October 14, 2026
Virginia Department of Medical Assistance Services (DMAS)
Attention: Syreeta Stewart
Regulatory Coordinator
600 E. Broad St., Suite 1300
Richmond, VA 23219
Syreeta.Stewart@dmas.virginia.gov
Submitted electronically via: https://www.townhall.virginia.gov/L/Comments.cfm?GdocForumID=2982
RE: Mental Health Services Manual, Appendix D, Applied Behavior Analysis changes
To Whom It May Concern,
The Council of Autism Service Providers (CASP) appreciates the opportunity to provide comments on the Virginia Department of Medical Assistance Services’ (DMAS) proposed revisions to the Mental Health Services Manual, Appendix D, including the proposed revisions governing applied behavior analysis (ABA) services. CASP is a nonprofit trade association representing autism service provider organizations throughout the United States. CASP promotes evidence-based practices and generally accepted standards of care in the delivery of services to individuals with autism.
CASP supports DMAS’s efforts to clarify the requirements governing ABA services, strengthen documentation of medical necessity, promote family involvement and care coordination, and ensure that services are appropriately individualized. We also appreciate DMAS’s explicit recognition that requests exceeding 20 hours per week may be considered through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) process.
At the same time, several provisions in the proposed revisions could unintentionally restrict access to medically necessary ABA services if interpreted as categorical limitations rather than individualized utilization-management standards. CASP therefore recommends several revisions to ensure that the policy remains consistent with individualized medical necessity determinations, EPSDT requirements, generally accepted ABA practice, and the clinical judgment of qualified practitioners.
THE 20-HOUR WEEKLY PROVISION SHOULD FUNCTION AS A UTILIZATION-MANAGEMENT THRESHOLD, NOT A BENEFIT LIMITATION
The proposed policy states:
“Services are authorized based on medical necessity and may not exceed 20 hours per week, except as authorized under EPSDT review.”
CASP appreciates that the proposed language expressly preserves the availability of EPSDT review for services exceeding 20 hours per week. However, the phrase “may not exceed 20 hours per week” could be interpreted as establishing a categorical limit on the amount of ABA available to Medicaid beneficiaries absent a separate EPSDT exception.
CASP recommends that DMAS clarify that 20 hours per week is a utilization-management threshold, not a limit on the amount of medically necessary ABA that may be covered.
Medical necessity should be determined based on the individual beneficiary’s clinical presentation, functional impairments, treatment goals, treatment response, and need for the requested intensity of intervention. The number of hours requested should not itself establish whether treatment is medically necessary.
CASP recommends language substantially similar to:
“Services are authorized based on individualized medical necessity. Requests for services exceeding 20 hours per week require EPSDT review and additional documentation supporting the requested intensity of treatment. The 20-hour threshold is not a categorical limitation on medically necessary services.”
This approach would preserve DMAS’s utilization-management process while making clear that beneficiaries with medically necessary needs exceeding 20 hours per week remain eligible for individualized consideration.
The proposed policy appropriately requires additional documentation explaining the requested services, therapeutic activities, and how those activities relate to treatment goals.
CASP recommends, however, that DMAS expressly state that EPSDT determinations are individualized and may not be denied solely because a beneficiary does not satisfy a predetermined number of additional criteria or because the requested number of hours exceeds a specified threshold.
For requests exceeding 20 hours per week, licensed behavior analysts (LBAs) and other qualified healthcare providers (QHPs) may demonstrate the clinical rationale for the requested intensity through documentation such as:
the beneficiary’s current functional impairments;
the frequency, severity, and duration of clinically significant behaviors;
communication and social deficits;
adaptive-functioning deficits;
behaviors that interfere with health, safety, learning, independence, or participation;
treatment goals and measurable objectives;
progress toward those goals;
the need for continued intensive intervention;
the role of ABA in preventing regression or promoting acquisition and generalization of critical skills; and
the clinical rationale for the requested number and distribution of hours.
CASP recommends that DMAS focus on whether the requested services are medically necessary for the individual beneficiary rather than establishing a rigid formula for determining the appropriate number of hours.
Federal regulations require a health plan provide specific rationale why a service is not medically necessary and include all the available tools, guidelines, or medical necessity criteria used when a denial is issued [( 42 CFR 438.404(b)(1) & 42 CFR section 438.404(b)(2)]. When an EPSDT review occurs, any subsequent adverse determination must be specific and individualized to the beneficiary and why the request failed to meet medical necessity for their unique needs and symptomatology.
MEDICAL NECESSITY AND TREATMENT INTENSITY SHOULD BE BASED ON INDIVIDUALIZED FUNCTIONAL NEEDS
The proposed admission criteria identify several clinical characteristics, including communication deficits, social impairment, self-injury or aggression, disruptive or repetitive behaviors, and sensory integration difficulties. CASP recommends revising these criteria to more clearly distinguish diagnostic eligibility from treatment intensity.
