RCG Behavioral Health Network appreciates DMAS’s efforts to clarify ABA medical-necessity and authorization requirements. We particularly support the proposed language requiring EPSDT review before the denial of services for a Medicaid member under age 21.

We are concerned, however, that the statement that ABA services “may not exceed 20 hours per week” could be interpreted by MCOs as a categorical benefit limit rather than an enhanced-review threshold. Treatment intensity should continue to be determined according to each youth’s individualized medical necessity. We recommend replacing this language with a requirement that requests exceeding 20 hours include enhanced clinical documentation and receive individualized EPSDT review.

DMAS should also clarify that EPSDT review is automatic before any adverse determination. Providers and families should not be required to initiate a separate EPSDT process after an initial denial, and an MCO should not reduce a request to 20 hours without first evaluating the complete clinical record and issuing an individualized medical-necessity determination.

RCG supports appropriate diagnostic evaluation, but access to qualified ASD diagnosticians remains limited in many areas of Virginia. Continued ABA services should not be denied or interrupted solely because a child remains on a diagnostic waitlist or because an external evaluator has not supplied appointment documentation, credential information, or a Type 1 NPI. When the provider documents continued medical necessity, clinical benefit, and reasonable efforts to obtain an evaluation, treatment should continue while that evaluation is pending.

We further recommend clarifying that ADI-R, ADOS, and CARS are examples rather than an exclusive list of acceptable instruments; permitting other validated evaluation methods, including clinically appropriate telehealth or hybrid evaluations; and allowing reasonable alternative documentation when information must be obtained from an independent evaluator.

Finally, we request adequate implementation protections. Existing authorizations should remain effective through their approved periods, the requirements should apply prospectively without retroactive recoupment, and providers and MCOs should receive standardized instructions and at least 90 to 180 days to implement the final requirements.

These revisions would preserve DMAS’s program-integrity objectives while reducing unnecessary treatment delays and ensuring that authorization decisions remain individualized, clinically driven, and consistent with EPSDT.

Behavioral Therapy Solutions, LLC appreciates the opportunity to comment on the proposed changes to Virginia Medicaid's Applied Behavior Analysis (ABA) requirements. As a clinician-owned provider of ABA and behavioral health services, we have several concerns about how these changes may affect access to care and how they will be implemented by the MCOs.

Our biggest concern is limiting ABA to youth with an Autism Spectrum Disorder (ASD) diagnosis, or a provisional ASD diagnosis for children age five and under.

ABA does not equal autism, nor is ABA an autism-only intervention. ABA is a treatment methodology used to address behavior, communication, adaptive functioning, skill development, independence, and other areas of functional impairment.

There is published research supporting behavioral and behavior-analytic interventions outside of ASD. This includes children and individuals with intellectual disability, Down syndrome, ADHD, developmental disabilities, and disruptive behavior disorders. For example, a 2021 systematic review of behavior-analytic interventions for young children with intellectual disability without ASD identified 49 studies and found established interventions for communication, adaptive, and pre-academic skills. A 2021 systematic review and meta-analysis of ABA interventions for individuals with Down syndrome identified 125 studies and reported positive effects across areas including communication and challenging behavior. Behavioral interventions also have a significant evidence base for ADHD and disruptive behavior disorders.

This does not mean every child with ADHD, Down syndrome, intellectual disability, developmental delay, ODD, or another diagnosis needs ABA. The issue is that diagnosis alone should not automatically exclude a child when an individualized assessment shows that ABA is medically necessary and appropriate for the child's functional needs.

This is especially concerning when looking at DMAS's own functional criteria. A youth must meet at least two criteria that include limited functional communication or language impairment; severe impairment in social interaction, social reasoning, reciprocity, or interpersonal relatedness; frequent intense behavioral outbursts involving self-injury or aggression; disruptive repetitive or ritualized behaviors; or difficulty with sensory integration. These needs are not exclusive to ASD.

A child with Down syndrome or intellectual disability may have limited functional communication and severe aggression. A child with developmental delay may have significant communication and adaptive deficits, self-injury, or other challenging behavior. A child with ADHD and a disruptive behavior disorder may have significant behavioral dysregulation and aggression across settings.

It is possible for two children to have very similar functional needs, but under the proposed criteria one could receive ABA because they have ASD while the other could be excluded because they have a different diagnosis.

We also worry about the unintended incentive this creates. Families should not feel that they need to pursue an ASD diagnosis simply because it is the only diagnosis that opens the door to ABA. Diagnosis should reflect the child's actual clinical presentation, and treatment should follow from the child's needs.

This is also a significant change from previous DMAS policy. The October 2023 ABA Medical Necessity Criteria required a current DSM psychiatric diagnosis or provisional psychiatric diagnosis rather than ASD specifically. The May 2024 Mental Health Services Manual similarly allowed a primary ICD diagnosis corresponding to a DSM diagnosis while separately requiring the youth to meet functional criteria.

We recognize that the ASD requirement originates in Item 291.WW.2 of the 2026 Appropriation Act rather than solely through DMAS policy. However, Item 291.WW.3 of that same Act specifically directs the ABA Benefit Utilization Workgroup to evaluate the appropriateness of ABA for children with diagnoses other than ASD. We therefore encourage DMAS to preserve all available EPSDT protections, collect and report data regarding the impact of the diagnostic restriction, and use the findings of the legislatively mandated workgroup to inform future recommendations to the General Assembly regarding eligibility for non-ASD youth. 

CMS has repeatedly emphasized the importance of EPSDT for Medicaid members under age 21. CMS's February 2026 Children's Behavioral Health and EPSDT Toolkit also discusses providing medically necessary behavioral health services without requiring a formal behavioral health diagnosis in appropriate circumstances.

We would appreciate specific clarification from DMAS on this question: If a Medicaid member under age 21 does not have ASD, but an appropriate clinician determines that ABA is medically necessary to correct or ameliorate the child's condition, can ABA be requested through EPSDT? If so, what is that process?

We also request clarification regarding the statement: “Services are authorized based on medical necessity and may not exceed 20 hours per week, except as authorized under EPSDT review.”

Does the 20-hour limit mean 20 hours of direct treatment under CPT 97153, or does it mean 20 total hours across all ABA CPT codes?

If a child clinically requires 20 hours of direct treatment per week in addition to BCBA protocol modification/clinical oversight and caregiver training, are those BCBA and caregiver services counted against the same 20 hours? If so, providing necessary clinical oversight or caregiver training would effectively reduce the child's direct treatment hours.

We recommend that DMAS clearly state whether the 20-hour limit applies to 97153 or to total ABA services and use the same interpretation across all MCOs. Without clear language from DMAS, there is significant potential for MCOs to interpret this differently. One MCO may consider the limit to apply to direct treatment while another may combine all ABA CPT codes. That could result in children receiving different benefits based simply on which MCO administers their Medicaid coverage.

The wording also appears different from prior DMAS policy. The July 2025 Mental Health Services Manual stated that requests exceeding 20 hours (80 units) per week required additional documentation regarding the schedule and therapeutic function of the requested hours. Twenty hours therefore triggered additional review rather than serving as an absolute limit.

We would appreciate clarification as to whether DMAS intends the new language to change that policy. The phrase “except as authorized under EPSDT review” also needs a clear process. Providers and families should know how to request more than 20 hours when medically necessary and should not have to first receive a denial or reduction from an MCO before learning how to request an EPSDT review.

We also have concerns about requiring a “comprehensive diagnostic evaluation conducted in-person.” A comprehensive diagnostic evaluation may include direct observation and clinical interview, but it can also include caregiver interviews, developmental history, review of school and medical records, standardized measures, collateral information, scoring and interpretation, differential diagnosis, diagnostic formulation, and preparation of the written report. There may certainly be circumstances where direct observation or other components should occur in person. However, record review, scoring, collateral consultation, diagnostic formulation, and report writing do not inherently require the child to be physically present.

We recommend that DMAS identify which portion of the evaluation must occur in person and allow qualified clinicians to use telehealth for portions that can appropriately be completed remotely within their scope of practice and clinical judgment.

We are particularly concerned about the impact on rural and underserved areas.

Families already experience waitlists for developmental and behavioral health evaluations. An in-person-only requirement further limits the pool of available clinicians and may require families to travel significant distances. Transportation may also be particularly difficult for families whose children have significant behavioral, sensory, developmental, or medical needs. This becomes an even greater concern when the evaluation is a required gateway to treatment.

A child could have severe aggression, self-injury, communication impairment, and significant functional needs but be unable to begin ABA because the family cannot find a Medicaid provider who can complete the required in-person diagnostic evaluation within a reasonable time or distance. We ask DMAS to consider provider availability and geographic access before implementing this requirement and to consider exceptions or alternatives when an appropriate in-person diagnostic provider is not reasonably available.

We also request clarification regarding reimbursement for the comprehensive diagnostic evaluation. Virginia Medicaid covers CPT 90791, Psychiatric Diagnostic Evaluation, and qualified LMHPs, including LCSWs acting within their scope of practice, can provide diagnostic assessment services.

However, a comprehensive diagnostic evaluation and written report can involve considerably more work than the clinical interview itself. Depending on the case, this may include hours of record review, standardized assessment scoring and interpretation, collateral review, differential diagnosis, integration of information, diagnostic formulation, and report writing.

If DMAS is going to require a comprehensive diagnostic evaluation as a condition of receiving ABA, how is the clinician reimbursed for completing all of the required components? Is DMAS expecting CPT 90791 to cover the face-to-face diagnostic evaluation as well as the additional time required for record review, scoring, interpretation, diagnostic formulation, and preparation of the comprehensive written report?

If not, what CPT codes or other reimbursement mechanisms should an LCSW or other qualified LMHP use for this work?

This needs clarification because reimbursement directly affects access. If clinicians are required to complete several hours of additional professional work without a way to bill for that work, fewer clinicians may be able or willing to provide comprehensive Medicaid diagnostic evaluations. When combined with the in-person requirement, this could create an additional bottleneck for families before they even reach the ABA authorization process.

In summary, we respectfully ask DMAS to consider:

1. Whether an individualized medical necessity or EPSDT pathway can remain available for youth without ASD when ABA is clinically appropriate;
2. How EPSDT applies when a non-ASD youth under 21 needs ABA to correct or ameliorate a condition;
3. Whether the 20-hour limit applies only to CPT 97153 or to all ABA CPT codes combined;
4. Providing one consistent interpretation of that limit for all Medicaid MCOs;
5. Clearly explaining the EPSDT process for requests exceeding 20 hours;
6. Defining what DMAS means by a “comprehensive diagnostic evaluation” and what portion must occur in person;
7. Allowing telehealth for portions of an evaluation that can appropriately be completed remotely;
8. Considering the impact of the in-person requirement on rural families and areas with diagnostic waitlists; and
9. Clarifying how LCSWs and other qualified LMHPs will be reimbursed for the time required to complete the comprehensive diagnostic evaluation and written report.

We appreciate DMAS considering feedback from providers and families before these changes are finalized. We support appropriate medical necessity standards and utilization review. At the same time, we hope the final policy allows enough flexibility to recognize that children with similar functional needs may have different diagnoses and that access to treatment should not unnecessarily depend on geography, MCO interpretation, or the availability of an in-person diagnostic provider. 

Thank you for the opportunity to comment on the proposed Applied Behavior Analysis changes within Appendix D of Virginia’s Medicaid program. I recognize that the purpose of the changes is to balance the cost of publicly-funded healthcare in Virginia, and focus services on prevention and away from crisis-management overall.

