RE: Proposed Mental Health Services Manual, Appendix D, Applied Behavioral Analysis Changes
To Whom It May Concern,
The Autism Families Alliance (AFA) is grateful for the opportunity to provide feedback regarding the Virginia Department of Medical Assistance Services’ (DMAS) proposed changes to Appendix D of the Mental Health Services Manual. AFA is a national advocacy organization dedicated to supporting Applied Behavior Analysis (ABA) providers and the families who rely on their services. We work to ensure that every child and family has access to the care they deserve. In Virginia, AFA partner companies provide ABA services to over 900 patients via 10 brick and mortar locations. They also employ approximately 830 employees across the Commonwealth.
AFA supports the Department’s efforts to strengthen oversight and promote family involvement and care coordination. We recognize that many of the proposed changes are a result of Item 291.WW.2 of the Appropriation Act. However, AFA is gravely concerned by several of the proposed changes to Mental Health Services Manual and the negative impacts we believe these changes will have not only on our patient population, but on the health of the state’s Medicaid program in the long-term. AFA remains ready to continue to work together with DMAS and solutions that will ensure access to the highest quality ABA supports. We offer the following comments and recommendations to amend certain proposed changes to the Manual.
20-Hour Per Week Cap
The proposed changes to the manual provide that ABA services "may not exceed 20 hours per week, except as authorized under EPSDT review," and that all ABA requests receive EPSDT review before denial. While we recognize there is an exception to the proposed language that allows for a soft cap to be permissible under EPSDT, AFA remains concerned that the treatment for vulnerable populations is being determined by an arbitrary hour limit and not in accordance with the individualized medical necessity of each beneficiary. Specifically, the inclusion of “may not exceed 20 hours per week” before the mention of EPSDT review may be misconstrued as a benefit limit that forces families of beneficiaries to seek out EPSDT medical necessity review following an initial denial. AFA is especially concerned that the presence of any numerical cap or threshold creates risks that managed care organizations (MCOs) will use that number as a pre-determined hard cap on treatment as opposed to basing treatment on each beneficiary’s actual medical necessity.
AFA Recommendation
Pursuant to Section 1905(r)(5) of the Social Security Act, a service is medically necessary under EPSDT if it is needed to correct or ameliorate defects and physical and mental illnesses and conditions" discovered by screening. AFA believes it is essential that DMAS clearly highlights EPSDT medical necessity screenings as the most important step in determining the number of care hours a beneficiary is approved to receive to ensure there is no confusion regarding the cap. We recommend that DMAS alters the proposed update to incorporate the following into the manual before any mention of the proposed 20-hour soft cap:
“ABA services are to be authorized based on medical necessity and EPSDT review is required before any medical-necessity determination regarding the number of hours a beneficiary can receive is made.”
AFA also asks that DMAS clarifies the exact reason behind the inclusion of a proposed 20-hour cap. We understand that the cap stems from Item 291.WW.2 which directs DMAS to impose a 20-hour-per-week cumulative limit on Medicaid-funded ABA services per recipient. While AFA recognizes that this is technically allowed by federal law as a tool to manage utilization, we are troubled by some of the utilization numbers that we are seeing across our member companies as well as the utilization numbers shared during DMAS’s first Autism Workgroup meeting on September 22nd. Utilization of ABA services based on approved hours across Virginia is already devastatingly low. This sub-optimal utilization is disrupting the continuity of care for beneficiaries and will not only prevent beneficiaries from receiving the care they need in the present but may also give way to downstream impacts in the future when beneficiaries are unable to graduate out of ABA services.
For this reason, we ask DMAS to clarify the exact rationale behind the presence of the 20-hour cap in the manual. Given the current utilization trends in ABA services, we also ask that DMAS reconsiders the presence of the cap if it is being used solely as a utilization-management tool. It is imperative that Virginia preserves access to medically necessary care under EPSDT. Making these changes and providing additional clarity will help ensure Virginia’s vulnerable populations receive the care they desperately need.
Family Participation
AFA appreciates DMAS for recognizing the importance of families as a key component of providing effective ABA care. While family involvement is crucial for progress, multiple systemic and personal barriers make active participation a major challenge for family members. We are concerned by the proposed changes requiring direct family involvement to take place on a “weekly” basis. AFA believes mandatory weekly participation from family members will inadvertently become a barrier to beneficiaries receiving the medically necessary care they require.
AFA Recommendation
Family involvement should be determined as clinically necessary for each individual beneficiary and not by an administrative rule that may inadvertently lead to beneficiaries not receiving the care they desperately need. We ask that DMAS remove the weekly basis requirement and consider replacing it with language that allows for family member participation when clinically appropriate in the beneficiary’s care plan.
In-Person Evaluations
AFA fully supports appropriate diagnostic evaluation and appreciates DMAS’s efforts to ensure beneficiaries are receiving the care that best aligns with their medical need. However, we are troubled by the proposed requirement for diagnostic evaluations to be conducted in person. Families across Virginia face extremely long waitlists for autism evaluations, with many evaluator waitlists being longer than one year. AFA is especially concerned by proposed alterations to the manual that would disallow telehealth as a modality by which beneficiaries may be evaluated. We fear this proposed change would specifically impact families in rural and underserved communities where qualified diagnostic providers are limited. For many rural families, telehealth evaluations provide an important pathway to obtaining a timely diagnosis where they can then begin to receive the medically necessary treatment they need. AFA is concerned DMAS would be inadvertently bifurcating Virginia’s Medicaid population by creating a barrier to evaluation for those who do not have readily available access to an in-person evaluation.
AFA Recommendation
AFA recommends that DMAS continue to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals. This will allow for the focus to remain on the clinical quality and appropriateness of the evaluation rather than imposing restrictions on how that evaluation is conducted.
31 Day Lapse Provision
AFA appreciates DMAS for recognizing how essential continuity of care is for beneficiaries receiving ABA services. Unfortunately, we believe the proposed provisions that require a provider to discharge a child If there is a lapse in ABA services 31 consecutive days will have an unintended negative impact on the continuity of care for so many beneficiaries. Restarting services requires a new assessment, ISP and authorization request. These unintended consequences may cause significant gaps in services and other delays that could lead to devastating downstream impacts for beneficiaries across the Commonwealth.
AFA Recommendation
AFA requests that DMAS increases this consecutive day proposal from 31 days to 60 days to ensure that any extenuating circumstances or workforce shortages do not disrupt the ability of beneficiaries to receive the care that they need.
Implementation Period
Lastly, AFA is deeply troubled by the implementation period initially proposed by DMAS that would allow for less than 48 hours to review changes made to the Manual. These changes will have a significant impact on vulnerable populations across the Commonwealth. We believe it is imperative that DMAS allows time to thoughtfully consider feedback from beneficiaries, families, providers, and organizations before finalizing the changes.
The Autism Families Alliance appreciates the opportunity to provide feedback regarding the proposed changes to Appendix D of the Mental Health Services Manual. AFA is committed to being an open and transparent partner with DMAS. We welcome the opportunity to discuss these proposed changes so that we can continue to best serve our patient population and work to improve access to care for vulnerable populations across the Commonwealth.
Respectfully,
Matthew La Violette