A beneficiary’s diagnosis establishes eligibility for an autism-specific benefit; the intensity and scope of treatment should be determined by the beneficiary’s individualized clinical presentation and functional needs. CASP recommends that the criteria focus on clinically significant impairments identified through comprehensive diagnostic and behavioral assessment, including direct observation, caregiver report, standardized assessment instruments, and other clinically appropriate methods.
CASP recommends that the proposed criteria be revised to address the following domains, which generally align with the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for autism spectrum disorder (ASD):
Communication deficits, identified through comprehensive diagnostic evaluation, norm- or criterion-referenced assessment, direct observation, and/or caregiver report. Examples may include absent or limited functional communication, pragmatic language deficits, unintelligible or echolalic speech, or receptive and expressive communication deficits.
Social-interaction deficits, identified through comprehensive assessment, direct observation, and/or caregiver report. Examples may include deficits in social initiation, response, acknowledgment, engagement, social reciprocity, social reasoning, or interpersonal relatedness.
Age-inappropriate maladaptive, disruptive, or harmful behavior, including self-injury, aggression, property destruction, pica, elopement, or other behaviors that interfere with health, safety, adaptive functioning, or meaningful participation in home, school, or community environments.
Inflexibility, disruptive, obsessive, repetitive, or ritualized behavior, when such behavior interferes with health, safety, adaptive functioning, learning, independence, or participation.
This approach would better align the medical-necessity determination with the beneficiary's individualized functional needs.
SCHOOL-BASED ABA SERVICES SHOULD NOT BE SUBJECT TO A CATEGORICAL LIMITATION
The proposed policy states that ABA may be provided in the home or community and that:
“Limited services are allowed in the school setting (see service limitations section). The setting must be justified in the ISP.”
CASP recommends that DMAS clarify that the school setting is not categorically excluded and that the appropriateness of a school-based service should be determined based on the beneficiary’s individualized clinical needs and treatment goals. ABA may appropriately address clinically significant behaviors and skill deficits across environments. For some beneficiaries, school is an important setting in which communication, social interaction, adaptive functioning, behavior reduction, and generalization goals can be addressed. The recently published Centers for Medicare and Medicaid Services (CMS) ABA Toolkit recognizes the importance of services provided across environments, including within educational settings. CASP therefore recommends replacing a potentially categorical limitation with language providing that services may be delivered in school settings when the setting is clinically appropriate, medically necessary, and supported by the individualized service plan.
The proposed policy requires direct family involvement “at a minimum weekly” and identifies assessment, training, observation, progress review, and goal updating as components of family involvement. CASP supports meaningful caregiver participation as an important component of effective ABA services. However, a mandatory weekly participation requirement could operate as a hard cap or become a basis for denying or reducing medically necessary services when a caregiver encounters circumstances that temporarily prevent participation. Family participation should therefore be addressed through individualized clinical planning and documented efforts to engage caregivers.
CASP recommends that DMAS require providers establish:
a clinically appropriate caregiver-participation plan;
provide caregiver training and education consistent with the beneficiary’s needs;
document efforts to engage caregivers;
document barriers to participation when they occur;
modify training methods or scheduling when clinically appropriate; and
avoid terminating or reducing otherwise medically necessary services solely because of barriers to caregiver participation when the provider has made reasonable efforts to facilitate participation and the client continues to benefit from ABA.
The proposed policy states that coordination with the primary care provider (PCP) is “essential” and “must be documented.” CASP supports care coordination. However, providers cannot control whether a PCP or another treating professional responds to a coordination request. CASP recommends that the policy require documentation of reasonable efforts to coordinate care, rather than requiring successful communication when another provider does not respond or when the beneficiary or caregiver declines authorization for information exchange.
Suggested language:
“The provider must make reasonable efforts to coordinate care with the beneficiary’s PCP and other relevant treating professionals, consistent with applicable consent and privacy requirements. Documentation must reflect the efforts made and any barriers to successful coordination.”
This approach preserves the importance of coordination while recognizing circumstances outside the ABA provider’s control. Further, CASP recommends that DMAS implement the CMS recommendation of conflict free case management and utilize MCO case managers in this capacity.
SUPERVISION, DIRECTION, AND CLINICAL SERVICE DELIVERY SHOULD BE DISTINGUISHED
The proposed revisions contain several provisions addressing supervision of ABA personnel, including monthly observation and supervision by an LBA, LABA, or LMHP.
CASP recommends that DMAS distinguish between:
clinical direction (clinical case supervision)
staff supervision (administrative oversight to maintain the Registered Behavior Technician [RBT] credential)
These activities are not interchangeable and should be described consistently with the scope of practice and competencies of the professionals performing them.