As the redesign is so broad, I am focusing my comment on ABA specifically. My biggest concern with the proposed changes surrounds the following:

• The diagnostic restriction of Autism for ABA services,
• The provisional diagnostic restriction for Virginians age 5 and under
• The requirements for assessment related to the diagnostic restriction

The diagnostic restriction of Autism/Provisional diagnosis of Autism to qualify for ABA services is based on and perpetuates the false belief that ABA and Autism are synonymous. The research indicates that ABA can be, and is, used effectively across diagnoses, and is not diagnosis-specific. At one point, ABA didn’t have codes to bill for services and everything was done through single-case agreements and private pay. Admittedly, we’ve done an excellent job in the field of behavior analysis of marketing our effectiveness with the Autistic population, but the reality is that the things that make ABA effective in supporting individuals with Autism, work for all people who could benefit from ABA, regardless of diagnosis. ABA is used effectively for ADHD, OCD, PTSD, Traumatic Brain Injury, Dementia, and a litany of other diagnoses. ABA is individualized, irrespective to diagnosis, as it focuses on the environment rather than the individual. ABA works from the “outside in” versus the “inside out” as with cognitive therapies, so it cannot be replicated with other Medicaid-funded home-based programs offered. My concern with this restriction is that individuals who need ABA will either be disqualified from ABA services, or provided less-effective services, leading to, best-case scenario, lengthened treatment time due to slower progress, and ultimately an increased cost.

For example, let’s take a hypothetical Virginian that I’ll call “Virginia.” Virginia is 8 years old and has diagnoses of Reactive Attachment Disorder, Sensory Processing Disorder, ADHD, and ODD. Virginia lives with foster parents in a rural area. She’s often overwhelmed by her environment, which, combined with her attachment history, makes attempts to teach Virginia self-regulation skills difficult. Virginia's team has recommended ABA services, as Intensive-In-Home nor outpatient were effective for her. There are few opportunities where she is regulated enough to instruct her, and it takes longer to develop rapport with her due to her attachment history. Virginia also struggles with ADHD symptoms, and exhibits hyperactive motor and verbal activity, which is exhausting for her caregivers, who already struggle to bond with her. Under the proposed changes, she isn’t able to qualify for ABA services because she doesn’t have an Autism Diagnosis, despite satisfying the other MNC with regards to having limited functional communication, severe social impairments, frequent intense behavioral outbursts, and sensory integration challenges.

With the new changes, Virginia’s guardian has two options:

1. Apply for EPSDT services (Virginia is on a waitlist for a comprehensive evaluation 6 months from now)
2. Apply for alternative home-based therapeutic services again, such as FFT

If Virginia goes with the first option, (her auth was approved for 8 hours, due to not being diagnosed with Autism), or the second option, due to the slower pace and less effective treatment, Virginia’s behavior becomes too much for her caregivers, and she changes foster placements. Now the process of obtaining services begins again, as she’s located in a different county, and Virginia is outside the service area of the private provider that was initially selected. If Virginia is approved for EPSDT, but for fewer hours, it impacts her ability to build rapport with her caregivers, and her foster family doesn’t feel like the service is effective; they begin cancelling sessions, which results in no progress being made and Virginia discharged. Now Virginia bounces around between foster placements for several years until her behavior is much less adaptive, her hyperactivity is worse, and she has collected a new PTSD diagnosis. Virginia, now 13, requires a residential placement and crisis services, has few community connections, and when she ages out of foster care when she is 18, statistically with her high ACE score, will either end up involved in the Department of Corrections, in and out of a substance use disorder program, unhoused, and/or requiring more intensive public assistance (housing, Food Stamps, etc.) which all ends up costing hundreds of thousands of dollars or more across her lifespan. It could be argued that if Virginia has a child and the pattern continues, then we’re looking at millions of dollars (and unnecessary trauma) just for Virginia and her child(ren) alone.

In this example, Virginia is one person it could be argued got a tough start in life, or fell through the cracks. If Virginia’s story is the same as just 25 people out of the 8.8 million in our state, however, we have just increased our spending by millions of dollars because we went with the option that cost less in the short term by limiting services to a population who would most greatly benefit from them.

My last concern regards the ABA assessment requirements. There are 2 parts to this: the first is the “in person” requirement for assessments, and the second is the extensive nature and follow up of a comprehensive diagnostic evaluation.

The “in-person” requirement limits assessments and unfairly biases against families who live in rural communities, speak English as a second language, have no/unreliable transportation, or who are unhoused. There are also portions of comprehensive assessments that include diagnostic inventories, scales, interviews, and other data collection by multiple sources, in order to consider a diagnosis. Not all of this has to be in-person. At times, it is beneficial for certain individuals to be observed remotely, so that the member is not as impacted by the presence of the diagnostician. This subject-bias can be avoided by offering telehealth as an alternative to face-to-face if the clinician can provide a rationale, at their clinical discretion. Additionally, a “comprehensive assessment” is comprehensive by nature. The tools listed (ADI-R, ADOS, CARS) are all multi-hour assessments, between the assessment itself, the review of data, and the write up necessary to diagnose. Due to the extensive nature of these assessments and the time commitment, waitlists for comprehensive assessments are often months to years long. What happens when Virginians with provisional diagnoses, diagnoses that are complex or not straight-forward, such as those with extensive trauma histories or medically co-occurring diagnoses, or who live in high-needs areas, are unable to get a comprehensive evaluation by the 12 month deadline? This could result in MCOs having room to authorize a less appropriate dosage of services, or families opting to disengage from services completely, resulting in more restrictive, emergency care later. Culturally, some families do not want to get a comprehensive assessment that would carry a label, resulting in being ostracized from their community and support network, instead of a screening tool plus meeting MNC, or a non-diagnostic specific assessment tool.

I urge DMAS to remove the diagnostic requirement limitation for ABA Therapy, or add clarity to the language for the process of applying for EPSDT services for those who do not meet the diagnostic requirements for both initial and continuing stays that reflects the current criteria that if the member needs the service, they can obtain it through documentation of the need, and the authorization is commensurate with the level of impact of the symptoms documented in the MNC. This failsafe is a must to prevent Virginian youth from falling through the cracks, resulting in exponentially increased costs associated with their care. Removing the “in person” criteria, or modifying it to allow for clinical judgement of the LMHP, and/or alternatives to the comprehensive evaluation requirement would remove the unnecessary burden, cost, service disruption, time, and cultural bias that would exist if the language remains as-is.

Thank you for taking the time to read my comment.

Thank you for sending these proposed changes out for public comments. I am a BCBA in the area of applied behavior analysis and would like to provide comments on how these proposed changes will directly impact some of my current clients.

I want to start by first commenting about the new diagnosis criteria for Autism Spectrum Disorder (F84.0) that is now required for services. The manual now states, "A comprehensive diagnostic evaluation conducted in-person confirming the diagnosis of ASD by a LMHP acting within their scope of practice that includes an evidenced based diagnostic tool such as one of the following: i. Autism Diagnostic Review (ADI-R) ii. Autism Diagnostic Observation Schedule (ADOS) iii. Childhood Autism Rating Scale (CARS). Documentation shall include the name, credential and Type 1 NPI of the evaluator " The points of concern for this statement includes 1) that the assessment needs to be completed in person, 2) that the paperwork requires the NPI number listed, and 3) it lists specific diagnostic tests. 1) The wait lists for an autism diagnosis can be multiple years long depending on the area or if there is not a diagnosing provider in a particular area. Some families seek a diagnosis from a telehealth provider to remediate these barriers. The current wording in the document would prevent those families from receiving services, even if the client has a diagnosis. 2) some diagnosing providers do not provide their NPI number on the diagnostic paperwork. The ABA provider can search the diagnosing provider's NPI number to add to the ISP as an alternative to it being required on the diagnostic paperwork. 3) The specific diagnostic evaluations listed are a great starting off point, however it is not an exhaustive list of evidence based diagnostic assessments. The document should clarify the list provided includes examples and are not the only three accepted evidence based assessments. 

These changes to the wording need to be completed or some families who have children with a diagnosis will have to seek a second diagnosis because their current diagnosis does not meet the listed criteria. That will increase waitlists and potentially cause families to have to travel significant distances if they are in a rural area.

Due to the change in diagnostic criteria required for ABA services, I recommend the initial and continued stay Medicaid form be edited to have boxes to easily provide information about the client's diagnosis or information about the waitlists the client is on. 

I want to continue by commenting on the schedule requirements listed on page 32 for authorizations over 20 hours. I am seeking clarification on if this is 20 cumulative hours or 20 hours of 97153 services. 

In conclusion, I recommend the comments be reviewed after the document is closed for commenting, changes be made to the manual/initial and continued stay forms, then the updates be posted on the DMAS website with an effective date 60-90 in advance. This will give families time to contact their diagnosing providers to get updated paperwork or potentially get on another waitlist. Implementing these changes so quickly without providing adequate notification times will cause undo stress to the families currently receiving services and diagnosing providers, both of which are already overwhelmed without having to scramble to make these changes. I hope you take this comment into consideration and make changes accordingly. 

Dear DMAS Representatives,

I am writing as the mother of a four-year-old son with Level 3 autism to express my serious concerns regarding the proposed changes to Virginia Medicaid's Applied Behavior Analysis (ABA) services.

My son, Niko, is nonverbal and requires substantial support in nearly every aspect of his daily life. He struggles with communication, following basic instructions, emotional and behavioral regulation, and understanding danger. He also has a history of elopement, which presents significant safety concerns.

For children like my son, ABA therapy is not simply an optional service or an extracurricular activity. It is a medically necessary intervention that helps them develop essential life skills, improve communication, and work toward greater independence.

My first concern is the proposed 20-hour weekly limit on ABA services. I understand that additional hours may be approved based on medical necessity, but requiring families and providers to navigate additional approval processes creates unnecessary barriers to treatment.

A child's disability does not become less significant after 20 hours of therapy. Children with Level 3 autism often require intensive, consistent intervention, and their needs should be determined by qualified professionals who work directly with them, not by a generalized weekly limit.

Even temporary disruptions in therapy can interfere with consistency, progress, and the development of critical skills. Families should not have to repeatedly fight to maintain treatment that their child's medical team has already determined is necessary.

My second concern is the mandatory weekly caregiver participation requirement. As a parent, I absolutely recognize the importance of being involved in my child's treatment. However, there is a difference between encouraging meaningful parental involvement and imposing rigid requirements that fail to consider individual family circumstances.

Many parents are balancing full-time employment, other children, medical appointments, and the demands of raising a child with significant disabilities. Parents should not have to choose between maintaining employment, meeting their family's basic needs, and ensuring their child continues receiving therapy.

Caregiver participation should be individualized, flexible, and designed to support families rather than create another obstacle to their child's care.

My third concern is the proposed discharge requirement following a break in services exceeding 31 days. This is particularly troubling because interruptions in therapy are not always within a family's control.

Children can experience serious illnesses, hospitalizations, family emergencies, or other circumstances that temporarily prevent them from attending therapy. Requiring families to restart the diagnostic, assessment, and authorization process after such interruptions could create substantial delays in resuming medically necessary services.

My son's autism does not disappear because he misses therapy for a month. His diagnosis, challenges, and need for support remain. It makes little sense to place additional administrative burdens on families simply because circumstances beyond their control temporarily interrupted treatment.

I also want to emphasize the emotional and practical realities of raising a child with significant developmental disabilities. We spend our days advocating, attending appointments, coordinating services, addressing behavioral challenges, and worrying about our children's futures.

We are doing everything we can to give our children the best possible opportunity to succeed in a world that is already difficult for them to navigate.

These children deserve individualized care based on their actual needs, not policies that prioritize administrative convenience over access to treatment.

