Thank you for taking the time to read and consider this feedback. I write from the perspective of someone who manages the day to day operations of more than 100 Board Certified Behavior Analysts , speaks with more than 500 current ABA families, and understands firsthand the challenges these children, families, and providers face every day.
While we understand that these proposed mandates may not originate within DMAS’s Behavioral Health Department, we strongly urge DMAS to advocate for practical, clinically appropriate policies that preserve access to medically necessary Applied Behavior Analysis (ABA) services.
Additional regulations, particularly when they create barriers to accessing or maintaining treatment, risk undermining the progress children can make through early intervention, placing additional strain on families already struggling to manage significant behavioral challenges, and contributing to further burnout among BCBAs. Many families turn to ABA after other services have not adequately addressed their children’s needs. They reach out to us overwhelmed, exhausted, and often crying for help because they do not know where else to turn.
Since the implementation of the most recent ABA regulatory changes, we have already observed managed care organizations (MCOs) recommending alternative services in place of ABA, challenging or reducing requested treatment hours, and questioning individualized treatment plans that BCBAs have spent many hours developing based on clinical assessments, ongoing data collection, and years of professional experience. These challenges create unnecessary administrative burdens, delay access to care, and undermine the clinical judgment of the professionals responsible for designing and implementing treatment.
The cumulative effect is an increasingly difficult environment for providers, families, and the children who depend on these services. We are concerned that continued regulatory burdens will further discourage qualified clinicians from remaining in the field, intensify workforce shortages, and threaten the long term sustainability of ABA services in Virginia that is already highly challenged.
With these concerns in mind, I would like to propose several practical recommendations that balance appropriate oversight with the need to protect access to medically necessary care.
1. Diagnostic Requirements and Access to Services
With wait times for appropriate in person diagnostic appointments in Virginia reportedly exceeding six months, we strongly recommend that DMAS permit a provisional diagnosis for one six-month authorization period for individuals of all ages, rather than limiting this option to children up to age five as proposed.
This flexibility would allow individuals to begin or continue medically necessary treatment while awaiting a comprehensive diagnostic appointment. Delaying services for months solely because a diagnostic appointment is unavailable risks lost developmental opportunities, increased family stress, and worsening behavioral challenges.
Telehealth diagnostic assessments should also be considered an acceptable option when clinically appropriate and consistent with applicable professional standards. Without a reasonable grace period or flexibility regarding assessment methods, children and adolescents who need services may be left without access to treatment simply because of provider availability.
We also ask DMAS to consider the following circumstances:
Members transitioning from other insurance coverage: Individuals who previously received services through an insurer that did not require the same comprehensive diagnostic documentation may face significant delays when transitioning to Medicaid. A reasonable grace period would help prevent interruptions in care while families obtain the newly required documentation.
Members with Medicaid as secondary insurance: Some members may have a primary insurer with less stringent diagnostic documentation requirements. If the Medicaid MCO requires additional documentation that the primary insurer does not, families may face delays or denials despite already receiving medically necessary services.
Current ABA recipients: If new diagnostic requirements are implemented for individuals already receiving ABA, an appropriate transition period should be provided to allow families to obtain the necessary assessments without experiencing a lapse in authorized treatment.
Finally, DMAS should clearly define the diagnostic documentation and required clinician credentials that will be accepted. Providers need an explicit, comprehensive list of acceptable evaluations and instruments, including clarification regarding the roles of the CARS, ADI-R, ADOS-2, Vineland, BASC-3, WISC-V, TELE-ASD-PEDS (TAP), and other commonly used assessments. Clear guidance would reduce inconsistent interpretations among MCOs, minimize avoidable denials, and help providers and families understand exactly what is required.
2. The Proposed 20-Hour ABA Cap
We recognize that the proposed 20-hour threshold has been described as a soft cap, with additional medically necessary services available through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) process when warranted.
However, the practical experience of providers with MCO'S suggests that this flexibility may not adequately protect access to care without clear and enforceable implementation standards.
Recent Medicaid documentation requirements have already created significant challenges for children seeking appropriate levels of ABA treatment. Even when providers comply with requirements such as submitting schedules of activities in 15 minute increments, requests may still be challenged or partially denied by MCOs. Providers are often required to participate in peer to peer reviews, which consume additional clinical and administrative time and do not always result in approval of the full amount of medically necessary care.
We are also seeing concerns with requests for fewer than 20 hours, as some MCOs recommend alternative services even when ABA is clinically indicated and the individualized treatment plan identifies specific needs involving communication, social functioning, adaptive skills, and behavior reduction. While other services can play an important role in a child's care, they should not automatically be treated as substitutes for ABA when ABA is medically necessary based on a team of clinicians with many years of experience.
