The Virginia Association for Behavior Analysis (VABA) appreciates the opportunity to comment on the draft revisions to Appendix D of the Mental Health Services Manual. VABA represents behavior analysts practicing across the Commonwealth, many of whom serve Medicaid members under the provisions at issue. We recognize that several revisions implement directives in Item 291.WW.2 of the Appropriation Act. Our comments are intended to help DMAS implement those directives in a manner that is clinically sound, consistent with federal requirements, and administrable by providers and managed care organizations (MCOs).

VABA respectfully requests that DMAS:

1. Establish a defined EPSDT pathway, with stated documentation standards, for youth who need behavior-analytic services but do not have an autism spectrum disorder (ASD) diagnosis, and reconcile the ASD requirement with the existing State Plan before the implementing amendment is finalized with CMS.
2. State the federal EPSDT standard in the manual, define how hours are counted, and confirm that 20 hours per week is a utilization-management threshold rather than a limit on medically necessary care.
3. Treat the utilization-management provisions as interim pending recommendations from the DMAS ABA Benefit Utilization Workgroup.
4. Revise several unchanged provisions whose effects change under the new requirements, and make the technical corrections listed in Appendix A of this Comment.

Behavior-Analytic Services Are Not Diagnosis-Specific

Item 291.WW.2 provides that "The department shall require a diagnosis of autism spectrum disorder prior to authorizing ABA services." VABA understands that this directive binds DMAS. We ask DMAS to implement it in a way that preserves access for youth whose needs fall outside it, because the Commonwealth's own law, State Plan, and manual recognize that behavior analysis is not limited to ASD. Three points support this.

First, the manual's service definition adopts the definition of behavior analysis in § 54.1-2900 of the Code of Virginia, which addresses "socially significant improvement in human behavior" and contains no diagnostic limitation.

Second, in SPA TN 24-0021, approved by CMS effective July 1, 2024, DMAS added licensed behavior analysts to the State Plan definition of "credentialed addiction treatment professional." The Commonwealth has thus represented to CMS that behavior analysts treat conditions other than ASD.

Third, Appendix D excludes Multisystemic Therapy and Functional Family Therapy for any youth whose functional impairment results solely from a developmental disability as defined in § 37.2-100. Before this revision, those youth could receive ABA under any primary DSM diagnosis. Under the draft, a youth with intellectual disability and severe self-injury has no Appendix D service available except through case-by-case EPSDT review.

The research literature supports behavior-analytic treatment for these populations. Examples include self-injury and other severe problem behavior among individuals with intellectual and developmental disabilities (Hanley et al., 2003; Kahng et al., 2002), pica (McAdam et al., 2004), pediatric feeding disorders (Sharp et al., 2010), and substance use disorders (Prendergast et al., 2006).

The draft states that EPSDT will review all ABA requests before denial, including requests for youth who do not meet diagnostic criteria. VABA supports this provision. However, the draft specifies documentation standards only for youth with a provisional diagnosis beyond 12 months and for requests exceeding 20 hours per week. VABA requests that DMAS add a third enumerated EPSDT pathway for youth without an ASD diagnosis, stating the minimum documentation required (for example, the current diagnosis, a functional assessment, and the treatment needs it identifies). Without a stated standard, each MCO will develop its own, and families will face inconsistent determinations for the same clinical presentation.

Item 291.WW.2 also authorizes DMAS to amend the State Plan to effect these changes. VABA encourages DMAS to reconcile the ASD requirement with SPA TN 24-0021 and with EPSDT obligations under 42 U.S.C. § 1396d(r)(5) before the implementing amendment is finalized with CMS. Addressing the inconsistency now will support federal approval and reduce the likelihood of later revision.

The 20-Hour Threshold and EPSDT Review

The draft provides that services "may not exceed 20 hours per week, except as authorized under EPSDT review," and that all ABA requests receive EPSDT review before denial. VABA supports this safeguard and requests the following clarifications so that it operates as intended.