I respectfully urge DMAS to reconsider these proposed requirements, preserve access to medically necessary ABA hours, allow flexibility in caregiver participation, and establish reasonable exceptions for unavoidable interruptions in care.

I understand the importance of responsible Medicaid spending and appropriate oversight. However, those goals should never come at the expense of vulnerable children who depend on these services.

My son cannot speak for himself, so I will continue to advocate for him. I ask that you listen to the families raising these children and consider the real-life consequences these changes could have.

Thank you for your time and consideration.

Sincerely,

A Concerned Virginia Parent

I am writing as the mother of a three-year-old son diagnosed with Level 3 Autism Spectrum Disorder who is nonverbal and requires substantial support in his daily life. I am deeply concerned about the proposed changes to Virginia’s Applied Behavior Analysis (ABA) services, particularly the 20-hour weekly baseline, mandatory weekly caregiver participation requirements, and the proposed 31-day break-in-care discharge policy.

I strongly urge DMAS to reconsider these proposals and fully evaluate the potentially devastating consequences for children with significant developmental disabilities and the families responsible for their care.

1. Service Intensity: Why Individualized ABA Therapy Hours Are Essential

My son has Level 3 autism, the most significant support classification within the autism spectrum. His challenges are not minor developmental delays that can simply be addressed through occasional intervention. His disability affects his ability to communicate, develop independence, navigate his environment, and acquire essential daily living skills.

For children like my son, ABA therapy is not an extracurricular activity, a convenience, or a luxury. When medically necessary and appropriately individualized, it is a critical intervention that supports communication, functional development, safety, and quality of life.

The proposed 20-hour weekly baseline is particularly concerning because it risks placing an administrative threshold ahead of individualized clinical judgment.

A child’s medical necessity should determine the intensity of treatment, not a predetermined number of hours established for administrative purposes.

Although the proposal reportedly allows exceptions through EPSDT review, requiring families and providers to navigate additional approval processes may create unnecessary delays and interruptions in care.

Children with significant disabilities should not have to overcome additional administrative barriers to receive services their qualified treatment professionals have already determined are medically necessary.

I strongly urge DMAS to preserve individualized treatment planning and ensure that children with substantial support needs are not disadvantaged by arbitrary service thresholds.

2. Potential Impacts: Caregiver Requirements and the 31-Day Discharge Policy

I recognize the importance of caregiver participation in a child’s therapeutic progress. As a mother, I understand that consistency between the home and therapy environment can be beneficial.

However, there is a significant difference between encouraging meaningful parental involvement and imposing inflexible requirements that could jeopardize a child’s access to treatment.

Parents of children with significant disabilities already carry extraordinary responsibilities. We manage medical appointments, educational planning, therapy schedules, behavioral challenges, communication barriers, employment obligations, and the needs of other family members.

For families raising multiple children, maintaining employment, or navigating medical emergencies, rigid weekly participation requirements can become punitive rather than supportive.

A parent’s inability to attend a particular weekly session should never be interpreted as a lack of commitment to their child.

Caregiver participation should be collaborative, flexible, and responsive to each family’s circumstances. Parents should be supported in participating meaningfully, not placed in situations where unavoidable conflicts threaten their child’s treatment.

I am even more concerned about the proposed 31-day break-in-care discharge policy.

The possibility that a child could be automatically discharged after a prolonged interruption in services, even when caused by illness, hospitalization, or a family emergency, is deeply troubling.

Children with profound developmental needs do not suddenly stop needing support because their family experiences an unexpected crisis.

Imagine a child who has spent months building trust with a therapist, learning to communicate basic needs, and developing essential daily living skills. A medical emergency interrupts treatment, and that child is subsequently required to restart the assessment and authorization process.

This is not continuity of care. It creates the possibility of unnecessary treatment gaps, disrupted therapeutic relationships, and regression in previously acquired skills.

Children should never be penalized for circumstances beyond their control, and families should never be forced to choose between managing a crisis and preserving their child’s access to medically necessary care.

I urge DMAS to eliminate automatic discharge provisions and instead establish reasonable, individualized procedures for maintaining or resuming services after unavoidable interruptions.

3. Progress and Results: The Importance of Early Intervention

As the mother of a nonverbal child with Level 3 autism, I understand how meaningful even the smallest developmental milestone can be.

For some families, progress may mean a child learning to request water, communicate discomfort, follow a safety instruction, tolerate a transition, or participate in a daily routine with greater independence.

These accomplishments may appear small to someone unfamiliar with severe developmental disabilities. For our children, however, they can represent extraordinary progress.

Early childhood is a critical period for developmental learning. Children with substantial support needs deserve timely access to appropriate interventions that help them develop functional communication, adaptive skills, and greater independence.

When medically necessary treatment is delayed, reduced, or interrupted, the consequences extend far beyond missed appointments. Families may experience increased caregiving demands, difficulty maintaining employment, and greater concern about their child’s long-term development and safety.

I refuse to accept a system in which children with the greatest needs face additional obstacles simply because their treatment requires more resources.

My son deserves the same opportunity to develop, learn, communicate, and experience a meaningful quality of life as any other child in Virginia. His disability should not diminish that opportunity.

I am writing to express my strong opposition to the proposed 20-hour-per-week cumulative cap on Applied Behavior Analysis (ABA) services across all billing codes. While I recognize the importance of responsible Medicaid spending, any policy governing ABA services must prioritize the individual’s medical necessity, clinical needs, developmental trajectory, and right to access medically necessary treatment.

ABA services must be individualized according to medical necessity, not restricted by an arbitrary, across-the-board limit. Individuals receiving ABA services have varying levels of functional impairment, communication abilities, adaptive skill deficits, behavioral needs, and learning profiles. A uniform 20-hour limit does not adequately account for these differences and risks preventing individuals with more significant needs from receiving the intensity of treatment necessary to make meaningful progress.

Early intervention is particularly important for young children with developmental delays and autism spectrum disorder. For some children, intensive, structured behavioral intervention provides critical opportunities to develop functional communication, social interaction, daily living skills, safety awareness, and greater independence during important developmental periods. Although treatment intensity should always be determined individually, evidence supports the use of higher-intensity intervention for some children based on their clinical presentation and treatment goals. Restricting services without an individualized clinical assessment could delay progress, limit skill acquisition, and reduce opportunities for children to develop foundational skills during critical periods of learning.

I am especially concerned that applying the 20-hour limit across all ABA billing codes collectively could further reduce access to direct treatment. ABA includes not only direct intervention but also essential clinical activities such as protocol modification, clinical oversight, caregiver guidance, and treatment planning. These services serve distinct and complementary purposes. When all services are counted toward a single weekly limit, necessary supervision and caregiver training may effectively reduce the number of hours available for direct treatment, potentially compromising treatment quality and effectiveness.

A policy that establishes 20 hours as a default ceiling, rather than a threshold for additional clinical review, risks placing administrative convenience above individualized treatment needs. Families and providers should not have to repeatedly overcome restrictive authorization barriers when a qualified clinician has documented why a particular level of care is medically necessary. Any review process must be timely, transparent, consistent across managed care organizations, and based on the individual’s clinical circumstances.

I respectfully urge DMAS to reconsider the proposed implementation and adopt the following safeguards:

1. Preserve individualized medical necessity determinations. Weekly ABA hours should be based on comprehensive assessment, functional needs, measurable treatment goals, developmental considerations, clinical progress, and the recommendations of qualified treating professionals.

2. Protect access to higher-intensity early intervention. Children whose documented clinical needs warrant more than 20 hours per week should retain access to the medically necessary level of care without arbitrary restrictions that interfere with timely treatment.

3. Clarify the treatment of individual billing codes. Direct treatment, clinical supervision, protocol modification, caregiver training, and other medically necessary ABA services should not be combined in a manner that inadvertently limits access to essential components of care.

4. Implement a clear and accessible EPSDT exception process. Requests exceeding 20 hours should receive individualized review based on documented medical necessity, with reasonable documentation requirements, timely decisions, and a transparent appeals process.

5. Evaluate the effects on children and families. Before implementing restrictive utilization policies, DMAS should assess the potential consequences for treatment continuity, developmental outcomes, family burden, access to care, and the possibility that inadequate treatment may contribute to greater needs and costs in the future.

6. Engage families, providers, and clinical experts. Policy decisions should incorporate input from those directly involved in delivering and receiving ABA services, as well as professionals with expertise in evidence-based behavioral intervention and early childhood development.

The goal of Medicaid policy should be to ensure that services are appropriate, effective, and medically necessary—not to impose a uniform number of hours that may be insufficient for some individuals and unnecessary for others. Responsible utilization management can be achieved through individualized assessments, clinical documentation, periodic review, and appropriate oversight without undermining access to essential care.

I strongly oppose a categorical 20-hour-per-week limit across all ABA billing codes when it functions as a barrier to individualized, medically necessary treatment. I urge DMAS to ensure that the final policy preserves meaningful access to the level and combination of ABA services everyone requires, particularly for children who need intensive early intervention to develop essential skills, improve functioning, and maximize their long-term independence.

I would like to take this opportunity to comment on the 20-hour cap on hours. This has the potential to have negative impacts on client care and I fear it sets a precedent to favor  administrative ease ahead of clinical judgment.

I strongly believe that clinically assessed medical necessity should determine the intensity of treatment, not a predetermined number of hours appplied to all clients. I am aware that this is not truly a cap on hours and that additional hours can be requested, however, that additional process of requesting often delays care to clients who need it most. 

I strongly urge DMAS to preserve individualized treatment planning based on medical necessity to ensure that client hours remain a clinical decision, not an adminstrative decision. 

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): 

1. 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.

2. 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.

3. 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.

4. 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.

FAMILY PARTICIPATION IS IMPORTANT, BUT THE POLICY SHOULD RECOGNIZE CLINICALLY AND PRACTICALLY REASONABLE BARRIERS

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.

CARE COORDINATION SHOULD REQUIRE DOCUMENTED EFFORTS, NOT SUCCESSFUL COOPERATION BY OTHER PROVIDERS

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.

CPT PROVISIONS SHOULD BE UPDATED TO REFLECT THE CURRENT AMA CPT CODE SET

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.

 SCHEDULING REQUIREMENTS SHOULD SUPPORT CLINICAL FLEXIBILITY

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.

DIAGNOSTIC TOOLS SHOULD BE IDENTIFIED AS EXAMPLES, NOT AN EXCLUSIVE LIST

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:

1. The 20-hour provision is treated as a utilization-management threshold rather than a categorical benefit limitation;

2. Services exceeding 20 hours remain available through individualized EPSDT review;

3. Treatment intensity is determined by individualized clinical and functional needs;

4. School-based services are available when clinically appropriate and medically necessary;

5. Caregiver participation requirements recognize reasonable barriers and provider efforts;

6. Care coordination requires documented reasonable efforts rather than successful cooperation by other providers;

7. Direction and supervision activities are clearly defined

8. Beneficiaries are provided adequate time for safe transitions between levels of care;

9. Break-in-care provisions recognize extenuating circumstances;

10. The ABA provisions are updated to reflect the 2027 CPT code set;

11. Scheduling requirements preserve necessary clinical flexibility; and

12. 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

A cap on service hours limits the availability to provide the level of care that is necessary for certain individuals. A comprehensive overall cap, limits the individualization of service provision resulting in decreased quality of life for specific individuals with greater levels of support needed. 

The Virginia Association for Behavior Analysis (VABA) appreciates the opportunity to comment on the draft revisions to Appendix D of the Mental Health Services Manual. VABA represents behavior analysts practicing across the Commonwealth, many of whom serve Medicaid members under the provisions at issue. We recognize that several revisions implement directives in Item 291.WW.2 of the Appropriation Act. Our comments are intended to help DMAS implement those directives in a manner that is clinically sound, consistent with federal requirements, and administrable by providers and managed care organizations (MCOs).

