Behavioral Therapy Solutions, LLC appreciates the opportunity to comment on the proposed changes to Virginia Medicaid's Applied Behavior Analysis (ABA) requirements. As a clinician-owned provider of ABA and behavioral health services, we have several concerns about how these changes may affect access to care and how they will be implemented by the MCOs.
Our biggest concern is limiting ABA to youth with an Autism Spectrum Disorder (ASD) diagnosis, or a provisional ASD diagnosis for children age five and under.
ABA does not equal autism, nor is ABA an autism-only intervention. ABA is a treatment methodology used to address behavior, communication, adaptive functioning, skill development, independence, and other areas of functional impairment.
There is published research supporting behavioral and behavior-analytic interventions outside of ASD. This includes children and individuals with intellectual disability, Down syndrome, ADHD, developmental disabilities, and disruptive behavior disorders. For example, a 2021 systematic review of behavior-analytic interventions for young children with intellectual disability without ASD identified 49 studies and found established interventions for communication, adaptive, and pre-academic skills. A 2021 systematic review and meta-analysis of ABA interventions for individuals with Down syndrome identified 125 studies and reported positive effects across areas including communication and challenging behavior. Behavioral interventions also have a significant evidence base for ADHD and disruptive behavior disorders.
This does not mean every child with ADHD, Down syndrome, intellectual disability, developmental delay, ODD, or another diagnosis needs ABA. The issue is that diagnosis alone should not automatically exclude a child when an individualized assessment shows that ABA is medically necessary and appropriate for the child's functional needs.
This is especially concerning when looking at DMAS's own functional criteria. A youth must meet at least two criteria that include limited functional communication or language impairment; severe impairment in social interaction, social reasoning, reciprocity, or interpersonal relatedness; frequent intense behavioral outbursts involving self-injury or aggression; disruptive repetitive or ritualized behaviors; or difficulty with sensory integration. These needs are not exclusive to ASD.
A child with Down syndrome or intellectual disability may have limited functional communication and severe aggression. A child with developmental delay may have significant communication and adaptive deficits, self-injury, or other challenging behavior. A child with ADHD and a disruptive behavior disorder may have significant behavioral dysregulation and aggression across settings.
It is possible for two children to have very similar functional needs, but under the proposed criteria one could receive ABA because they have ASD while the other could be excluded because they have a different diagnosis.
We also worry about the unintended incentive this creates. Families should not feel that they need to pursue an ASD diagnosis simply because it is the only diagnosis that opens the door to ABA. Diagnosis should reflect the child's actual clinical presentation, and treatment should follow from the child's needs.
This is also a significant change from previous DMAS policy. The October 2023 ABA Medical Necessity Criteria required a current DSM psychiatric diagnosis or provisional psychiatric diagnosis rather than ASD specifically. The May 2024 Mental Health Services Manual similarly allowed a primary ICD diagnosis corresponding to a DSM diagnosis while separately requiring the youth to meet functional criteria.
We recognize that the ASD requirement originates in Item 291.WW.2 of the 2026 Appropriation Act rather than solely through DMAS policy. However, Item 291.WW.3 of that same Act specifically directs the ABA Benefit Utilization Workgroup to evaluate the appropriateness of ABA for children with diagnoses other than ASD. We therefore encourage DMAS to preserve all available EPSDT protections, collect and report data regarding the impact of the diagnostic restriction, and use the findings of the legislatively mandated workgroup to inform future recommendations to the General Assembly regarding eligibility for non-ASD youth.
CMS has repeatedly emphasized the importance of EPSDT for Medicaid members under age 21. CMS's February 2026 Children's Behavioral Health and EPSDT Toolkit also discusses providing medically necessary behavioral health services without requiring a formal behavioral health diagnosis in appropriate circumstances.
We would appreciate specific clarification from DMAS on this question: If a Medicaid member under age 21 does not have ASD, but an appropriate clinician determines that ABA is medically necessary to correct or ameliorate the child's condition, can ABA be requested through EPSDT? If so, what is that process?
We also request clarification regarding the statement: “Services are authorized based on medical necessity and may not exceed 20 hours per week, except as authorized under EPSDT review.”
Does the 20-hour limit mean 20 hours of direct treatment under CPT 97153, or does it mean 20 total hours across all ABA CPT codes?
