I am a Board Certified Behavior Analyst and Licensed Behavior Analyst with 3.5 years of experience. I oversee ABA for 13 children with autism in Fredericksburg, Suffollk, Roanoke, Narrows Virginia most of them covered by Medicaid. I support DMAS’s goals of accountability and strong documentation. But several provisions in the proposed Appendix D would delay or reduce medically necessary care for the children I serve.

20-hour threshold (p. 28). The draft says services “may not exceed 20 hours per week, except as authorized under EPSDT review.” It is imperative that these recommendations be based on the recommendations of the assessor and individualized to the child.  CMS’s 2026 ABA Toolkit says states may not apply hard limits to services for children covered by EPSDT. A three-year-old on my caseload needed 25 hours a week of direct service (97153) to address physical aggression, elopement; and severe deficits in communication which places the child at risk. These hours are utilized to address each of these high need, high risk areas.   I ask DMAS to state that 20 hours triggers a review, not a cap. I also ask that only the child’s face-to-face treatment time count (97153), so supervision overlap, parent training and assessment don’t use up a child’s hours.

EPSDT review (p. 31). The draft promises an EPSDT review before any denial but doesn’t say who reviews or how fast. I would request that the reviews be completed in a timely manner (within 7 business days) and be completed by a BCBA who is qualified to evaluate the treatment plan from the scope of Applied Behavior Analysis. It is also imperative that during this review process the child's services are not affected. Continued collaboration with the assessing BCBA should continue to ensure that all necessary avenues to ensure client care are achieved

In-person diagnostic evaluations (p. 28). The draft requires evaluations to be done in person, with no exceptions. Families that I have recently evaluated have reported signficant wait times exceed 3-5 months due to availability of in-person assessors. Additionally, there are individuals in rural areas who are more than 30-40 miles from the closest assessor.  That wait comes out of the years when intervention matters most. I ask DMAS to keep in-person as the norm but allow telehealth when no in-person appointment is available within a reasonable time or distance. DMAS should also accept evaluations children already have.

Provisional diagnosis (pp. 24, 29). I support letting children 5 and under start ABA on a provisional diagnosis. A four year old child that I worked with made progress in communication, social skills, and behavior reduction which allowed him to be more prepared for the transition to Kindergarten. I ask DMAS to let nurse practitioners and physician assistants give a provisional diagnosis, as DMAS’s own State Plan amendment allows. Children over 5 who are on a waitlist should also have a path to services through EPSDT review.

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. Parent training is imperative and absolutely crucial but this new guideline does not account for families with multiple children, who work shifts that are inflexible. I have several parents on my caseload who complete parent training after 8PM at night or will miss 1-2 weeks due to cycling illnesses through the home. While these direct 1:1 meetings may be hard to achieve at times, open communication via check-ins, observations of session, and telehealth ensure continued involvement in their child's plan of care. I ask DMAS to allow for extenuating circumstances. Discharge should come only after documented efforts to engage, the standard this appendix already uses for other youth services (MST and FFT).

ABA works best when intensity matches each child’s needs and families can count on continuity. I ask DMAS to keep the accountability in this revision while making these changes, so children don’t lose medically necessary care to caps, delays or paperwork. Thank you for considering my comments.