I am a Board Certified Behavior Analyst with over eight years of experience providing clinical oversight of ABA services. I currently oversee ABA treatment for more than eight children with autism in the Central Virginia region, most of whom receive services through Medicaid. I support the DMAS goals of accountability, quality assurance, and thorough clinical documentation; however, I am concerned that several provisions in the proposed Appendix D could delay access to or reduce medically necessary ABA services for the children I serve.

1. The proposed manual states that services “may not exceed 20 hours per week, except as authorized under EPSDT review.” Treatment intensity should be based on each child’s individualized assessment, clinical needs, safety risks, and response to treatment rather than a preset numerical threshold. I urge DMAS to state that a request of 20 hours triggers a clinical review rather than as a cap on medically necessary services.

A five-year-old child on a previous caseload required 30 hours of ABA treatment per week to address severe self-injurious behavior, aggression, and unsafe elopement. Within two months of intensive, individualized treatment, the child made progress in functional communication with caregivers, siblings, and ABA staff, alongside reductions in all tracked target behaviors. This example illustrates why treatment intensity should remain dependent on individual clinical needs.

I also request that DMAS clearly define which service components count toward the 20-hour threshold. Direct treatment hours should not be reduced by counting overlapping supervision, caregiver training, or assessment activities against the child’s direct treatment time. 

2.  The proposed manual references an EPSDT review before denial of services, but does not clearly identify who will conduct the review or establish a specific timeframe for completion. I request that reviews be conducted by a BCBA or another qualified professional with expertise in ABA and medical necessity determinations.  An expedited review process should be established for urgent clinical or safety concerns, with a maximum time frame of seven calendar days for routine reviews to promote timely, clinically appropriate decisions and minimize disruptions to medically necessary services. Current authorized service hours should remain in place while a timely request for review is pending to prevent interruptions in medically necessary ABA services. Services should not be reduced or discontinued until the review is completed and a determination is issued.

3. The proposed requirement for in-person diagnostic evaluations, without clearly defined exceptions, may create barriers to timely diagnosis and treatment. Families I serve have reported waiting more than ten months for an evaluation, and some live approximately 100 miles from the nearest available in-person evaluator. These delays can prevent children from accessing services during critical periods of early development.

I ask that DMAS retain in-person evaluations, but allow telehealth evaluations when in-person appointments are unavailable within a reasonable timeframe or accessible distance. DMAS should also accept existing diagnostic evaluations that meet clinical and documentation requirements to avoid unnecessary repeat assessments. These changes would reduce delays, travel burdens, and barriers to accessing services while maintaining appropriate diagnostic standards and ensuring timely access to medically necessary care.

4.  I support allowing children age five and younger to access ABA services based on an eligible provisional diagnosis while awaiting a comprehensive diagnostic evaluation. In my clinical experience, a three-year-old child began ABA treatment with a provisional diagnosis and made progress in functional communication, including requesting wants and needs, while experiencing reductions in tantrums and aggression. These improvements supported the child's ability to participate in school and community activities. This illustrates the potential benefits of early intervention and the importance of reducing delays in accessing medically necessary services while families pursue comprehensive diagnostic evaluations.

I ask that DMAS clarify that qualified nurse practitioners and physician assistants may provide provisional diagnoses when permitted under applicable state law and DMAS policy. 

5. Family involvement is essential to effective ABA treatment.  I incorporate caregiver training into treatment plans to promote generalization and consistency across settings; however, rigid weekly participation requirements and potential discharge may unintentionally penalize families facing work schedule changes, transportation difficulties, illness, or other circumstances beyond their control. For example, a parent on my caseload missed two weeks of scheduled participation due to unexpected work schedule changes, but parent guidance and support continued through brief weekly check-ins. I ask that DMAS allow exceptions for extenuating circumstances.  Discharge due to limited caregiver participation should occur only after documented efforts to engage the family, assess barriers, and provide reasonable accommodations when feasible.

ABA is most effective when treatment intensity aligns with each child’s clinical needs and families can rely on continuity of care. I ask DMAS to maintain accountability while ensuring these revisions do not create unnecessary barriers or delays that prevent children from accessing medically necessary services. Thank you for considering my comments.