VABA respectfully requests that DMAS:

1. Establish a defined EPSDT pathway, with stated documentation standards, for youth who need behavior-analytic services but do not have an autism spectrum disorder (ASD) diagnosis, and reconcile the ASD requirement with the existing State Plan before the implementing amendment is finalized with CMS.
2. State the federal EPSDT standard in the manual, define how hours are counted, and confirm that 20 hours per week is a utilization-management threshold rather than a limit on medically necessary care.
3. Treat the utilization-management provisions as interim pending recommendations from the DMAS ABA Benefit Utilization Workgroup.
4. Revise several unchanged provisions whose effects change under the new requirements, and make the technical corrections listed in Appendix A of this Comment.

Behavior-Analytic Services Are Not Diagnosis-Specific

Item 291.WW.2 provides that "The department shall require a diagnosis of autism spectrum disorder prior to authorizing ABA services." VABA understands that this directive binds DMAS. We ask DMAS to implement it in a way that preserves access for youth whose needs fall outside it, because the Commonwealth's own law, State Plan, and manual recognize that behavior analysis is not limited to ASD. Three points support this.

First, the manual's service definition adopts the definition of behavior analysis in § 54.1-2900 of the Code of Virginia, which addresses "socially significant improvement in human behavior" and contains no diagnostic limitation.

Second, in SPA TN 24-0021, approved by CMS effective July 1, 2024, DMAS added licensed behavior analysts to the State Plan definition of "credentialed addiction treatment professional." The Commonwealth has thus represented to CMS that behavior analysts treat conditions other than ASD.

Third, Appendix D excludes Multisystemic Therapy and Functional Family Therapy for any youth whose functional impairment results solely from a developmental disability as defined in § 37.2-100. Before this revision, those youth could receive ABA under any primary DSM diagnosis. Under the draft, a youth with intellectual disability and severe self-injury has no Appendix D service available except through case-by-case EPSDT review.

The research literature supports behavior-analytic treatment for these populations. Examples include self-injury and other severe problem behavior among individuals with intellectual and developmental disabilities (Hanley et al., 2003; Kahng et al., 2002), pica (McAdam et al., 2004), pediatric feeding disorders (Sharp et al., 2010), and substance use disorders (Prendergast et al., 2006).

The draft states that EPSDT will review all ABA requests before denial, including requests for youth who do not meet diagnostic criteria. VABA supports this provision. However, the draft specifies documentation standards only for youth with a provisional diagnosis beyond 12 months and for requests exceeding 20 hours per week. VABA requests that DMAS add a third enumerated EPSDT pathway for youth without an ASD diagnosis, stating the minimum documentation required (for example, the current diagnosis, a functional assessment, and the treatment needs it identifies). Without a stated standard, each MCO will develop its own, and families will face inconsistent determinations for the same clinical presentation.

Item 291.WW.2 also authorizes DMAS to amend the State Plan to effect these changes. VABA encourages DMAS to reconcile the ASD requirement with SPA TN 24-0021 and with EPSDT obligations under 42 U.S.C. § 1396d(r)(5) before the implementing amendment is finalized with CMS. Addressing the inconsistency now will support federal approval and reduce the likelihood of later revision.

The 20-Hour Threshold and EPSDT Review

The draft provides that services "may not exceed 20 hours per week, except as authorized under EPSDT review," and that all ABA requests receive EPSDT review before denial. VABA supports this safeguard and requests the following clarifications so that it operates as intended.

State the EPSDT standard: The manual should state that services above 20 hours per week are authorized when they are necessary to correct or ameliorate the youth's condition, consistent with 42 U.S.C. § 1396d(r)(5), and that the number of hours requested is not by itself a basis for denial or reduction. This aligns with Item 291.WW.2, which states that the limit "can be exceeded based upon documented medical necessity."

Distinguish intensity from medical necessity: The final paragraph of the EPSDT section groups requests above 20 hours with requests for youth who "do not meet stated MNC." A youth who needs 30 hours per week may fully meet medical necessity criteria. VABA recommends revising that paragraph to treat the two categories separately.

Define how hours are counted: The draft does not specify what counts toward 20 hours. The billing section permits concurrent billing, including 97153 with 97155, two technicians each billing 97153, and youth services alongside family training delivered by separate staff. If the threshold sums units across codes, 20 hours of treatment that includes two hours of concurrent QHP direction would register as 22 hours and trigger EPSDT review. VABA recommends defining hours as face-to-face time with the youth, counted once regardless of how many staff bill, and excluding caregiver-only and non-face-to-face services. We also ask DMAS to specify whether the weekly measure is a calendar week or an average across the authorization period. An average accommodates planned intensity changes, such as summer schedules and tapering before discharge.

Make reviews transparent: Item 291.WW.2 directs DMAS to require MCO reporting that can be analyzed across MCOs, regions, and providers. VABA requests that notices denying or reducing requests above 20 hours state the EPSDT analysis applied, and that MCO reporting include the number and outcomes of EPSDT reviews for ABA. This gives DMAS the data to evaluate the threshold and gives providers and families a clear basis for appeal.

Address federal parity requirements: Medicaid MCOs are subject to mental health parity requirements under 42 CFR Part 438, Subpart K. A weekly hour threshold that can be exceeded on documented medical necessity functions as a nonquantitative treatment limitation. Under 42 CFR § 438.910(d), the processes, strategies, evidentiary standards, and other factors used to apply such a limitation to mental health benefits must be comparable to, and applied no more stringently than, those applied to medical/surgical benefits in the same classification. VABA asks DMAS to confirm that it has completed, or will complete, a comparative analysis before implementation, including how the threshold compares with any limits applied to physical, occupational, and speech therapy. If the threshold were applied as a fixed ceiling, it would instead be a quantitative treatment limitation subject to § 438.910(b). The clarifications above reduce that compliance risk for the Commonwealth.

Treatment Schedules

For requests above 20 hours per week, the draft requires an individualized schedule, a description of the interventions planned for each timeframe, and, in clinic settings, a distinction between therapeutic and recreational time. VABA supports documentation of how requested hours will be used and recommends two refinements.

First, the schedule should describe the distribution and therapeutic purpose of services across the week rather than fix the intervention for each time block. The manual's own service definition requires "consistent, ongoing, objective assessment and data analysis to inform clinical decision-making." Session content that changes in response to the youth's data is sound practice, not a departure from the authorized plan.

Second, the distinction between therapeutic and recreational time should rest on function, not format. Naturalistic and play-based procedures embed instruction in activities that resemble recreation, and some ISP objectives target leisure skills directly. VABA recommends defining an activity as therapeutic when it addresses ISP objectives and collects data on those objectives.

Diagnostic Documentation

The draft identifies diagnostic instruments (ADI-R, ADOS, and CARS) and screening instruments (RITA-T and STAT) introduced by "such as." In practice, MCO reviewers often treat illustrative lists as exhaustive. VABA recommends introducing each list with "including but not limited to" and adding "or another validated instrument." We also recommend that the manual direct reviewers to weigh the diagnosing professional's training, experience, and clinical judgment. An ASD diagnosis is a clinical determination informed by instruments, not a score on any single one.

Coordination With the ABA Benefit Utilization Workgroup

The EPSDT documentation requirements, schedule requirements, and hour-counting rules fall squarely within the DMAS ABA Benefit Utilization Workgroup's charge, which will continue meeting after this comment period closes. VABA requests that DMAS designate these provisions as interim and commit to revisiting them when the workgroup issues its recommendations.

Related Provisions

Several provisions were not revised but will operate differently under the new requirements.

Family participation: Weekly family involvement and discharge criterion 5 (family "refuses or is unable to participate meaningfully") are appropriate in principle. For youth receiving more than 20 hours per week, that criterion now also bears on EPSDT review. VABA recommends that providers not reduce or terminate services on this basis when they have documented a caregiver-participation plan, efforts to engage caregivers, adjustments to training methods or scheduling, and continued clinical benefit to the youth.

Care coordination: The manual requires documented coordination with the youth's primary care provider. Providers cannot compel another practitioner to respond or override a caregiver's consent decision. VABA recommends satisfying the requirement with documented good-faith efforts and any barriers encountered. 

Supervision: Supervising unlicensed personnel is a clinical activity that maintains treatment integrity and is required by Board of Medicine regulations (18VAC85-150), regardless of the technician's certification. VABA recommends that the manual describe it as clinical supervision and revise the heading "LMHP Oversight of Services" to include LBAs and LABAs, who perform most of this supervision.

2027 CPT code set: The AMA's 2027 code set, effective January 1, 2027, deletes 0362T and 0373T, adds new Category I adaptive behavior codes, and revises the descriptors for 97151 through 97158. The draft's code table, concurrent-billing combinations, and team-based provisions reference the current codes. VABA recommends updating the manual to the 2027 code set, with a crosswalk, before January 1, 2027, and applying the hour-counting definition requested above to the new codes.

Closing

VABA shares DMAS's interest in services that are medically necessary, well documented, and consistently administered across MCOs. We appreciate the Department's consideration of these comments and welcome the opportunity to discuss them.

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References

Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior: A review. Journal of Applied Behavior Analysis, 36(2), 147–185. https://doi.org/10.1901/jaba.2003.36-147

Kahng, S., Iwata, B. A., & Lewin, A. B. (2002). Behavioral treatment of self-injury, 1964 to 2000. American Journal on Mental Retardation, 107(3), 212–221. https://www.ncbi.nlm.nih.gov/books/NBK69354/

McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Napolitano, D. A. (2004). Behavioral interventions to reduce the pica of persons with developmental disabilities. Behavior Modification, 28(1), 45–72. https://doi.org/10.1177/0145445503259219

Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A meta-analysis. Addiction, 101(11), 1546–1560. https://doi.org/10.1111/j.1360-0443.2006.01581.x

Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13(4), 348–365. https://doi.org/10.1007/s10567-010-0079-7

Appendix A: Technical Corrections

The following corrections address drafting and citation issues in Appendix D's ABA section.

1. Admission Criteria, 2.a (p. 24): Only ICD-10 code F84.0 is named, and older diagnoses may be recorded under other F84 codes. Requested revision: Accept a documented ASD diagnosis recorded under any applicable F84 code.
2. Admission Criteria, 2.b (p. 24), and Initial Service Authorization, 2.b and 2.c (pp. 28-29): "Age 5 or under" and "37 months to 5 years old" can be read inconsistently. Requested revision: State age bands in months (e.g., 37 through 71 months).
3. Initial Service Authorization, 2.a (p. 24), and Additional Continued Stay Criteria, 1 (p. 31): "Autism Diagnostic Review (ADI-R)" is misnamed. Requested revision: "Autism Diagnostic Interview-Revised (ADI-R)."
4. Additional Continued Stay Criteria, 1 (p. 31): "Shall submit" reads as mandatory at every continued stay and conflicts with item 2. Requested revision: Begin with "When a comprehensive diagnostic evaluation has been completed."
5. Additional Continued Stay Criteria (pp. 30-31): No provision addresses a full evaluation that does not confirm ASD. Requested revision: Continue services under EPSDT review with a documented transition plan.
6. Required Activities (p. 23): The heading "LMHP Oversight of Services" omits LBAs and LABAs. Requested revision: "LBA, LABA, and LMHP Oversight of Services."
7. Discharge Criteria, 4 (p. 26): Failure to maintain gains is listed as grounds for discharge, although it typically indicates a need for maintenance programming. Requested revision: Apply this criterion only after implementing and documenting maintenance and generalization procedures.