State the EPSDT standard: The manual should state that services above 20 hours per week are authorized when they are necessary to correct or ameliorate the youth's condition, consistent with 42 U.S.C. § 1396d(r)(5), and that the number of hours requested is not by itself a basis for denial or reduction. This aligns with Item 291.WW.2, which states that the limit "can be exceeded based upon documented medical necessity."

Distinguish intensity from medical necessity: The final paragraph of the EPSDT section groups requests above 20 hours with requests for youth who "do not meet stated MNC." A youth who needs 30 hours per week may fully meet medical necessity criteria. VABA recommends revising that paragraph to treat the two categories separately.

Define how hours are counted: The draft does not specify what counts toward 20 hours. The billing section permits concurrent billing, including 97153 with 97155, two technicians each billing 97153, and youth services alongside family training delivered by separate staff. If the threshold sums units across codes, 20 hours of treatment that includes two hours of concurrent QHP direction would register as 22 hours and trigger EPSDT review. VABA recommends defining hours as face-to-face time with the youth, counted once regardless of how many staff bill, and excluding caregiver-only and non-face-to-face services. We also ask DMAS to specify whether the weekly measure is a calendar week or an average across the authorization period. An average accommodates planned intensity changes, such as summer schedules and tapering before discharge.

Make reviews transparent: Item 291.WW.2 directs DMAS to require MCO reporting that can be analyzed across MCOs, regions, and providers. VABA requests that notices denying or reducing requests above 20 hours state the EPSDT analysis applied, and that MCO reporting include the number and outcomes of EPSDT reviews for ABA. This gives DMAS the data to evaluate the threshold and gives providers and families a clear basis for appeal.

Address federal parity requirements: Medicaid MCOs are subject to mental health parity requirements under 42 CFR Part 438, Subpart K. A weekly hour threshold that can be exceeded on documented medical necessity functions as a nonquantitative treatment limitation. Under 42 CFR § 438.910(d), the processes, strategies, evidentiary standards, and other factors used to apply such a limitation to mental health benefits must be comparable to, and applied no more stringently than, those applied to medical/surgical benefits in the same classification. VABA asks DMAS to confirm that it has completed, or will complete, a comparative analysis before implementation, including how the threshold compares with any limits applied to physical, occupational, and speech therapy. If the threshold were applied as a fixed ceiling, it would instead be a quantitative treatment limitation subject to § 438.910(b). The clarifications above reduce that compliance risk for the Commonwealth.

Treatment Schedules

For requests above 20 hours per week, the draft requires an individualized schedule, a description of the interventions planned for each timeframe, and, in clinic settings, a distinction between therapeutic and recreational time. VABA supports documentation of how requested hours will be used and recommends two refinements.

First, the schedule should describe the distribution and therapeutic purpose of services across the week rather than fix the intervention for each time block. The manual's own service definition requires "consistent, ongoing, objective assessment and data analysis to inform clinical decision-making." Session content that changes in response to the youth's data is sound practice, not a departure from the authorized plan.

Second, the distinction between therapeutic and recreational time should rest on function, not format. Naturalistic and play-based procedures embed instruction in activities that resemble recreation, and some ISP objectives target leisure skills directly. VABA recommends defining an activity as therapeutic when it addresses ISP objectives and collects data on those objectives.

Diagnostic Documentation

The draft identifies diagnostic instruments (ADI-R, ADOS, and CARS) and screening instruments (RITA-T and STAT) introduced by "such as." In practice, MCO reviewers often treat illustrative lists as exhaustive. VABA recommends introducing each list with "including but not limited to" and adding "or another validated instrument." We also recommend that the manual direct reviewers to weigh the diagnosing professional's training, experience, and clinical judgment. An ASD diagnosis is a clinical determination informed by instruments, not a score on any single one.

Coordination With the ABA Benefit Utilization Workgroup

The EPSDT documentation requirements, schedule requirements, and hour-counting rules fall squarely within the DMAS ABA Benefit Utilization Workgroup's charge, which will continue meeting after this comment period closes. VABA requests that DMAS designate these provisions as interim and commit to revisiting them when the workgroup issues its recommendations.

Related Provisions

Several provisions were not revised but will operate differently under the new requirements.

