I have been a BCBA since 2021, but my work with children with autism began in 2016 as an educator in an autism classroom. Over the years, I have worked with children with a wide range of needs, and one thing has remained consistent: no two children are the same, and their treatment shouldn't be either. I support DMAS's goals of accountability and strong documentation, but I have concerns about how some of these proposed changes could affect the children and families we serve.

20-Hour Weekly Threshold (p. 28) The draft says services “may not exceed 20 hours per week, except as authorized under EPSDT review.” Intensity should follow each child’s assessment, not a preset number. CMS’s 2026 ABA Toolkit says states may not apply hard limits to services for children covered by EPSDT.  My biggest concern is the proposed 20-hour weekly threshold. For children with significant support needs, especially those engaging in severe aggression, self-injury, or elopement, 20 hours may not come close to meeting their needs. This is especially concerning for children whose behaviors make it difficult or unsafe to participate in full-day school programs, childcare, or other community settings. These are often the children who need the most consistent and intensive support to build communication, safety, and daily living skills. Treatment hours should be based on each child's individual assessment and medical necessity, not a predetermined threshold. I fear that requiring additional approval could delay treatment for children and families already struggling to access the support they need.

EPSDT review (p. 31). The draft promises an EPSDT review before any denial but doesn’t say who reviews or how fast. I appreciate that the proposal includes an EPSDT review before denying services exceeding 20 hours. However, I am concerned about the lack of clarity regarding who will complete these reviews and how quickly decisions will be made. Delays in authorization can disrupt treatment, affect staffing consistency, and create additional stress for families. I would encourage DMAS to establish clear review timelines, ensure decisions are made by professionals familiar with ABA, and allow existing services to continue while reviews are pending.

In-person diagnostic evaluations (p. 28). The draft requires evaluations to be done in person, with no exceptions.  I understand the importance of in-person diagnostic evaluations, particularly for an initial diagnosis. However, I would encourage allowing reassessments to be completed through telehealth on an as-needed basis when clinically appropriate and when the child and family meet established eligibility criteria. This would provide flexibility while maintaining the quality of evaluations. It could also reduce unnecessary travel, missed work, and delays in continued services. Previously completed evaluations should also be accepted when they meet appropriate clinical standards.

Family involvement (pp. 23, 26). I build family training into every treatment plan. But the manual requires weekly involvement and allows discharge when a family can’t participate. I strongly believe in caregiver involvement and include family training as part of treatment planning. However, I also recognize that families are doing their best to balance work, other children, and everyday life. Our current systems often make it incredibly difficult for parents of children with higher support needs to manage everything without sacrificing additional time, income, or employment opportunities just to access necessary services. We should be finding ways to make caregiver participation more accessible and realistic rather than creating another reason a child could lose services. Discharge should only be considered after documented efforts to engage and support the family, with consideration given to individual circumstances.

I fully support accountability and ensuring ABA services are medically necessary. My hope is that these changes will consider the realities families and clinicians face every day while keeping the individual needs and well-being of children at the center of treatment decisions.

Thank you for taking the time to consider my feedback.

Amanda Johnson-Kennehan, MS, BCBA, LBA