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October 14, 2026

Virginia Department of Medical Assistance Services

Attention: Syreeta Stewart, Regulatory Coordinator

600 E. Broad St., Suite 1300

Richmond, VA 23219

Submitted via the Virginia Regulatory Town Hall (Forum ID 2982)

RE: Proposed Revisions to the Mental Health Services Manual, Appendix D – Applied Behavior Analysis (draft dated 9/21/26)

Dear DMAS Behavioral Health Team:

My name is Callie Plattner, and I am the Chief Clinical Officer of Mosaic Pediatric Therapy. I am a doctoral-level Board Certified Behavior Analyst (BCBA-D) and Licensed Psychological Associate, a two-time past President of the North Carolina Association for Behavior Analysis, and a subject matter expert for the Behavior Analyst Certification Board (BACB) and the Council of Autism Service Providers (CASP). Mosaic provides ABA therapy to children and families affected by autism in Virginia and North Carolina. In Virginia, we operate eight clinics in the Richmond region and Southwest Virginia, with a ninth opening by the end of the year, and employ over 300 staff members.

We pride ourselves on our relentless focus on maximizing client outcomes through quality service delivery. This is not easy work. Mosaic has invested for years in measuring, analyzing and modeling clinical outcomes for every child we serve. On average, our patients achieve clinical outcomes that are 40–60% better than the published ABA benchmarks.¹ And our patient/family net promoter score (NPS) of 82 places us in the top 3% of ABA providers nationally.²

We share DMAS's goals of medically necessary, individualized and well-documented ABA services, and we are unequivocally supportive of stronger program integrity. We especially welcome the commitment that every ABA request will be reviewed under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) criteria before a denial. Our central concern is the proposed 20-hour weekly limit, which we believe would restrict medically necessary care for the children who need it most. We address it first, followed by the diagnostic and provisional-diagnosis changes.

Summary of requested changes

1. The 20-hour weekly limit (p. 28)

What the draft changes

Today, the manual states that "services are authorized based on medical necessity," and requests over 20 hours per week require a structured schedule. The draft strikes the schedule requirement and adds a ceiling: services are authorized based on medical necessity "and may not exceed 20 hours per week, except as authorized under EPSDT review." Every request above 20 hours would move to a separate EPSDT process with added documentation, including a description of the interventions planned "for each timeframe."

This is a material change. The current standard asks whether more hours are medically necessary. The proposed standard presumes they are not.

A ceiling is inconsistent with EPSDT

Under EPSDT, children under 21 are entitled to medically necessary services to correct or ameliorate their conditions (42 U.S.C. § 1396d(r)(5)). The Centers for Medicare & Medicaid Services (CMS) issued its State Medicaid & Children's Health Insurance Program Applied Behavior Analysis Toolkit (the Toolkit) in August 2026 to guide state ABA coverage policy. It is explicit: "for EPSDT-eligible children, states must cover ASD-related interventions that are coverable under section 1905(a) when the services are medically necessary." It warns that utilization review relying "solely on singular factors such as diagnosis codes, age, or preset hourly thresholds, risks conflicting with EPSDT," and that thresholds "should not operate as absolute caps when additional medically necessary services are needed." A presumptive limit, with individualized review available only as an exception, is exactly what CMS cautions against.

In practice, a number written into the manual as a ceiling becomes the default. This is already happening: Virginia providers report that at least one managed care organization (MCO) issues at least partial denials on every request above 20 hours, using generic language rather than an individualized EPSDT review. Codifying a ceiling would make that the norm. Federal rules require MCOs to furnish services in an "amount, duration, and scope that is no less than" under fee-for-service Medicaid, including EPSDT for children (42 C.F.R. § 438.210(a)(2)). Denial notices must also state the reasons and give families access to the medical necessity criteria used (42 C.F.R. § 438.404(b)). Generic denials that skip individualized EPSDT review do not meet these standards, and a ceiling in the manual would invite more of them.

The limit falls hardest on the children with the greatest needs

Twenty hours sits below the range for comprehensive treatment. The current (third) edition of CASP's practice guidelines, as CASP presented to DMAS's ABA Utilization Workgroup on September 22, describes focused treatment as 10–25 hours and comprehensive treatment as 25–40 hours per week of direct treatment, set case by case rather than by a fixed number. Under the draft, every child who needs comprehensive treatment would require an exception.

This is not a cap on outliers. DMAS's own data, presented to the ABA Utilization Workgroup on September 22, show that in 2025 about 71% of children ages 0–4 and 53% of children ages 5–10 received 20 or more hours of ABA in a week. These two age groups make up roughly 90% of the children served. The draft would therefore require EPSDT review, and risk reductions, for most of the youngest children in the program, the age group in which intensity matters most. In Mosaic's experience, these children typically have significant deficits across communication, social and adaptive skills, and often self-injury, aggression or elopement. The Toolkit's own best practice is that providers "must consider the individual's age, ASD symptoms and severity, needs, tolerance, and response to treatment." A fixed limit considers none of these.

The research supports individualized intensity, not a uniform ceiling. The most recent individual participant data meta-analysis, pooling 15 controlled studies of children ages 2 to 6, found that children receiving 26 to 40 hours per week gained an average of 22.4 IQ points, roughly double the 11.1-point gain of children in low-intensity programs, with parallel gains in adaptive behavior and autism severity (Eldevik et al., 2026). For children under 7, Granpeesheh et al. (2009) found no point of diminishing returns up to roughly 40 hours per week. The Toolkit also notes studies that found no association, most prominently Sandbank et al. (2024), but a reanalysis of that same dataset found significant, clinically meaningful dose effects once pre-intervention IQ was controlled (Frazier et al., 2025). The Toolkit concludes that "there is no consensus on a set number of hours recommended for treatment." We agree, and that conclusion applies equally to a fixed 20-hour ceiling. If no single number fits every child, a limit applied to every child is the wrong tool.

Underserving young children has lasting costs. Lifetime costs for an autistic person in the United States have been estimated at $1.4 million to $2.4 million, driven largely by special education and lost productivity (Buescher et al., 2014). In a U.S. Medicaid-enrolled cohort, shorter delays to early intensive behavioral intervention were associated with higher rates of general education placement (Dimian et al., 2021). A cap that saves hours at age three may cost the Commonwealth far more over that child’s lifetime. 

CMS guidance and Virginia's current policy: review, not caps

The Toolkit lists "service hour thresholds that trigger review" as a feature of effective prior authorization, and states that higher intensity "should only be authorized based on the [individualized treatment plan's] documentation of needs and goals that warrant extensive treatment." This is CMS guidance to every state, not one state's choice. Virginia already has a policy that meets it: DMAS's December 2025 ABA bulletin requires requests above 20 hours to include an individualized schedule and clear justification, and the Toolkit features that policy as a "State Spotlight" on high-intensity review. North Carolina, also highlighted in the Toolkit, takes the same approach, requiring plans over 16 hours per week to be reviewed and approved rather than capped. The draft would replace the approach CMS highlighted with a ceiling. Virginia can meet DMAS's program-integrity goals by keeping it.

Addressing the Department's concerns directly

We understand the concerns behind this proposal. The Toolkit reports a 22% increase in average weekly hours since 2021. It also warns that very high-intensity schedules can "take on the characteristics of respite care and childcare." We share these concerns, and we agree that 40 hours should never be a default. The right response is to scrutinize high-intensity requests closely, not to limit every child. A review threshold paired with the documentation standard below would:

• require a clinical justification tied to assessment results for every hour above 20;

• require schedules that distinguish skill-building from breaks and downtime, while recognizing that mealtime, toileting, dressing and other self-care routines are often treatment targets themselves. The Toolkit acknowledges that ABA "may focus on activities such as food selectivity or enuresis." Whether time is therapeutic should depend on whether the activity has programmed objectives, data collection and documentation tied to an active goal, not on whether it looks recreational;

• require goals and criteria for reducing intensity, so high-intensity plans are time-limited by design; and

• give DMAS and MCOs a clear basis to deny requests that are not supported.

How Mosaic manages intensity

Mosaic's practice shows that intensity can be managed responsibly without a ceiling. Every hours recommendation follows a structured medical-necessity model and is reviewed against standardized outcome measures (the Vineland, the VB-MAPP Barriers Assessment and the Autism Impact Measure), using the outcome-measurement framework my colleagues and I published this year (Cox et al., 2026). Higher intensity is reserved for children whose assessments show it is needed and is tapered as goals are met. DMAS can require this standard of every provider.

Practical consequences

• Appeals and administrative cost. When services are reduced, families are entitled to notice and a fair hearing, and in managed care, benefits may continue pending appeal (42 C.F.R. Part 431, Subpart E; 42 C.F.R. § 438.420). Applied to thousands of children now above 20 hours, a ceiling could generate appeals costing DMAS, MCOs and families more than up-front clinical review.

Recommendations

1. Replace the ceiling with a review threshold. Recommended language: "Services are authorized based on individualized medical necessity. Requests for direct treatment exceeding 20 hours per week require additional documentation supporting the requested intensity and are reviewed under EPSDT criteria. The 20-hour threshold is not a limitation on medically necessary services."

2. Count direct treatment only (e.g., 97153 and 97154), consistent with CASP's guidelines, so that clinically important caregiver training or supervision does not push a child over the threshold.

3. Use a clinical documentation standard. Each treatment plan should state whether the program is focused or comprehensive, the clinical justification for the hours, and the goals and criteria for reducing intensity. Schedules should show the distribution and therapeutic purpose of services, for example "4 hours per day, 5 days per week, targeting individualized service plan (ISP) goals in communication, social skills and behavior reduction," rather than the intervention planned for every timeframe.

4. Make EPSDT determinations individualized. No request should be denied solely because hours exceed a threshold, and MCO decisions should document an individualized review rather than generic language.

5. Protect children already in care. Apply the new standard at each member's next reauthorization, with at least 90 days for implementation, so no child's hours are reduced while review is pending.

6. Let the data guide any future threshold. Before setting a fixed number, we ask DMAS to publish data on authorizations above 20 hours, including the number of children, their ages and severity, and their outcomes, and to review it with the ABA workgroup. Mosaic will contribute its outcome data to that review.

2. Diagnosis and the provisional-diagnosis pathway (pp. 24, 28–31)

ASD diagnosis requirement (p. 24). We understand the concern behind this change. DMAS's data show that 88% of children receiving ABA in 2025 had an autism diagnosis, and one plan reported to the ABA Utilization Workgroup that non-ASD diagnoses, led by ADHD, accounted for 12.2% of its 2025 ABA spending. We agree that comprehensive ABA should be reserved for autism. But focused, function-based treatment for severe behavior can be medically necessary for children with other diagnoses. We ask DMAS to state in the admission criteria that youth without an ASD diagnosis may receive focused ABA for severe behavior through individualized EPSDT review.

Diagnostic documentation (p. 28). The draft requires the comprehensive diagnostic evaluation to be "conducted in-person." We agree that every evaluation should include in-person direct assessment. The Toolkit prefers in-person evaluation but recognizes a role for telehealth when families lack "qualified providers available within a reasonable travel distance," and its implementation checklist asks that evaluations not be "100 percent telehealth." We recommend a hybrid model: direct assessment such as the ADOS in person, with developmental history, caregiver interviews, records review and feedback permitted by telehealth. A fully in-person requirement would reduce diagnostic capacity, particularly in rural regions such as Southwest Virginia, where Mosaic operates three clinics. We also recommend allowing correction of missing administrative items, such as an evaluator's National Provider Identifier (NPI), rather than denial.