Family participation: Weekly family involvement and discharge criterion 5 (family "refuses or is unable to participate meaningfully") are appropriate in principle. For youth receiving more than 20 hours per week, that criterion now also bears on EPSDT review. VABA recommends that providers not reduce or terminate services on this basis when they have documented a caregiver-participation plan, efforts to engage caregivers, adjustments to training methods or scheduling, and continued clinical benefit to the youth.

Care coordination: The manual requires documented coordination with the youth's primary care provider. Providers cannot compel another practitioner to respond or override a caregiver's consent decision. VABA recommends satisfying the requirement with documented good-faith efforts and any barriers encountered. 

Supervision: Supervising unlicensed personnel is a clinical activity that maintains treatment integrity and is required by Board of Medicine regulations (18VAC85-150), regardless of the technician's certification. VABA recommends that the manual describe it as clinical supervision and revise the heading "LMHP Oversight of Services" to include LBAs and LABAs, who perform most of this supervision.

2027 CPT code set: The AMA's 2027 code set, effective January 1, 2027, deletes 0362T and 0373T, adds new Category I adaptive behavior codes, and revises the descriptors for 97151 through 97158. The draft's code table, concurrent-billing combinations, and team-based provisions reference the current codes. VABA recommends updating the manual to the 2027 code set, with a crosswalk, before January 1, 2027, and applying the hour-counting definition requested above to the new codes.

Closing

VABA shares DMAS's interest in services that are medically necessary, well documented, and consistently administered across MCOs. We appreciate the Department's consideration of these comments and welcome the opportunity to discuss them.

--------------------

References

Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior: A review. Journal of Applied Behavior Analysis, 36(2), 147–185. https://doi.org/10.1901/jaba.2003.36-147

Kahng, S., Iwata, B. A., & Lewin, A. B. (2002). Behavioral treatment of self-injury, 1964 to 2000. American Journal on Mental Retardation, 107(3), 212–221. https://www.ncbi.nlm.nih.gov/books/NBK69354/

McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Napolitano, D. A. (2004). Behavioral interventions to reduce the pica of persons with developmental disabilities. Behavior Modification, 28(1), 45–72. https://doi.org/10.1177/0145445503259219

Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A meta-analysis. Addiction, 101(11), 1546–1560. https://doi.org/10.1111/j.1360-0443.2006.01581.x

Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13(4), 348–365. https://doi.org/10.1007/s10567-010-0079-7

Appendix A: Technical Corrections

The following corrections address drafting and citation issues in Appendix D's ABA section.

1. Admission Criteria, 2.a (p. 24): Only ICD-10 code F84.0 is named, and older diagnoses may be recorded under other F84 codes. Requested revision: Accept a documented ASD diagnosis recorded under any applicable F84 code.
2. Admission Criteria, 2.b (p. 24), and Initial Service Authorization, 2.b and 2.c (pp. 28-29): "Age 5 or under" and "37 months to 5 years old" can be read inconsistently. Requested revision: State age bands in months (e.g., 37 through 71 months).
3. Initial Service Authorization, 2.a (p. 24), and Additional Continued Stay Criteria, 1 (p. 31): "Autism Diagnostic Review (ADI-R)" is misnamed. Requested revision: "Autism Diagnostic Interview-Revised (ADI-R)."
4. Additional Continued Stay Criteria, 1 (p. 31): "Shall submit" reads as mandatory at every continued stay and conflicts with item 2. Requested revision: Begin with "When a comprehensive diagnostic evaluation has been completed."
5. Additional Continued Stay Criteria (pp. 30-31): No provision addresses a full evaluation that does not confirm ASD. Requested revision: Continue services under EPSDT review with a documented transition plan.
6. Required Activities (p. 23): The heading "LMHP Oversight of Services" omits LBAs and LABAs. Requested revision: "LBA, LABA, and LMHP Oversight of Services."
7. Discharge Criteria, 4 (p. 26): Failure to maintain gains is listed as grounds for discharge, although it typically indicates a need for maintenance programming. Requested revision: Apply this criterion only after implementing and documenting maintenance and generalization procedures.

--------------------