EPSDT REVIEW CRITERIA SHOULD CLEARLY DISTINGUISH BETWEEN NATURALISTIC TEACHING OPPORTUNITIES AND NON-THERAPEUTIC ACTIVITIES
As drafted, EPSDT review criteria treat “recreational and non-therapeutic” activities as a single category. This criteria places programmed naturalistic teaching, such as play, transitions, and peer social groups, alongside “non-therapeutic” activities, risking a reduction in authorized, medically necessary hours. We recommend that DMAS clarify that this distinction hinges on whether an activity has programmed objectives, associated data collection, and documentation that clearly ties the activity back to an active goal or objective rather than whether the activity can be classified as recreational.
THE TEN-DAY CONTINUED-STAY PROVISION SHOULD ALLOW A REASONABLE TRANSITION PERIOD
The proposed policy allows up to 10 additional days of services when continued-stay criteria are no longer met. However, a less intensive level of care is not immediately available, objectives are being achieved, and a step-down is occurring, or discharge services are being coordinated but are unavailable.
CASP supports the concept of transition services. However, 10 days may not provide sufficient time to safely and effectively transition a beneficiary from an intensive ABA service when another appropriate service, provider, or level of care is not immediately available. CASP recommends that DMAS consider a longer transition period, such as 30 days, when clinically necessary and when the provider documents active efforts to coordinate an appropriate transition. A reasonable transition period can protect continuity of care and avoid abrupt termination of services solely because another appropriate service has not yet become available.
The proposed policy continues to reference legacy Category III ABA codes, including 0362T and 0373T, as well as older code descriptions. CASP recommends that DMAS update the policy to reflect the current CPT code set applicable to ABA services and remove obsolete code references. CASP recommends that DMAS:
update all ABA CPT codes and descriptors to the applicable 2027 CPT code set;
remove obsolete 0362T and 0373T references where those codes will be replaced;
ensure that all references to adaptive behavior treatment and analysis correspond to the correct 2027 CPT code;
ensure that billing provisions accurately distinguish QHP services from technician-delivered services;
review the provisions governing team-based services and multiple staff; and
ensure that the CPT table and narrative provisions are internally consistent.
DMAS should ensure that the final manual uses the current published code descriptors and does not create Medicaid-specific descriptions that conflict with the CPT code set.
The proposed policy requires detailed schedules for requests exceeding 20 hours per week, including a description of each activity and its therapeutic function. CASP supports documentation of how requested hours will be used. However, the policy should not be interpreted as requiring providers to predetermine the exact therapeutic activity that will occur during every discrete period of a treatment day.
ABA treatment necessarily involves clinical decision-making based on the beneficiary’s response to intervention. A session may appropriately change based on engagement, skill acquisition, the emergence of challenging behavior, generalization opportunities, or other clinical circumstances. CASP recommends that DMAS require a general individualized schedule describing the distribution and therapeutic purpose of services while preserving clinical flexibility to modify specific activities during treatment.
The proposed policy identifies specific diagnostic tools, including the ADI-R, ADOS, and CARS. CASP recommends that references to specific diagnostic instruments use the phrase:
“including, but not limited to”
This language recognizes that qualified diagnostic professionals may appropriately use other validated diagnostic instruments or combinations of assessment methods based on the individual beneficiary. CASP recommends applying this terminology consistently throughout the policy wherever examples of diagnostic or assessment tools are provided. The policy should also recognize the importance of the diagnosing professional’s training, expertise, clinical experience, and knowledge of the beneficiary when evaluating diagnostic documentation.
IN CONCLUSION
CASP appreciates DMAS’s efforts to clarify the requirements governing ABA services and supports the Department’s goal of ensuring that services are medically necessary, appropriately documented, clinically effective, and delivered in accordance with generally accepted standards of care.
CASP recommends that DMAS revise the proposed language to ensure that:
The 20-hour provision is treated as a utilization-management threshold rather than a categorical benefit limitation;
Services exceeding 20 hours remain available through individualized EPSDT review;
Treatment intensity is determined by individualized clinical and functional needs;
School-based services are available when clinically appropriate and medically necessary;
Caregiver participation requirements recognize reasonable barriers and provider efforts;
Care coordination requires documented reasonable efforts rather than successful cooperation by other providers;
Direction and supervision activities are clearly defined
Beneficiaries are provided adequate time for safe transitions between levels of care;
Break-in-care provisions recognize extenuating circumstances;
The ABA provisions are updated to reflect the 2027 CPT code set;
Scheduling requirements preserve necessary clinical flexibility; and
Diagnostic and assessment tools are identified as examples rather than exclusive requirements.
CASP appreciates the opportunity to provide these comments and welcomes continued engagement with DMAS as the Department finalizes the revisions to Appendix D. We also thank DMAS for its continued efforts to align the Mental Health Services Manual, Appendix D, Applied Behavior Analysis services with generally accepted standards of care, established documentation and billing standards, and appropriate utilization management and program integrity guardrails that preserve access to this medically necessary, life-changing service.
Respectfully submitted,
Mariel C. Fernandez, MS, BCBA, LBA (TX)
Vice President of Government Affairs
Phone: (334) 332-2504
Email: mfernandez@casproviders.org