Align with Virginia's own diagnostic initiatives (pp. 28–29). Through the Virginia Mental Health Access Program (VMAP), the Commonwealth trains primary care clinicians "to screen and diagnose young children for autism" using the STAT. The draft, however, lists the STAT only as a screening tool and names the ADI-R, ADOS and CARS as diagnostic examples. DMAS should state that STAT-based diagnoses by trained primary care clinicians qualify. Otherwise, families diagnosed through the state's own initiative would need a second evaluation, adding months of delay and lengthening specialty waitlists.

Provisional diagnosis (pp. 28–31). We strongly support letting young children begin ABA while awaiting evaluation. The Toolkit notes that "some families [wait] two years between ASD screening and diagnosis" (Chen et al., 2023), and recognizes that states may authorize "limited, time-bound ABA services" under EPSDT in these circumstances. To make the pathway workable:

• Use one screening standard. Children 36 months and under must submit a RITA-T or STAT screening; children 37 months to 5 years do not. One validated-screening standard should apply to the whole age range, and it should include the M-CHAT-R/F, the screener most widely used in pediatric primary care.

• Allow a provisional diagnosis after borderline findings. For children under 36 months whose evaluation yields borderline findings, the evaluating clinician should be able to issue a provisional diagnosis valid for six months, followed by reassessment, as North Carolina allows.

• Accept family-provided documentation. Appointment and waitlist proof "obtained directly from the evaluating entity" (p. 31) places providers between families and evaluators. Confirmation letters or patient-portal records provided by the family should suffice.

• Account for evaluator capacity at 6 and 12 months. When a family has an active appointment or waitlist placement, the absence of a completed evaluation at 6 months, or a final diagnosis at 12 months, reflects evaluator capacity rather than clinical need. Services should continue while the child shows clinical benefit, and item 3 (p. 31) should carry the same appointment and waitlist language as item 2.

• Include older children. Older children face the same waitlists and are often identified later, particularly girls. DMAS should state that they may receive time-limited services under EPSDT review.

Closing

The single most important change DMAS can make is to replace the 20-hour ceiling with a review threshold, preserving accountability while ensuring the children with the greatest needs receive the care that is medically necessary for them. We would welcome the opportunity to share our full outcome data with DMAS and the ABA workgroup as the Department finalizes Appendix D.

Sincerely,

Callie Plattner, PhD, LPA, BCBA-D

Chief Clinical Officer, Mosaic Pediatric Therapy

cplattner@mosaictherapy.com · 980-202-7437

Sources

1. Mazurek, M. O., et al. (2020). Autism Research, 13(11), 1867–1879.

2. BHCOE (2022). Strategic Benchmark Report: Parent & Guardian Satisfaction.

3. Cox, D. J., Godwin, J., Filer, M. R., & Plattner, C. (2026). A guide to choosing a balanced outcomes measurement portfolio for ABA organizations. Behavior Analysis in Practice. https://doi.org/10.1007/s40617-026-01164-2

4. CMS (2026). State Medicaid & Children's Health Insurance Program Applied Behavior Analysis Toolkit.

5. CASP (2024). Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder (3rd ed.), as presented to the DMAS ABA Utilization Workgroup, September 22, 2026.

6. Virginia DMAS (September 22, 2026). ABA Utilization Workgroup, Meeting #1 (slide deck).

7. Virginia Mental Health Access Program (VMAP). Free STAT Certification. vmap.org.

8. Eldevik, S., et al. (2026). Autism Research, 19(1), e70169.

9. Sandbank, M., et al. (2024). JAMA Pediatrics, 178(8), 763–773.

10. Frazier, T. W., Chetcuti, L., & Uljarevic, M. (2025). Evidence that intervention dosage is associated with better outcomes in autism. JAMA Pediatrics, 179(1), 101–102.

11. Granpeesheh, D., et al. (2009). Research in Autism Spectrum Disorders, 3(4), 1014–1022.

12. Buescher, A. V. S., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). JAMA Pediatrics, 168(8), 721–728.

13. Dimian, A. F., Symons, F. J., & Wolff, J. J. (2021). Journal of Autism and Developmental Disorders, 51(4), 1054–1066.

14. Chen, Y. H., et al. (2023). Cited in CMS (2026).

Comments on Proposed Virginia DMAS ABA Policy Updates

Submitted October 15, 2026

To the Virginia Department of Medical Assistance Services (DMAS):

Golden Steps ABA appreciates the opportunity to submit comments regarding the proposed updates to Virginia’s Applied Behavior Analysis (ABA) policies. We support DMAS’s responsibility to ensure program integrity, appropriate utilization, and the delivery of high-quality, medically necessary services. At the same time, we urge DMAS to avoid policy changes that would delay diagnosis, interfere with individualized clinical decision-making, or unnecessarily restrict access to treatment for children enrolled in Virginia Medicaid.

1. Preserve Access to Clinically Appropriate Telehealth Diagnostic Evaluations

We respectfully request that DMAS reconsider a categorical requirement that all autism diagnostic evaluations occur in person. Families across Virginia already face lengthy waits for qualified diagnostic providers. An in-person-only policy could compound those delays, particularly in rural and underserved communities where specialist availability and transportation are limited.

Telehealth can offer an important pathway to timely evaluation when a qualified diagnosing professional determines that the format is clinically appropriate and a reliable, comprehensive diagnostic assessment can be completed. We do not advocate for brief or clinically insufficient remote encounters. Rather, we recommend a flexible standard that considers diagnostic complexity, the clinician’s judgment, and whether direct in-person assessment is necessary for the individual child.

Accordingly, DMAS should retain a clinically justified telehealth option, with appropriate documentation and safeguards, rather than impose a blanket in-person requirement that may delay the commencement of medically necessary early intervention.

2. Remove Predetermined ABA Hour Caps and Utilization Thresholds

Golden Steps ABA strongly recommends that DMAS eliminate the proposed 20-hour-per-week limitation and any other predetermined numerical hour caps or utilization thresholds from the ABA Provider Manual. Our concern extends beyond whether a threshold is formally described as a hard cap: once a numerical benchmark appears in policy, it can influence authorizations and treatment recommendations even when the child’s documented needs warrant more intensive care.

ABA treatment is inherently individualized. Qualified clinicians develop recommendations after considering the child’s functional needs, developmental presentation, assessment findings, treatment goals, and response to intervention. A single statewide hourly benchmark cannot adequately account for these differences. To the extent that it displaces clinician judgment, an arbitrary limit risks denying children a portion of the treatment determined to be medically necessary, much as a blanket restriction on a prescribed therapy would do regardless of the patient’s individual need.

This position is consistent with the federal requirement that medically necessary services for EPSDT-eligible children not be subject to absolute limits. In its August 2026 State Medicaid & CHIP Applied Behavior Analysis Toolkit, CMS notes that states may use utilization thresholds as review tools, but that such thresholds and authorization limits should not become absolute caps when additional medically necessary services are required (p. 123, note 319). The toolkit also explains that states may use reviewable “soft limits,” while prohibiting hard limits that can never be exceeded for EPSDT-covered services (pp. 54–55). Its utilization-management checklist asks states to examine whether their policies impose hard limits or other restrictions on medically necessary EPSDT services (p. 145).

Although these federal principles permit certain review thresholds, Golden Steps ABA recommends that Virginia go further by omitting numerical thresholds from the Provider Manual entirely. This is a prudent policy choice to preserve genuinely individualized treatment and reduce the risk of misapplication by Medicaid managed care organizations (MCOs).

Specifically, we are concerned that MCOs could interpret a 20-hour figure as the presumptive maximum, resulting in routine denials, escalating documentation demands, or pressure on providers to reduce recommendations notwithstanding clear evidence of medical necessity. Even where exceptions technically exist, burdensome review processes can create practical limits through delays and interruptions in care. These consequences would disproportionately affect children who require higher-intensity treatment.

We fully support clinically grounded authorization and reauthorization review. DMAS and its contracted MCOs should assess requested hours against individualized evaluations, treatment plans, measurable goals, progress, and documented medical necessity. Meaningful oversight does not require a predetermined hourly benchmark. Rather, review criteria should be transparent, clinically appropriate, and applied consistently, without automatic denials tied to a numerical threshold.

Requested Policy Actions

Continue to permit telehealth diagnostic evaluations when a qualified professional documents that the approach is clinically appropriate and sufficient for a reliable assessment.

Remove the proposed 20-hour-per-week limitation and all other predetermined ABA hour caps or utilization thresholds from the Provider Manual.

Require individualized medical-necessity determinations supported by appropriate clinical documentation, rather than standardized numerical limits.

Issue explicit guidance to contracted MCOs prohibiting the use of numerical benchmarks as de facto caps, automatic denial criteria, or grounds to reduce medically necessary treatment.

Conclusion

Golden Steps ABA supports accountable, clinically sound oversight of ABA services. We ask DMAS to adopt policies that protect access to timely diagnosis and ensure treatment intensity remains responsive to each child’s individual medical needs. These changes would strengthen the program without placing unnecessary obstacles between Virginia children and medically necessary care.

Thank you for your consideration of these comments.

Respectfully submitted,

/s/ Pinny Berger

Golden Steps ABA

Reference

Centers for Medicare & Medicaid Services, State Medicaid & Children’s Health Insurance Program Applied Behavior Analysis Toolkit (August 2026), pp. 54–55, 123 n.319, 145. https://www.medicaid.gov/medicaid/downloads/autism-services-aba-toolkit.pdf

Thank you for the opportunity to provide feedback on the proposed ABA policy updates. While we support DMAS's efforts to strengthen oversight and ensure appropriate utilization, we have several concerns regarding the potential impact on access to medically necessary services.

1. In-Person Diagnostic Requirements

We strongly encourage DMAS to reconsider requiring diagnostic evaluations to be conducted in person. Families across Virginia already face extremely long waitlists for autism evaluations, and this requirement would create additional barriers and further delay access to critical early intervention services.

This would particularly impact families in rural and underserved communities where qualified diagnostic providers are limited.

We recommend continuing to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals.

2. 20-Hour EPSDT Documentation Threshold

We recommend that the proposed 20-hour threshold for enhanced EPSDT documentation apply specifically to direct treatment hours (CPT 97153) rather than total ABA service hours.

Clinical supervision (97155) and caregiver training (97156) are essential components of treatment and should not count toward this threshold.

Including these services would effectively reduce the amount of direct treatment a child can receive before additional documentation requirements are triggered, creating unnecessary administrative burdens.

3. Clarification of the 20-Hour Limitation

We are particularly concerned with the proposed wording that ABA services "may not exceed 20 hours per week."

This language could be interpreted by Medicaid managed care organizations (MCOs) as an absolute benefit cap rather than a threshold requiring additional clinical review.

The CMS State Medicaid & CHIP ABA Toolkit, released August 4, 2026, specifically states on page 123 that utilization thresholds and authorization limits "should not operate as absolute caps" when additional medically necessary services are required.

CMS further recognizes that treatment intensity should be individualized based on each child's clinical needs, consistent with federal EPSDT requirements.

We recommend replacing the proposed language with:

"Requests exceeding 20 hours per week of direct ABA treatment (CPT 97153) shall require enhanced clinical documentation and individualized medical necessity review under EPSDT. This threshold shall not constitute an absolute service limitation, and additional medically necessary hours may be authorized based on the individual needs of the child."

DMAS should also explicitly instruct MCOs that requests exceeding this threshold must receive individualized review rather than automatic denial.

Conclusion

We appreciate DMAS's commitment to improving ABA services in Virginia. However, these changes should not create additional barriers for families already struggling to access care.

