To the Department of Medical Assistance Services:

I am submitting these comments as a Board Certified Behavior Analyst and Licensed Behavior Analyst serving children and families in Virginia. I support accountability and standards that promote effective treatment. However, I am concerned that the proposed revisions could restrict access to medically necessary ABA, interrupt established care, and reduce the effectiveness of individualized treatment.

1. The proposed 20-hour weekly limit could restrict medically necessary treatment.

Children receiving ABA have different communication, adaptive, behavioral, and safety needs. Treatment intensity should reflect an individualized assessment of those needs and the child’s response to intervention.

Although the proposal permits additional hours through EPSDT review, review does not guarantee approval or timely access. Requiring an exception when assessed needs exceed 20 hours creates an additional barrier that may result in delayed, reduced, or interrupted treatment.

For a child developing functional communication or receiving treatment for dangerous behavior, insufficient treatment may limit progress and leave significant needs unaddressed. I urge DMAS to reconsider the weekly limit and preserve access to the amount of treatment supported by individualized medical necessity.

2. Diagnostic requirements should support timely access, including provisional diagnoses for children age five and younger.

I support allowing children age five and younger to begin medically necessary ABA with a provisional ASD diagnosis from a qualified professional while awaiting a comprehensive diagnostic evaluation. Children with significant communication, adaptive, behavioral, or safety needs should have access to early treatment while diagnostic clarification is underway.

Requiring an in-person comprehensive diagnostic evaluation may create barriers for families facing transportation difficulties, limited local evaluators, or lengthy appointment waitlists. Please allow telehealth diagnostic evaluations when clinically appropriate and completed by qualified professionals.

The provisional diagnosis pathway should be practical and accessible, with clear documentation requirements and protections against treatment interruptions when evaluation delays are outside the family’s control. Continued access should reflect the child’s documented medical necessity and clinical needs while the family pursues the full evaluation.

DMAS should also clarify acceptance of existing diagnostic evaluations and protect continuity of care while families obtain required documentation.

3. Caregiver participation requirements should accommodate barriers without jeopardizing the child’s treatment.

Caregiver involvement supports meaningful progress and use of skills beyond treatment sessions. However, employment, illness, childcare, and other caregiving responsibilities may affect a family’s ability to participate in a particular week.

A child’s need for treatment does not disappear when a caregiver encounters these barriers. Please allow flexible, clinically appropriate participation methods and require consideration of documented barriers, outreach, and accommodations before services are reduced or terminated.

4. Mandatory discharge after a service interruption could prolong gaps in care.

The requirement to discharge a child after a lapse exceeding 31 consecutive calendar days and submit a new assessment, treatment plan, and authorization request could extend an already disruptive interruption.

A lapse caused by hospitalization, illness, staffing shortages, or authorization delays does not necessarily reflect reduced medical necessity. Requiring the child to restart the admission process may delay resumption of established treatment and increase the risk of lost skills or worsening behavior.

Please establish exceptions for circumstances outside the family’s control and allow updated clinical information when a complete reassessment is unnecessary.

5. Documentation and scheduling requirements should support responsive treatment planning.

Documentation should help clinicians evaluate progress and make timely treatment decisions. Additional requirements should avoid duplicating existing clinical information in ways that divert time from analyzing the child’s response and updating interventions.

Individualized schedules should also allow adjustments based on the child’s presentation, motivation, safety needs, and learning opportunities. Play, meals, and daily routines can provide clinically meaningful opportunities to address communication, adaptive skills, and behavior. Their therapeutic value should be evaluated through the goals, interventions, and data rather than the activity’s appearance alone.

Please accept existing records when they contain the required information and preserve flexibility for clinically appropriate changes during treatment.

6. Implementation should protect existing treatment relationships.

Families need clear information about how the changes will affect current services. Providers and MCOs need consistent instructions for existing authorizations, pending requests, diagnostic documentation, and EPSDT review.

Please provide an adequate transition period and safeguards against interruptions caused by changing requirements or inconsistent interpretations across health plans.

My central concern is whether children will continue to receive timely, individualized, and effective treatment. I urge DMAS to evaluate these proposed changes together and revise requirements that could delay access, interrupt care, or limit treatment below a child’s medically necessary needs.

Thank you for considering my comments.

Respectfully,

Gina Thompson, BCBA, LBA
Virginia