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, we have several concerns regarding the potential impact on access to medically necessary services.

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.

We recommend continuing to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals.

2. 20-Hour EPSDT Documentation Threshold

We recommend that the proposed 20-hour threshold for enhanced EPSDT documentation apply specifically to direct treatment hours (CPT 97153) rather than total ABA service hours.

Clinical supervision (97155) and caregiver training (97156) are essential components of treatment and should not count toward this threshold.

Including these services would effectively reduce the amount of direct treatment a child can receive before additional documentation requirements are triggered, creating unnecessary administrative burdens.

3. Clarification of the 20-Hour Limitation

We are particularly concerned with the proposed wording that ABA services "may not exceed 20 hours per week."

This language could be interpreted by Medicaid managed care organizations (MCOs) as an absolute benefit cap rather than a threshold requiring additional clinical review.

The CMS State Medicaid & CHIP ABA Toolkit, released August 4, 2026, specifically states on page 123 that utilization thresholds and authorization limits "should not operate as absolute caps" when additional medically necessary services are required.

CMS further recognizes that treatment intensity should be individualized based on each child's clinical needs, consistent with federal EPSDT requirements.

We recommend replacing the proposed language with:

"Requests exceeding 20 hours per week of direct ABA treatment (CPT 97153) shall require enhanced clinical documentation and individualized medical necessity review under EPSDT. This threshold shall not constitute an absolute service limitation, and additional medically necessary hours may be authorized based on the individual needs of the child."

DMAS should also explicitly instruct MCOs that requests exceeding this threshold must receive individualized review rather than automatic denial.

Conclusion

We appreciate DMAS's commitment to improving ABA services in Virginia. However, these changes should not create additional barriers for families already struggling to access care.

We respectfully request that DMAS maintain flexibility for diagnostic evaluations, apply the 20-hour documentation threshold specifically to direct treatment, and clearly establish that treatment intensity must be determined by individualized medical necessity rather than an arbitrary hourly cap.

Thank you for your consideration!