Additionally, we have encountered situations in which the 20 hour threshold appears to be interpreted cumulatively across services rather than as a threshold for direct 97153 ABA treatment hours. This creates further uncertainty for providers and families and highlights the need for consistent written guidance.
A 20 hour threshold could have significant consequences for children with Level 3 autism who are not making meaningful progress through school-based services or other programs and who require intensive, individualized clinical ABA treatment. Restricting access to medically necessary care may negatively affect developmental progress, communication, independence, adaptive functioning, and overall quality of life, while placing additional burdens on families and caregivers.
For preschool-aged children receiving early intervention in a clinical setting, access to individualized, appropriately intensive ABA may be particularly important. Research supports the potential benefits of early intervention for some children, although the appropriate intensity and duration of treatment must be determined by each child's individual needs, clinical assessment, and response to treatment.
We respectfully recommend that DMAS:
Establish clear, objective, and enforceable criteria for approving medically necessary ABA services beyond 20 hours per week.
Require MCOs to evaluate requests based on the individual child's clinical needs, treatment data, functional impairments, and progress rather than relying primarily on a numerical threshold.
Clarify that direct ABA treatment hours must be distinguished from parent training, supervision, and other separately defined services when applying the threshold.
Establish consistent standards for documentation and medical necessity determinations across all MCOs.
Ensure that EPSDT remains a meaningful pathway to obtaining medically necessary treatment beyond the threshold, rather than a process that creates additional administrative barriers or routinely results in partial denials.
Ensure that alternative services are recommended as part of a coordinated treatment approach when appropriate, rather than used as an automatic replacement for clinically indicated ABA.
A threshold should not become a de facto cap simply because the process for obtaining additional hours is so burdensome that families and providers cannot reasonably navigate it. Children with significant support needs must have a fair opportunity to receive the treatment their individual clinical circumstances warrant.
3. Weekly Parent Training Requirements
Parent participation and caregiver training are essential components of effective ABA treatment. We fully support efforts to encourage meaningful caregiver involvement and to equip parents with strategies they can use in everyday settings.
However, many families are already managing substantial demands related to their child's behavioral, communication, medical, educational, and daily living needs. Work schedules, transportation, childcare responsibilities, family circumstances, and caregiver stress can make weekly participation difficult even when parents are committed to treatment.
Requiring parent training every week, particularly when missing a session could jeopardize authorization for the child's remaining services, risks placing an unreasonable burden on families who are already overwhelmed.
We recommend that weekly parent training remain a clinical goal when appropriate, while a minimum requirement of twice monthly be considered a more reasonable standard. Providers should retain the flexibility to individualize caregiver training frequency based on family circumstances, clinical necessity, treatment goals, and progress.
Caregiver engagement should be encouraged and supported, not become a barrier that places a child's access to medically necessary treatment at risk because a family cannot participate every single week.
4. The 31-Day Rule and Continuity of Care
We understand that the 31-day rule is already in effect. However, staffing shortages, clinician availability, family vacations, illnesses, scheduling conflicts, and other ordinary interruptions can make it difficult to maintain uninterrupted direct services.
We recommend that a documented parent training session occurring within the applicable 31 day period be recognized as a qualifying treatment-related service that demonstrates continued engagement in care, even when direct ABA sessions have temporarily paused.
We have encountered situations in which some MCOs do not recognize parent training for purposes of this rule, potentially resulting in automatic discharge despite ongoing treatment-related engagement. This inconsistency creates confusion for providers and families and can lead to unnecessary disruptions in care.
The goal should be to prevent unnecessary discharge and preserve continuity of medically necessary treatment, rather than penalize families and providers for temporary disruptions that do not reflect an abandonment of care.
Conclusion
We appreciate DMAS's responsibility to ensure appropriate oversight, accountability, and the responsible use of Medicaid resources. We share those goals and believe that strong clinical standards and appropriate safeguards are necessary.
However, regulations must also reflect the realities faced by children, families, and providers in the field. When requirements create prolonged delays, inconsistent authorization decisions, unnecessary administrative burdens, or interruptions in medically necessary treatment, the consequences extend far beyond paperwork. They affect children's developmental opportunities, families' ability to manage daily life, and the stability of the clinical workforce responsible for providing care.
We respectfully ask DMAS to consider these recommendations and to advocate for policies that promote consistency among MCOs, preserve individualized clinical decision-making, and protect continuity of care. In particular, diagnostic flexibility, a clinically driven approach to treatment hours, reasonable caregiver-training requirements, and clear continuity-of-care standards would help balance accountability with the needs of the individuals Medicaid serves.
The children and families receiving ABA services deserve a system that supports meaningful progress rather than unintentionally creating additional obstacles to care. We welcome the opportunity to contribute our operational experience and frontline perspective to help develop policies that are both responsible and workable.
Thank you for your time, consideration, and continued commitment to the children and families of Virginia.
