSII, and the Expanded Core Service Agency Definition Mean for Child and Adolescent Behavioral Health Providers

July 6, 2026

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The short answer: what changes on July 6, 2026

Effective July 6, 2026, the Maryland Behavioral Health Administration (BHA) is amending COMAR to require the Child and Adolescent Service Intensity Instrument (CASII) for youth ages 6 through 21 and the Early Childhood Service Intensity Instrument (ECSII) for children ages 0 through 5 as the standardized service-intensity assessment tools for public behavioral health, and to expand the definition of Core Service Agency (CSA). If you serve Maryland Medicaid youth, your assessors need CASII and ECSII training, your clinical documentation templates need to carry the six CASII dimensions and the ECSII composite score, and your policies need to reflect the revised CSA referral and coordination workflow before the effective date.

This is not a soft rollout. Maryland behavioral health programs are already required to be both licensed and accredited, and the regulatory framework sits in COMAR 10.63 with accreditation from CARF, The Joint Commission, or COA as a prerequisite for licensure. Under the amended rule, level-of-care determinations tied to CASII and ECSII scores will be read alongside your accreditation standards during BHA audits. Two audit lanes. One documentation file.

One more thing to know up front. The Administrative Services Organization changed. The ASO transitioned from Optum to Carelon Behavioral Health on January 1, 2025, so authorization requests, medical necessity reviews, and CASII/ECSII score submissions now flow through Carelon’s ProviderConnect. If your policy manual still names Optum as the ASO, that is your first fix.

Why BHA is standardizing on CASII and ECSII

CASII and ECSII are not new instruments. They are AACAP-developed tools that Maryland has already been using for 1915(i) eligibility and level-of-care decisions. The amendment tightens the rule so that every child-serving provider uses the same yardstick. The CASII is designed for use in all child-serving systems, including behavioral health, physical health, education, child welfare, juvenile justice, and substance use, which is what makes it useful when a CSA is coordinating across systems.

The clinical case is well documented. The CASII assesses the client across six key dimensions: risk of harm, functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. In peer-reviewed testing, inter-rater reliability among psychiatrists showed intra-class correlation coefficients ranging from 0.63 to 0.91, with Cronbach’s alpha higher than 0.97. For ECSII, AACAP field-testing trials showed excellent inter-rater reliability and validity. Surveyors and BHA reviewers can lean on that evidence base, which means your documentation should show how the score was derived, not just what it was.

The need is real. Between 2016 and 2020, Maryland children ages 3 to 17 with anxiety or depression rose 36%, from 9.4% (105,000 young people) to 12.8% (143,000 young people). Nationally, KFF reports that in 2024, 15% of adolescents (3.8 million) reported a past-year major depressive episode and 19% (4.9 million) reported moderate to severe symptoms of anxiety. BHA is aligning the tool set to the volume.

The Core Service Agency piece: what the expanded definition actually means

Under existing COMAR, the Core Service Agency has the meaning stated in COMAR 10.63.01.02, and the Local Behavioral Health Authority has the meaning stated there as well. The amendment expands the CSA definition to reflect the broader coordination role that CSAs and LBHAs now play, particularly for youth eligibility determinations and cross-system referrals.

Here is the workflow you actually need to change. Under Maryland’s 1915(i) State Plan Amendment logic, the evaluator uses a psychosocial assessment to generate a score on the ECSII or CASII, then compares it to the score generated by the CSA or LBHA using the same documentation. If the two scores diverge, the evaluator gathers additional information by telephone or other means in conjunction with the CSA or LBHA. Your policy needs a named workflow for that reconciliation call, a documentation template that captures both scores, and a defined escalation path when scores don’t match.

Eligibility triggers matter for medical necessity. Youth must receive a score of 3 (Moderate Service Intensity), 4 (High Service Intensity), or 5 (Maximal) on the CASII to qualify for higher levels of care, with additional criteria such as inpatient psychiatric history or referral from a specified source. For children under 6, a score of 3 or 4 on the ECSII plus a qualifying referral source drives eligibility. If your chart doesn’t show the score, the dimension anchors, and the qualifying condition, an auditor will call it a documentation gap.