We respectfully request that DMAS maintain flexibility for diagnostic evaluations, apply the 20-hour documentation threshold specifically to direct treatment, and clearly establish that treatment intensity must be determined by individualized medical necessity rather than an arbitrary hourly cap.

Thank you for your consideration.

Reference: CMS, State Medicaid & CHIP Applied Behavior Analysis Toolkit, August 2026, particularly pages 54 and 123.

https://www.medicaid.gov/medicaid/downloads/autism-services-aba-toolkit.pdf

I am concerned that implementing a 20-hour limit on treatment services could create unnecessary barriers for individuals who require more intensive care. Treatment decisions should be guided by each client’s clinical needs, progress, and medical necessity rather than a standardized hourly limit.

Although I recognize that providers may request authorization for hours beyond the proposed limit, this additional administrative step could delay access to essential services and place an unnecessary burden on providers, clients, and their families. For individuals who depend on consistent, intensive treatment to make meaningful progress, such delays may have significant consequences.

I encourage DMAS to prioritize individualized, evidence-based treatment recommendations and ensure that qualified clinicians retain the ability to determine appropriate treatment intensity based on medical necessity. Policies governing service delivery should support timely access to effective care rather than create administrative obstacles that may compromise client outcomes.

:::

To the Department of Medical Assistance Services:

Genesis Autism Center is a clinic-based ABA provider in Hampton serving young children and their families, many of whom rely on Medicaid. We share DMAS’s commitment to quality and accountability. However, we are concerned that the proposed Appendix D, as written, will delay or deny medically necessary care to the children who need it most and can least afford to wait.

1. The diagnosis requirement narrows eligibility for children who currently qualify. Current Appendix D criteria allow ABA for youth with a qualifying DSM diagnosis and documented functional impairment. Requiring an ASD diagnosis removes a pathway for children with other conditions who benefit from ABA today. These children will now depend on case-by-case EPSDT review, which adds delay and uncertainty for families already in crisis.

2. Diagnostic wait times will become treatment wait times. Families across Virginia already wait 6-12 months for a comprehensive autism evaluation. Requiring an in-person evaluation with specific tools and evaluator credentials before authorization, and limiting provisional diagnoses to children 5 and under, means older children cannot begin treatment until an evaluation is complete. Early intervention matters most during the very months these children will spend waiting.

3. Medicaid families face the greatest barriers. Families with limited transportation, inflexible work hours, or no access to nearby evaluators will be hit hardest by in-person requirements and documentation that must be “obtained directly from the evaluating entity.” Commercially insured families do not face these hurdles. This widens an existing gap in access.

4. Administrative burden reduces clinical capacity. New schedule requirements, weekly summary notes, and expanded re-authorization packets shift BCBA time from children to paperwork. In a field with a well-documented workforce shortage, every hour spent on administration is an hour of care not delivered.

5. The 31-day lapse rule penalizes families for hardship. Requiring a full new assessment after a hospitalization, illness, or family emergency delays the return to care at the moment a child is most vulnerable.

6. The timeline leaves no room to protect continuity of care. An October 22 effective date, one day after comments close, gives providers no time to adjust and risks authorization disruptions for children currently in treatment.

We respectfully request that DMAS:

• Retain the current diagnostic pathway, or allow a provisional diagnosis for all ages while an evaluation is pending.
• Accept validated telehealth evaluations and family-provided waitlist documentation.
• Allow an assessment addendum, rather than a new assessment, after documented hardship lapses.
• Delay implementation at least 90 days and honor all active authorizations through their end dates.

Every month of delay is a month of lost progress for a child. We urge DMAS to adopt standards that strengthen accountability without closing the door on the families who depend on Medicaid most.

Respectfully,

Cameron S. Ashworth, M.A.
Co-founder, Genesis Autism Center and COO of Genesis Counseling Center              Hampton Roads, Virginia

As a Board Certified Behavior Analyst (BCBA) and Clinical Director with approximately eight years of experience working with children with autism, I am deeply concerned about Virginia’s proposed implementation of a 20-hour-per-week limit on Applied Behavior Analysis (ABA) services.

Throughout my career, I have worked with children who have significant communication deficits, severe behavioral challenges, and difficulties with essential daily living skills. I have also witnessed firsthand the incredible progress that can occur when children receive consistent, individualized, medically necessary treatment.

ABA is not a one-size-fits-all treatment, and neither should the number of hours a child receives be. Some children may make meaningful progress with 10–20 hours per week, while others require 25–40 hours to appropriately address their clinical needs. Treatment recommendations should be based on comprehensive assessments, individualized goals, behavioral severity, and ongoing clinical data, not a predetermined number of hours.

Many of the children we serve struggle with behaviors such as aggression, self-injury, and elopement, which can present serious safety concerns. Others have significant communication and adaptive skill deficits that require consistent intervention across environments and daily routines. Arbitrarily restricting treatment hours risks limiting opportunities to develop functional communication, independence, social skills, and safer alternatives to challenging behaviors.

I am also concerned about the additional barriers this could create for families. Parents already navigate lengthy diagnostic processes, insurance authorizations, and difficulties accessing services. Requiring additional justification to exceed 20 hours could result in treatment delays, unnecessary administrative burdens, and disruptions in care, particularly for children with the most significant needs.

While I recognize that the proposed policy includes an exception for documented medical necessity under EPSDT, it is essential that this process be clear, timely, accessible, and consistently applied across insurance providers. Children should not have to experience interruptions or reductions in medically necessary treatment simply because their needs exceed an established threshold.

Additionally, I strongly encourage clarification regarding whether the 20-hour limit includes only direct treatment or also encompasses BCBA supervision, treatment planning, and caregiver training. These services are essential components of effective ABA treatment and should not come at the expense of a child’s medically necessary direct intervention hours.

I understand the importance of responsible healthcare spending and appropriate utilization of services. However, reducing access to early, individualized intervention may create greater challenges for children and families in the long term.

Medical necessity should determine treatment intensity, not an arbitrary weekly limit.

I strongly urge Virginia policymakers and DMAS to preserve individualized treatment recommendations, ensure meaningful access to medically necessary services beyond 20 hours, and involve practicing clinicians and families in decisions that directly affect the children we serve.

These decisions have real consequences for real children and families. Every child deserves access to the level of care necessary to develop meaningful skills, improve their quality of life, and reach their fullest potential.

Thank you for the opportunity to provide feedback on the proposed ABA policy updates. While we support DMAS's efforts to strengthen oversight and ensure appropriate utilization of services, we have significant concerns regarding the potential impact of these changes on access to medically necessary ABA treatment for children across Virginia.

1. In-Person Diagnostic Requirements

We strongly encourage DMAS to reconsider requiring diagnostic evaluations to be conducted in person. Families across Virginia already face extremely long waitlists for autism evaluations, and this requirement would create additional barriers and further delay access to critical early intervention services.

This would particularly impact families in rural and underserved communities where qualified diagnostic providers are limited. For many families, telehealth evaluations provide an important pathway to obtaining a timely diagnosis and beginning medically necessary treatment.

We recommend that DMAS continue to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals. The focus should remain on the clinical quality and appropriateness of the evaluation rather than imposing restrictions on how that evaluation is conducted.

2. Removal of All ABA Hour Caps and Utilization Thresholds

We strongly recommend that DMAS completely remove any proposed hourly caps or utilization thresholds from the ABA Provider Manual, including the proposed 20-hour weekly limitation.

ABA is an extremely individualized form of treatment. Our clinicians utilize their professional experience, clinical expertise, and comprehensive assessments to determine the appropriate treatment plan and recommended number of hours per week for each child. These recommendations are based on the unique clinical needs of the individual, not a standardized approach to care.

Establishing an arbitrary hourly cap or threshold undermines the very foundation of individualized ABA treatment. It effectively substitutes an administrative policy for clinical judgment. To put this into perspective, limiting a child's access to clinically recommended ABA hours is comparable to telling a family that their child can receive only half of their prescribed medication, regardless of what their treating physician has determined is medically necessary.

This concern is particularly significant in light of the CMS State Medicaid & CHIP Applied Behavior Analysis Toolkit, released August 4, 2026, which emphasizes that utilization thresholds and authorization limits should not operate as absolute caps when additional medically necessary services are required. CMS recognizes that treatment intensity must be individualized and based on each child's clinical needs, consistent with federal EPSDT requirements.

We fully recognize and support DMAS's responsibility to provide appropriate oversight of ABA services. DMAS should maintain rigorous authorization and clinical review processes to ensure that requested treatment hours are medically necessary, appropriately documented, and supported by individualized assessments. However, there is a fundamental difference between oversight of medical necessity and establishing an arbitrary numerical threshold that influences or restricts treatment recommendations.

Additionally, we are extremely concerned about how Medicaid managed care organizations (MCOs) will interpret and implement such language. Even if DMAS intends the 20-hour threshold to trigger additional documentation or review rather than serve as an absolute limitation, we are concerned that MCOs will treat it as a hard cap in practice. This could lead to automatic denials, pressure to reduce clinically recommended hours, and significant barriers for children whose treatment needs exceed the established threshold.

The inclusion of any numerical cap or threshold in the Provider Manual creates an unnecessary risk that MCOs will use that number as the default maximum level of treatment rather than evaluating each child's actual medical necessity. Families with children requiring more intensive services would be disproportionately affected, despite having clinical documentation supporting those needs.

Our recommendation is clear: DMAS should remove the 20-hour limitation and any other predetermined hourly caps or utilization thresholds from the ABA Provider Manual entirely. Authorization decisions should be based on individualized medical necessity, supported by appropriate clinical documentation and subject to reasonable oversight by DMAS and its contracted MCOs.

We believe this approach would allow DMAS to maintain appropriate accountability while protecting access to medically necessary services and preserving the individualized nature of ABA treatment.

Conclusion

We appreciate DMAS's commitment to improving ABA services in Virginia. However, any changes to the Provider Manual must be carefully considered to ensure they do not create additional barriers for families already struggling to access care.

We respectfully request that DMAS:

1. Continue allowing telehealth diagnostic evaluations when clinically appropriate.
2. Completely remove the proposed 20-hour limitation and any other predetermined hourly caps or utilization thresholds from the ABA Provider Manual.
3. Ensure that all ABA treatment authorizations are determined through individualized medical necessity reviews, with appropriate clinical oversight rather than arbitrary numerical restrictions.
4. Provide clear direction to contracted MCOs that medically necessary ABA treatment must not be restricted through the application of predetermined hourly caps.

Ultimately, the number of hours a child receives should be determined by their individual clinical needs and the recommendations of qualified treating professionals, not by a predetermined number established in a provider manual.

Thank you for your consideration and your continued commitment to ensuring that children with autism across Virginia have access to the care they need.

Reference: CMS, State Medicaid & CHIP Applied Behavior Analysis Toolkit, August 2026, particularly pages 54 and 123.

I am deeply concerned about the impact the proposed Virginia Medicaid changes could have on children and families who rely on Applied Behavior Analysis (ABA) services. While ensuring quality care and responsible oversight is important, these changes must not come at the expense of access to medically necessary treatment.

A 20-hour-per-week cap on ABA therapy could significantly limit the progress and opportunities of the clients we serve. Every individual has unique needs, and treatment should be determined by clinical necessity, individualized assessments, and measurable progress—not an arbitrary limit on the number of hours a person can receive. For some clients, 20 hours may be appropriate, but for others, it may not be enough to address communication barriers, develop essential daily living skills, increase independence, and reduce behaviors that interfere with learning and safety.