If a child clinically requires 20 hours of direct treatment per week in addition to BCBA protocol modification/clinical oversight and caregiver training, are those BCBA and caregiver services counted against the same 20 hours? If so, providing necessary clinical oversight or caregiver training would effectively reduce the child's direct treatment hours.
We recommend that DMAS clearly state whether the 20-hour limit applies to 97153 or to total ABA services and use the same interpretation across all MCOs. Without clear language from DMAS, there is significant potential for MCOs to interpret this differently. One MCO may consider the limit to apply to direct treatment while another may combine all ABA CPT codes. That could result in children receiving different benefits based simply on which MCO administers their Medicaid coverage.
The wording also appears different from prior DMAS policy. The July 2025 Mental Health Services Manual stated that requests exceeding 20 hours (80 units) per week required additional documentation regarding the schedule and therapeutic function of the requested hours. Twenty hours therefore triggered additional review rather than serving as an absolute limit.
We would appreciate clarification as to whether DMAS intends the new language to change that policy. The phrase “except as authorized under EPSDT review” also needs a clear process. Providers and families should know how to request more than 20 hours when medically necessary and should not have to first receive a denial or reduction from an MCO before learning how to request an EPSDT review.
We also have concerns about requiring a “comprehensive diagnostic evaluation conducted in-person.” A comprehensive diagnostic evaluation may include direct observation and clinical interview, but it can also include caregiver interviews, developmental history, review of school and medical records, standardized measures, collateral information, scoring and interpretation, differential diagnosis, diagnostic formulation, and preparation of the written report. There may certainly be circumstances where direct observation or other components should occur in person. However, record review, scoring, collateral consultation, diagnostic formulation, and report writing do not inherently require the child to be physically present.
We recommend that DMAS identify which portion of the evaluation must occur in person and allow qualified clinicians to use telehealth for portions that can appropriately be completed remotely within their scope of practice and clinical judgment.
We are particularly concerned about the impact on rural and underserved areas.
Families already experience waitlists for developmental and behavioral health evaluations. An in-person-only requirement further limits the pool of available clinicians and may require families to travel significant distances. Transportation may also be particularly difficult for families whose children have significant behavioral, sensory, developmental, or medical needs. This becomes an even greater concern when the evaluation is a required gateway to treatment.
A child could have severe aggression, self-injury, communication impairment, and significant functional needs but be unable to begin ABA because the family cannot find a Medicaid provider who can complete the required in-person diagnostic evaluation within a reasonable time or distance. We ask DMAS to consider provider availability and geographic access before implementing this requirement and to consider exceptions or alternatives when an appropriate in-person diagnostic provider is not reasonably available.
We also request clarification regarding reimbursement for the comprehensive diagnostic evaluation. Virginia Medicaid covers CPT 90791, Psychiatric Diagnostic Evaluation, and qualified LMHPs, including LCSWs acting within their scope of practice, can provide diagnostic assessment services.
However, a comprehensive diagnostic evaluation and written report can involve considerably more work than the clinical interview itself. Depending on the case, this may include hours of record review, standardized assessment scoring and interpretation, collateral review, differential diagnosis, integration of information, diagnostic formulation, and report writing.
If DMAS is going to require a comprehensive diagnostic evaluation as a condition of receiving ABA, how is the clinician reimbursed for completing all of the required components? Is DMAS expecting CPT 90791 to cover the face-to-face diagnostic evaluation as well as the additional time required for record review, scoring, interpretation, diagnostic formulation, and preparation of the comprehensive written report?
If not, what CPT codes or other reimbursement mechanisms should an LCSW or other qualified LMHP use for this work?
This needs clarification because reimbursement directly affects access. If clinicians are required to complete several hours of additional professional work without a way to bill for that work, fewer clinicians may be able or willing to provide comprehensive Medicaid diagnostic evaluations. When combined with the in-person requirement, this could create an additional bottleneck for families before they even reach the ABA authorization process.
In summary, we respectfully ask DMAS to consider:
We appreciate DMAS considering feedback from providers and families before these changes are finalized. We support appropriate medical necessity standards and utilization review. At the same time, we hope the final policy allows enough flexibility to recognize that children with similar functional needs may have different diagnoses and that access to treatment should not unnecessarily depend on geography, MCO interpretation, or the availability of an in-person diagnostic provider.