The operator readiness path before July 6

Here is the checklist we walk Maryland child and adolescent BH providers through. You can run this internally, or our Compliance Managed Services and Regulatory Affairs teams at AccrediCulture can run it with you.

Assessor training roster. Identify every clinician who administers intake assessments for youth. Enroll them in AACAP’s online CASII training and ECSII training. Track completion dates. BHA already requires annual CANS renewal for youth care coordinators, so build CASII/ECSII into the same annual competency calendar.
Documentation templates. Rebuild the youth psychosocial assessment to capture all six CASII dimensions (risk of harm, functional status, co-occurring conditions, recovery environment, resiliency, involvement in services) with anchor-point rationale, plus the composite score. Add a parallel ECSII template for the 0–5 population. Include a field to record the CSA/LBHA comparison score and the reconciliation notes.
Medical necessity language. Update your treatment plan and continuing-stay narrative to tie the requested level of care back to the CASII or ECSII composite plus the qualifying condition. Vague notes lose authorizations under Carelon utilization review the same way they lost them under the prior ASO.
Policy revisions. Update your admission, assessment, and utilization review policies with the new COMAR citations. Rename any references to Optum as the ASO. Add the expanded CSA definition and the referral/coordination workflow. Route to the governing body for approval before July 6.
Internal audit. Pull 15 to 25 open youth charts. Confirm each has a CASII or ECSII score dated within the required window, dimension anchors documented, and a level-of-care recommendation that matches the score. Log every gap in a corrective action plan with an owner and a close-out date.
Staff training and attestation. Roll the updated policies out to clinical, intake, and UR staff. Capture attestations. Keep the sign-in sheet in your accreditation binder alongside your CARF, Joint Commission, or COA evidence.

If you do those six things, survey week gets quieter. That is the whole point.

Frequently asked questions

When exactly does the COMAR amendment take effect and which provider types are in scope?
The effective date is July 6, 2026. Scope includes any Maryland behavioral health program serving youth ages 0 through 21 under the Public Behavioral Health System, including OMHCs, PRPs for minors, Intensive In-Home Services, 1915(i) providers, Targeted Case Management for children and youth, and residential treatment centers. If you are licensed under COMAR 10.63 and serve minors, plan on being in scope.

Who must be trained and certified to administer CASII and ECSII, and what documentation is required?
Any clinician generating a service-intensity score for a youth participant. AACAP offers online CASII and ECSII trainings through its store, and in-person training is available by request. Your chart should carry the trained clinician’s name, training completion date, the dimension-level anchor rationale, and the composite score.

How does the expanded Core Service Agency definition change referral, authorization, and coordination workflows?
The CSA or LBHA runs a parallel score using the same documentation. When your evaluator’s score and the CSA score diverge, the two parties reconcile by phone or written exchange. Your workflow needs a named owner, a documentation template, and a service-level expectation for turnaround so authorization requests don’t stall at Carelon.

How should medical necessity and level-of-care determinations be documented to survive a BHA audit under the new rule?
Tie every level-of-care decision to a CASII or ECSII composite score, cite the qualifying condition where applicable, and show the six-dimension narrative that produced the score. Include the CSA/LBHA reconciliation. Reviewers should be able to trace the recommendation back to the assessment without asking a follow-up question.

What is the risk exposure if a provider is not compliant by July 6, 2026?
Three lanes. Licensure findings from BHA that can trigger a corrective action plan or conditional license. Medicaid claim recoupments from Carelon utilization review when medical necessity is not supported. And accreditation findings from CARF, The Joint Commission, or COA when documentation does not match the standard cited. The good news: the fix is the same across all three, which is a clean CASII/ECSII workflow with score, rationale, and reconciliation on every youth chart.

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