I am writing as a Licensed and Board Certified Behavior Analyst with a decade of clinical experience in Virginia, including eight years as a Registered Behavior Technician (RBT) and two years as a practicing BCBA. I currently oversee Applied Behavior Analysis (ABA) services for seven children across the Commonwealth, ranging from urban centers to extremely remote rural communities. The majority of these children rely on Medicaid.
While I fully support DMAS’s commitment to strong documentation and oversight, several provisions in the proposed Appendix D create administrative barriers that will delay or reduce medically necessary care for vulnerable children. Below are my specific concerns and actionable recommendations to ensure accountability without compromising patient care.
Concern: The draft states that services "may not exceed 20 hours per week, except as authorized under EPSDT review." Treatment intensity must be dictated by individualized clinical assessments—not arbitrary numerical caps. A child with Level 3 severity requires significantly more intensive intervention than a child with Level 1 or 2 severity. Capping hours risks retarding progress, decreasing intervention efficacy, and prolonging the overall duration a child requires ABA services. Furthermore, CMS’s 2026 ABA Toolkit explicitly states that states may not apply hard limits to medically necessary services for children covered under EPSDT.
Recommendations:
Clarify that the 20-hour mark functions strictly as a trigger for administrative review, not a clinical ceiling or hard cap.
Specify that only direct, face-to-face treatment time with the child counts toward this 20-hour threshold, ensuring that essential indirect care—such as supervision overlap, parent training, and assessments—does not reduce the child's direct therapy hours.
Concern: While the draft promises an EPSDT review prior to any service denial, it lacks operational details regarding review timelines and provider qualifications. Delays in this process directly threaten service continuity.
Recommendations:
Mandate that EPSDT reviews be conducted by a qualified BCBA or peer ABA expert.
Enforce a standard 7-calendar-day turnaround time for review decisions.
Guarantee that existing authorized service hours remain active throughout the review process to prevent gaps in medically necessary care.
Concern: Requiring strict, in-person diagnostic evaluations with zero exceptions creates severe access barriers for rural families. I regularly travel over two hours each way because my agency is the sole provider willing and able to cover certain rural areas. Families in these regions routinely wait months—sometimes years—for care. Mandating rigid in-person logistics introduces risks from weather delays, scheduling conflicts, and environmental factors. Furthermore, requiring external evaluators unfamiliar to the child can skew clinical results compared to assessments conducted by a primary BCBA who understands the child's baseline behaviors, family dynamic, and local care ecosystem.
Recommendations:
Maintain in-person evaluations as the standard, but allow telehealth options when an in-person evaluator is unavailable within a reasonable timeframe or geographic distance.
Allow DMAS to accept existing, valid diagnostic evaluations that children have already completed, eliminating redundant administrative delays during critical developmental windows.
Concern: I support allowing children age 5 and under to begin services under a provisional diagnosis. Early intervention during these peak developmental years is critical. For example, I treat a child under age 5 who is currently making significant progress in ABA while specialists determine whether their presentation is Autism Spectrum Disorder (ASD) or another developmental condition. Losing access to care now would jeopardize those developmental gains. Furthermore, ABA methodology is clinically proven to benefit complex developmental conditions beyond ASD; limiting coverage solely to ASD restricts vital care for other vulnerable populations.
Recommendations:
Authorize Nurse Practitioners (NPs) and Physician Assistants (PAs) to issue provisional diagnoses, aligning Appendix D with DMAS’s existing State Plan Amendment.
Establish a clear pathway via EPSDT review for children over age 5 on diagnostic waitlists to access provisional ABA services.
Concern: Caregiver involvement is a cornerstone of my treatment plans. However, requiring rigid weekly participation under threat of discharge fails to account for real-world family circumstances. Many Medicaid families navigate extreme hardships—working multiple jobs, managing lack of childcare, or supporting multiple children with special needs. Imposing unrealistic participation quotas causes unnecessary anxiety, deters families from seeking care, and unfairly punishes children for their parents' structural barriers. Flexible engagement (e.g., telehealth check-ins, phone updates, tailored home goals) maintains effective care coordination without penalizing the child.
Recommendations:
Incorporate extenuating circumstances provisions for caregiver participation requirements.
Permit discharge based on non-participation only after documented, multi-modal engagement efforts have been exhausted—matching the standard DMAS already uses for other youth services like Multisystemic Therapy (MST) and Functional Family Therapy (FFT).
ABA therapy yields the highest outcome measures when service intensity reflects individual clinical needs and families are supported by reliable, continuous care. I ask DMAS to preserve the accountability measures in this revision while implementing these essential adjustments so Virginia’s children do not lose medically necessary care to rigid caps, rural access barriers, or administrative delays.
Thank you for your time, leadership, and consideration of these comments.
Daria Ditzler, MS, BCBA, LBA