I am a Board Certified Behavior Analyst (BCBA) and Licensed Behavior Analyst (LBA) with 6 years of experience providing Applied Behavior Analysis (ABA) services to children with autism in Southwest Region of Virginia. Although I have been a BCBA for 6 years, I have been in the field of ABA for 11 years. My work involves developing individualized treatment plans, overseeing behavior-reduction and skill-acquisition programs, and supporting families in addressing significant communication and behavioral needs. I support DMAS’s goals of accountability, quality care, and thorough clinical documentation. However, I am concerned that several provisions in the proposed Appendix D could create barriers to medically necessary treatment for children with complex needs.

The proposed language stating that ABA services “may not exceed 20 hours per week, except as authorized under EPSDT review” raises concerns about children whose clinical needs require more intensive treatment. Treatment hours should be determined by individualized assessments, behavioral data, developmental needs, and medical necessity rather than a predetermined threshold. I currently oversee treatment for a 7-year-old girl with autism who has severe language delays and engages in self-injurious behaviors. She has been approved for 30 hours of ABA per week to address significant communication deficits, increase functional communication, develop adaptive skills, and reduce behaviors that may compromise her safety. Reducing her treatment to 20 hours without an individualized clinical review could limit opportunities to teach safer alternatives to self-injury, establish effective communication, and build skills necessary for greater independence. Her authorized hours reflect her individualized treatment needs, not a one-size-fits-all recommendation. I ask DMAS to clarify that the 20-hour threshold triggers a clinical review rather than functioning as a cap on medically necessary services. I also recommend that only the child’s direct, face-to-face treatment hours count toward this threshold, so clinical supervision, parent training, and assessment activities do not reduce the time available for direct treatment.

Although the proposed language indicates that an EPSDT review will occur before services exceeding the threshold are denied, it does not clearly establish who will conduct the review or how quickly a determination will be made. For example, children with significant communication delays and self-injurious behaviors, delays in authorization decisions can interrupt treatment during a critical period of development. In the case of the 7-year-old girl I serve, continuity of her approved 30 hours of ABA per week is important to ensure consistent implementation of her behavior-reduction and communication programs. An interruption or reduction in services could limit her access to intervention targeting safety, functional communication, and independence. I ask DMAS to establish a timely review process conducted by a BCBA or another qualified professional with expertise in ABA, with decisions made within the applicable standard seven-day timeframe when required. Existing authorized services should continue while a timely request for continued or increased medically necessary care is under review, preventing avoidable interruptions in treatment.

Family participation is an important component of effective ABA treatment, and I incorporate caregiver training into every treatment plan. However, requiring weekly family involvement without sufficient flexibility may disproportionately affect families managing work schedules, childcare responsibilities, transportation barriers, or other significant circumstances. These barriers do not necessarily indicate a lack of commitment to their child’s treatment. For example, a child with severe language delays and self-injurious behaviors, caregiver collaboration can help promote consistency across environments, strengthen communication skills, and support the safe implementation of behavior strategies. When a family experiences barriers to participating in traditional training sessions, providers should be able to offer reasonable alternatives, such as telehealth, brief check-ins, flexible scheduling, or caregiver coaching integrated into existing appointments. I ask DMAS to allow for extenuating circumstances and require documented efforts to collaborate with families before considering discharge due to limited participation. Family involvement should remain an important treatment objective without becoming a barrier to medically necessary services when families face circumstances beyond their immediate control.

ABA is most effective when treatment intensity is individualized, services are delivered consistently, and families receive appropriate support. I respectfully ask DMAS to retain the accountability measures included in the proposed revision while ensuring that individualized clinical needs, timely EPSDT reviews, and reasonable flexibility for families remain central to authorization decisions. Children should not lose access to necessary care solely because of a predetermined hourly threshold, administrative delays, or barriers to caregiver participation.

Thank you for considering my comments.

Haley Copper, M.Ed, BCBA, LBA