As a dedicated advocate for expanding access to vital services, I strongly support removing the requirement that initial assessments for individuals with autism requiring ABA (Applied Behavior Analysis) therapy must be completed in person, as outlined in the Mental Health Services Manual, Appendix D. This revision ensures timely, equitable access to care, aligns with evidence-based practices, and reflects evolving standards in behavioral health service delivery. Below are several key reasons why this update is essential:

• Improved Accessibility to ABA Services: Individuals with autism, especially those in rural or underserved areas, often face significant challenges in accessing in-person services. Removing the in-person initial assessment requirement bridges this gap, enabling timely access to critical therapy services without forcing families to endure delays or logistical hardships.

• Evidence-Based Support from CASP and BACB: The Council of Autism Service Providers (CASP) and the Behavior Analyst Certification Board (BACB), both respected authorities in the ABA field, provide strong support for the use of telehealth. CASP’s Practice Parameters for Telehealth Implementation of Applied Behavior Analysis and BACB’s ethical guidelines emphasize that telehealth-based assessments can deliver the same high level of effectiveness as in-person services when conducted appropriately by credentialed providers.

• Consistency with CMS Guidance on Telehealth: The Centers for Medicare & Medicaid Services (CMS) has long acknowledged the importance of telehealth in reducing service delivery barriers. CMS extended approval for ABA-related CPT codes (97151-97158, 0362T, 0373T) for telehealth delivery into 2025, further solidifying telehealth’s role in increasing accessibility without compromising care quality.

• Widespread Industry Consensus: Telehealth has gained widespread support across healthcare bodies such as the Autism Society and the American Psychological Association (APA). These organizations recognize the importance of modernizing healthcare delivery methods to better meet the needs of individuals requiring behavioral therapies, supporting policies that remove outdated limitations like in-person-only requirements.

• Faster Initiation of Treatment: In-person requirements often lead to delays, which can impede progress for individuals requiring ABA therapy. Allowing for remote initial assessments ensures a prompt start to services, aligning with treatment goals and optimizing therapeutic outcomes.

• Resource Optimization for Providers and Clients: Requiring in-person initial assessments not only imposes logistical and financial burdens on clients but also monopolizes limited resources for providers. Removing this requirement allows providers to extend their reach, especially in areas with limited behavioral health professionals.

• Maintaining High Standards of Care: Telehealth assessments comply with rigorous professional and ethical standards, including privacy and security, and ensure quality in alignment with CASP, BACB, and CMS guidelines. The technology-enabled modality ensures that individuals with autism receive comprehensive evaluations tailored to their needs.

• Alignment with State and Nationwide Health Priorities: The revision of Appendix D of the Mental Health Services Manual reflects the evolving standards of care and helps further the state’s broader goals of improving healthcare access, leveraging technology, and driving better patient outcomes.

In conclusion, removing the in-person initial assessment requirement from the Mental Health Services Manual, Appendix D, is an essential step to modernize ABA services, incorporate consensus-driven standards, and enhance accessibility for individuals with autism. This change aligns with the authoritative guidance of CASP, BACB, CMS, and other leading organizations, ensuring evidence-based practices and equitable care delivery.

To the Department of Medical Assistance Services (DMAS):

This comment is submitted on behalf of stakeholders providing Applied Behavior Analysis (ABA) services to Virginia Medicaid members, with a request for Virginia Medicaid to re-evaluate its supervisory co-signature requirement as outlined in DMAS Mental Health Manual, Appendix D. This policy, which states,

"Documentation of all billed services shall include the amount of time or billable units spent to deliver the service and shall be signed and dated on the date of the service by the practitioner rendering the service and include any applicable supervisor co-signature,"

is incongruent with widely recognized industry standards for ABA documentation and introduces unnecessary inefficiencies without enhancing care quality.

As clarified by the Council of Autism Service Providers (CASP) in its Applied Behavior Analysis Practice Guidelines, ABA services function under distinct professional frameworks, separate from other forms of healthcare delivery that utilize "incident to" billing models. Specifically:

• ABA Documentation Standards: Session notes for behavior technician-provided services, including CPT codes 97152, 97153, and 97154, are designed to be signed solely by the rendering technician. CASP confirms that supervisory co-signatures on these notes are not standard or required in the field of ABA.
• Supervisory Oversight is Established Elsewhere: Supervising Board Certified Behavior Analysts (BCBAs) oversee ABA services through signed treatment plans and separate supervision documentation. These processes ensure that adequate oversight and accountability are maintained without imposing redundant requirements.
• Alignment with AMA CPT Guidelines: The CPT codes specific to ABA services reflect the independent and distinct nature of these services, demonstrating that co-signatures are not necessary for compliance.

Mandating BCBA co-signatures for every session note disrupts operational efficiencies without providing additional safeguards or quality improvements for Medicaid members. It also places undue administrative demands on providers, potentially diverting valuable resources away from direct patient care.

To this end, we strongly urge DMAS to align its policies with national best practices and clarify that behavior technician session notes can be properly documented with their signature alone, as supported by CASP and AMA CPT guidelines. Adopting this modification would modernize Medicaid policies and ensure they reflect the unique characteristics of ABA service provision.

Currently there is only one resource that manually reviews and adjudicates the TDO claims submitted to the TDO fund. The current turnaround is significant and results in aging accounts receivable.  An electronic submission option is not currently available when submitting to the TDO Fund for payment. There are also claim specific requirements that some electronic health records are not able to accommodate so they need to be handwritten on the claim form submitted. Adding ECO reimbursement under the TDO program for non-Medicaid eligible individuals or secondary coverage through the TDO program will increase the volume of claims submitted to the TDO Fund. There will need to be an increase in resources to manage and adjudicate these claims timely. It is also reasonable that there is an electronic option that does not include direct data entry for the additional claim volume anticipated.

 Page 7 does not include an appropriate taxonomy for ECO services for non-facility setting.  We provide ECO activity in the hospital setting, not in our CSU or 23hr Crisis Receiving center so would need an appropriate taxonomy code to utilize for billing.

For non-Medicaid eligible individuals under an ECO in any setting, claims for prescreening assessments conducted through emergency services pursuant to section §37.2-800 et. seq. and section §16.1-335 et seq. of the Code of Virginia may be submitted to the TDO Program using the H2011 HCPCS code. Providers should use the 32 modifier to indicate that the prescreening was conducted under an ECO and the appropriate team modifier (see Appendix G to the Mental Health Services Manual for details). DBHDS Virginia Crisis Connect requirements apply but providers do not have to submit a registration form to the TDO Program.

Submission of registration for Mental Health Case Management Services within one business day of admission is unreasonable.  I recommend increasing this timeline to 3 business days to ensure appropriate time to gather necessary information to facilitate the registration.

Please consider increasing the requirement to submit registration for MHCM services to 3 business days; one business day is unrealistic and 3 business days will allow necessary time to gather needed information to facilitate the registration.

Submission of registration for Mental Health Case Management Services within one business day is unreasonable. Please consider increasing this timeline to 3 business days to ensure appropriate time to gather necessary information to facilitate the registration.

While #1 is appropriate (schedule) to include in the ISP, the other two requirements are not appropriate for the ISP. For #2, the progress note should document the clinical appropriateness and #3 is simply not appropriate for inclusion in the ISP.