Thank you for the opportunity to provide feedback on the proposed ABA policy updates. While we support DMAS's efforts to strengthen oversight and ensure appropriate utilization of services, we have significant concerns regarding the potential impact of these changes on access to medically necessary ABA treatment for children across Virginia.
1. In-Person Diagnostic Requirements
We strongly encourage DMAS to reconsider requiring diagnostic evaluations to be conducted in person. Families across Virginia already face extremely long waitlists for autism evaluations, and this requirement would create additional barriers and further delay access to critical early intervention services.
This would particularly impact families in rural and underserved communities where qualified diagnostic providers are limited. For many families, telehealth evaluations provide an important pathway to obtaining a timely diagnosis and beginning medically necessary treatment.
We recommend that DMAS continue to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals. The focus should remain on the clinical quality and appropriateness of the evaluation rather than imposing restrictions on how that evaluation is conducted.
2. Removal of All ABA Hour Caps and Utilization Thresholds
We strongly recommend that DMAS completely remove any proposed hourly caps or utilization thresholds from the ABA Provider Manual, including the proposed 20-hour weekly limitation.
ABA is an extremely individualized form of treatment. Our clinicians utilize their professional experience, clinical expertise, and comprehensive assessments to determine the appropriate treatment plan and recommended number of hours per week for each child. These recommendations are based on the unique clinical needs of the individual, not a standardized approach to care.
Establishing an arbitrary hourly cap or threshold undermines the very foundation of individualized ABA treatment. It effectively substitutes an administrative policy for clinical judgment. To put this into perspective, limiting a child's access to clinically recommended ABA hours is comparable to telling a family that their child can receive only half of their prescribed medication, regardless of what their treating physician has determined is medically necessary.
This concern is particularly significant in light of the CMS State Medicaid & CHIP Applied Behavior Analysis Toolkit, released August 4, 2026, which emphasizes that utilization thresholds and authorization limits should not operate as absolute caps when additional medically necessary services are required. CMS recognizes that treatment intensity must be individualized and based on each child's clinical needs, consistent with federal EPSDT requirements.
We fully recognize and support DMAS's responsibility to provide appropriate oversight of ABA services. DMAS should maintain rigorous authorization and clinical review processes to ensure that requested treatment hours are medically necessary, appropriately documented, and supported by individualized assessments. However, there is a fundamental difference between oversight of medical necessity and establishing an arbitrary numerical threshold that influences or restricts treatment recommendations.
Additionally, we are extremely concerned about how Medicaid managed care organizations (MCOs) will interpret and implement such language. Even if DMAS intends the 20-hour threshold to trigger additional documentation or review rather than serve as an absolute limitation, we are concerned that MCOs will treat it as a hard cap in practice. This could lead to automatic denials, pressure to reduce clinically recommended hours, and significant barriers for children whose treatment needs exceed the established threshold.
The inclusion of any numerical cap or threshold in the Provider Manual creates an unnecessary risk that MCOs will use that number as the default maximum level of treatment rather than evaluating each child's actual medical necessity. Families with children requiring more intensive services would be disproportionately affected, despite having clinical documentation supporting those needs.
Our recommendation is clear: DMAS should remove the 20-hour limitation and any other predetermined hourly caps or utilization thresholds from the ABA Provider Manual entirely. Authorization decisions should be based on individualized medical necessity, supported by appropriate clinical documentation and subject to reasonable oversight by DMAS and its contracted MCOs.
We believe this approach would allow DMAS to maintain appropriate accountability while protecting access to medically necessary services and preserving the individualized nature of ABA treatment.
Conclusion
We appreciate DMAS's commitment to improving ABA services in Virginia. However, any changes to the Provider Manual must be carefully considered to ensure they do not create additional barriers for families already struggling to access care.
We respectfully request that DMAS:
Ultimately, the number of hours a child receives should be determined by their individual clinical needs and the recommendations of qualified treating professionals, not by a predetermined number established in a provider manual.
Thank you for your consideration and your continued commitment to ensuring that children with autism across Virginia have access to the care they need.
Reference: CMS, State Medicaid & CHIP Applied Behavior Analysis Toolkit, August 2026, particularly pages 54 and 123.