Thank you for the opportunity to provide feedback on the proposed ABA policy updates. We support DMAS’s efforts to strengthen oversight and promote appropriate utilization of services. However, we have significant concerns about the potential impact of these changes on access to medically necessary ABA treatment for children and families across Virginia.

We respectfully encourage DMAS to reconsider the proposed requirement that diagnostic evaluations be conducted in person. Families throughout Virginia already face lengthy waitlists for autism evaluations, and requiring in-person appointments could create additional barriers and further delay access to essential early intervention services.

This requirement would be especially challenging for families in rural and underserved communities where access to qualified diagnostic providers is limited. Telehealth evaluations offer an important alternative for families who may otherwise experience significant delays in obtaining a diagnosis and accessing medically necessary treatment.

We recommend that DMAS continue to permit telehealth diagnostic evaluations when clinically appropriate and conducted by qualified professionals. Decisions should prioritize the quality, validity, and clinical appropriateness of the evaluation rather than restrict access based solely on the method of delivery.

We strongly recommend that DMAS remove all proposed hourly caps and utilization thresholds from the ABA Provider Manual, including the proposed 20-hour-per-week limitation.

ABA is an individualized treatment that must be tailored to each child's unique clinical needs. Clinicians rely on their professional training, clinical expertise, comprehensive assessments, and ongoing data analysis to determine the appropriate treatment plan and recommended service hours. These recommendations are based on the individual child's needs rather than a standardized model of care.

Implementing predetermined hourly caps or utilization thresholds risks undermining the individualized nature of ABA treatment by allowing administrative guidelines to influence clinical recommendations. Restricting access to clinically recommended treatment hours is comparable to limiting a patient's prescribed medication without considering the treating provider's determination of medical necessity. In both situations, decisions about care should be guided by the individual's needs rather than an arbitrary numerical limit.

This concern is particularly relevant in light of the CMS State Medicaid & CHIP Applied Behavior Analysis Toolkit, released August 4, 2026, which addresses utilization thresholds and authorization limits in the context of medically necessary services and federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements. As reflected in the toolkit, utilization controls should not function as absolute limits when additional services are medically necessary to meet an individual child's needs.

We recognize and support DMAS's responsibility to ensure appropriate oversight of ABA services. Authorization processes should include thorough clinical reviews to confirm that requested hours are medically necessary, supported by appropriate documentation, and based on individualized assessments. However, there is an important distinction between reviewing medical necessity and establishing a predetermined numerical threshold that may influence or restrict clinical decision-making.

We are also concerned about how Medicaid managed care organizations (MCOs) may interpret and apply this language. Even if DMAS intends the proposed 20-hour threshold to prompt additional documentation or review rather than establish an absolute limit, there is a substantial risk that MCOs could interpret it as a maximum allowable number of hours in practice. This could result in automatic denials, pressure on providers to reduce clinically recommended treatment hours, and additional barriers for children whose needs require more intensive services.

Including a numerical threshold in the Provider Manual could inadvertently establish a default standard for service authorization rather than encourage individualized assessments of medical necessity. Children who require treatment beyond the proposed threshold could face disproportionate challenges obtaining authorization, even when their treatment plans are supported by comprehensive clinical assessments and documented medical necessity.

Our recommendation is that DMAS remove the proposed 20-hour limitation and all other predetermined hourly caps or utilization thresholds from the ABA Provider Manual. Authorization decisions should be based on each child's individualized medical necessity, supported by appropriate clinical documentation and subject to reasonable review and oversight by DMAS and its contracted MCOs.

This approach would allow DMAS to maintain accountability and appropriate utilization oversight while protecting access to medically necessary services and preserving the individualized foundation of ABA treatment.

We appreciate DMAS's continued efforts to improve the delivery and oversight of ABA services throughout Virginia. However, proposed policy changes must be carefully evaluated to ensure they do not introduce additional barriers for families who are already experiencing difficulties accessing timely, appropriate care.

We respectfully request that DMAS:

Ultimately, the number of hours a child receives should reflect that child's individual clinical needs, treatment goals, and the recommendations of qualified treating professionals. These decisions should be made through individualized clinical review rather than predetermined numerical limits 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 medically necessary services and supports they need.

Reference: CMS, State Medicaid & CHIP Applied Behavior Analysis Toolkit, August 2026, particularly pages 54 and 123.