ABA is not a one-size-fits-all service. When a client's medically necessary treatment exceeds an imposed cap, families and providers may be left in an impossible position: reduce services before treatment goals have been met or face barriers to obtaining the additional care the client needs. These limitations could disrupt progress, place additional pressure on caregivers, and make it more difficult for individuals to reach their full potential. Access to medically necessary treatment should be based on the needs of the individual, not a predetermined hourly ceiling.

I am equally concerned about the requirement for in-person-only assessments. Although in-person evaluations can be valuable, eliminating flexibility for assessments conducted through telehealth could create substantial barriers for families in rural Virginia and underserved communities.

For families living in rural areas, accessing an in-person assessment may require traveling long distances, taking time off work, arranging transportation, and coordinating childcare. For families already navigating financial hardship or limited local healthcare resources, these requirements can make an already difficult process even more challenging.

The impact could be especially significant in rural communities and historically underserved populations, where access to qualified providers may already be limited. If a family cannot access an in-person assessment in a reasonable timeframe, the result may be delayed treatment, prolonged waitlists, or an inability to access services altogether. Telehealth can offer a valuable alternative when clinically appropriate, helping families overcome geographic barriers and connect with qualified professionals.

We must consider the real-world consequences of policies that restrict both the amount of care available and the ability to access the assessments required to begin that care. A limit on treatment hours can affect the continuity and effectiveness of services, while restrictions on assessment methods can prevent families from accessing those services in the first place.

Virginia Medicaid should pursue responsible oversight while preserving a family's ability to access the care their child needs. Cost-containment measures should never become barriers that prevent children from receiving medically necessary, individualized treatment.

I urge Virginia policymakers and DMAS to reconsider the potential consequences of these restrictions and prioritize policies that protect access to ABA services. Specifically, I encourage decision-makers to:

• Preserve individualized treatment planning that allows ABA hours to be determined by medical necessity rather than a rigid weekly cap.

• Maintain exceptions for medically necessary treatment when a client's documented needs exceed 20 hours per week, with a clear and accessible authorization process.

• Allow telehealth assessments when clinically appropriate, rather than making in-person evaluations the only pathway for families who face geographic, financial, or transportation barriers.

• Consider the needs of rural and underserved communities when developing policies that affect access to behavioral healthcare.

• Include families, providers, and individuals receiving services in the decision-making process so that policy changes reflect the realities of the people most affected.

Every child deserves the opportunity to learn, communicate, develop independence, and build skills that will support them throughout their lives. Families should not have to choose between meeting their basic needs and traveling hours to obtain an assessment. Nor should they have to worry that their child's progress will be limited by an arbitrary restriction that does not reflect their individual clinical needs.

Behind every authorization is a real child, a family, and a future. These decisions have consequences that extend far beyond paperwork and budgets. They affect access to care, family stability, developmental progress, and the opportunities available to children who already face significant challenges.

Virginia has an opportunity to develop policies that support accountability without sacrificing accessibility or quality of care. I strongly encourage our state leaders to listen to the families and providers who see these challenges firsthand and ensure that Medicaid policy puts the needs of the individuals it serves at the center of every decision.

Access to ABA therapy should be determined by clinical need, not geographic location or arbitrary limitations. Every child deserves a fair opportunity to reach their full potential.

Dear DMAS Behavioral Health Team,

My name is Richard Gooden Jr., and I (along with my wife, Shelby) are the owners and founders of Boundless ABA, located in Roanoke, VA. I am writing to you today to provide insight into how the proposed changes will actually affect the families who are currently receiving services, as well as the many who are waiting to begin services. I would like to address one of the many proposed changes, and how implementing that change as currently written would be a disservice for the families who desperately need assistance. 

Proposal: Weekly hours (p. 28)
"May not exceed 20 hours per week." (Except under EPSDT review)
Goal: Reduce the number of hours a client can receive services to lower overall costs to Medicaid and help prevent over-prescription of hours by providers who are committing fraud.
Reality: Many families who receive services that they need will instead receive reduced or no services due to vague wording that may be interpreted as a hard-cap of hours by MCO's. Overall costs will increase as services are required for significantly longer time frames to make progress. Every hour invested now saves multiple hours of services later. Prevention and early intervention is always less expensive than continuous, ongoing services, which will also include costs into adulthood. The administrative burden will increase significantly, as every request over 20 hours will now go through a EPSDT review. This burden leads to additional costs and time delays for services. It should also be noted that the vague wording of this proposal needs to be clarified regardless of whether it is amended, changed, or removed. Does the 20 hour limit apply to any portion of the services provided, or only the direct services. The changes coming to ABA CPT codes in the near future would cause this 20 hour restriction to realistically only provide ~10 hours of service a week, as the remainder would need to be split to supervision, report writing, reassessment, and other currently non-reimbursable time spent supporting a client.
Comment: I fully support the effort to reduce fraud and over-prescription of hours by providers. I do not pretend that every provider and company is making decisions based off of medical necessity only, and not the financial incentives that they may perceive from those actions. However, many clients do require significant support to make progress towards independence. The reality many parents face is that the options offered in public schools or other federally funded sources are not adequate to support the medically necessary needs of their child. Additionally, they face constant suspensions, expulsions, classroom disruptions (affecting their peers), and direct service professionals to support them. This limit will not save money, even in the short term, as the cost of services will merely be passed to other support systems with worse outcomes. Over time, the additional costs of continued services, or other, more expensive support systems into adulthood, will increase the total costs to the budget.
Solution: Remove, or clarify the wording of this proposal to be clear that it is a guideline, and not a hard limit applied to every applicant. Increase monitoring and investigations into possible fraud - remove the bad actors while maintaining medical services when it is appropriate. 

Proposal: Weekly hours (p. 28)
"May not exceed 20 hours per week." (Except under EPSDT review)
Goal: Reduce the number of hours a client can receive services to lower overall costs to Medicaid and help prevent over-prescription of hours by providers who are committing fraud.
Reality: Many families who receive services that they need will instead receive reduced or no services due to vague wording that may be interpreted as a hard-cap of hours by MCO's. Overall costs will increase as services are required for significantly longer time frames to make progress. Every hour invested now saves multiple hours of services later. Prevention and early intervention is always less expensive than continuous, ongoing services, which will also include costs into adulthood. The administrative burden will increase significantly, as every request over 20 hours will now go through a EPSDT review. This burden leads to additional costs and time delays for services.
Comment: I fully support the effort to reduce fraud and over-prescription of hours by providers. I do not pretend that every provider and company is making decisions based off of medical necessity only, and not the financial incentives that they may perceive from those actions. However, many clients do require significant support to make progress towards independence. The reality many parents face is that the options offered in public schools or other federally funded sources are not adequate to support the medically necessary needs of their child. Additionally, they face constant suspensions, expulsions, classroom disruptions (affecting their peers), and direct service professionals to support them. This limit will not save money, even in the short term, as the cost of services will merely be passed to other support systems with worse outcomes. Over time, the additional costs of continued services, or other, more expensive support systems into adulthood, will increase the total costs to the budget.
Solution: Remove, or clarify the wording of this proposal to be clear that it is a guideline, and not a hard limit applied to every applicant. Increase monitoring and investigations into possible fraud - remove the bad actors while maintaining medical services when it is appropriate. 

While this proposal is mine (and others) largest concern, there are many other proposed changes that just don't make sense - especially the implementation timeline. Everyone involved needs time to make the drastic changes to how services are monitored, managed, and provided and the requirement to do that in a few short months (since the bill was proposed) to days (since the bill goes into effect) are just not possible. We ask that everyone is provided a realistic time frame to implement any and all the changes. I strongly urge your team to consider the actual outcome of the changes that have been proposed. Every medical service should be based on medical necessity, and not the limits suggested by politicians or driven by financial decisions. 

Sincerely,

Richard Gooden Jr, Founder and Owner, Boundless ABA

richard@boundlessaba.com · 540.212.4069

I am a State Director with a masters degree in Industrial and Organizational Psychology with 3+ years of experience in the ABA field. I oversee ABA for 150 children with autism throughout the entire state of 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.” 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. I support many children under my purview who require 25-30 hours a week of therapy, and have benefited greatly from it. 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, 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 ask that a BCBA or other ABA expert do these reviews within the standard 7-day timeframe. Current hours should continue while a timely request is reviewed.

In-person diagnostic evaluations (p. 28). The draft requires evaluations to be done in person, with no exceptions. Families I work with wait about 24 months for an evaluation, and some live 100  miles from the nearest in-person evaluator. That wait consumes years where 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 3-year-old I worked with started on a provisional diagnosis and made significant progress before the full evaluation was completed.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).  Family training is built  into every treatment plan. But the manual requires weekly involvement and allows discharge when a family can’t participate. A parent on my caseload missed a couple of weeks because of health issues and a hospitalization; we kept them engaged through brief check ins. 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.

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.

I’ve been a BCBA for four and a half years, and in that time I’ve practiced in nearly every setting ABA offers. I started in family homes, moved into a role split between a clinic and homes, and now provide services entirely through telehealth. Today I also train and mentor the BCBAs who work with Virginia children, most of whom rely on Medicaid. Each of those settings has taught me the same thing: progress depends on giving a child the amount of support their assessment calls for, and giving it without long gaps. I’m writing because parts of the proposed Appendix D would make that harder.

My biggest concern is the 20-hour weekly line on page 28. When my team builds a treatment plan, the hours aren’t a guess. They come from what we observe and measure. Some children do well with fewer than 20. Others, especially those whose behavior makes them unsafe at home or keeps them out of school, need more to make meaningful progress. Federal guidance from CMS this year makes clear that children covered by EPSDT shouldn’t face hard limits on care. I’d ask DMAS to write the rule so that going above 20 hours starts a closer look rather than a likely denial. I’d also ask that the count include only time spent directly treating the child. Coaching parents and supervising staff are some of the most valuable work we do, and they shouldn’t be what pushes a family over the threshold.

That closer look also needs a clear owner and a clock. The section on page 31 promises a review but doesn’t say who conducts it or how long it can take. Every week a child waits at reduced hours is a week of lost ground. Please have these requests decided by someone with ABA expertise, within about a week, and let the child keep their current services until a decision comes back.

My telehealth work makes me especially worried about requiring every diagnostic evaluation to happen in person For a toddler, a long wait for a diagnosis means a long wait for treatment, during the years it helps most. I’m not asking DMAS to drop in-person evaluations. I’m asking for a fallback when a family truly can’t get one in a sensible timeframe or distance, and for DMAS to honor valid evaluations a child has already received.

Oversight and good care aren’t in conflict. With a few adjustments to these sections, DMAS can keep the checks it’s looking for while making sure Virginia children get the right amount of help at the right time. Thank you for reading.

Brandon Eason, MS, BCBA, LBA

As a Board Certified Behavior Analyst (BCBA) and Licensed Behavior Analyst (LBA) practicing in Virginia, I am writing to express concern regarding the proposed changes to Medicaid-funded Applied Behavior Analysis (ABA) services, particularly the proposed 20-hour utilization threshold and in-person diagnostic requirements.

ABA treatment should be individualized based on each recipient’s assessed needs, functional impairments, treatment response, progress data, and medical necessity. A standardized utilization threshold should not restrict access to clinically appropriate services for individuals who require more intensive treatment. Treatment hours should be determined through comprehensive assessment, ongoing data analysis, and the clinical judgment of qualified professionals in collaboration with families and other members of the treatment team.

I am also concerned that rigid in-person diagnostic requirements may create unnecessary barriers for families who face transportation challenges, geographic limitations, scheduling difficulties, financial constraints, or limited access to qualified diagnostic providers. These requirements could delay assessments and treatment initiation, particularly for families already navigating significant barriers to care.

I respectfully encourage DMAS to ensure that the final policy preserves individualized treatment planning, allows clinically justified exceptions to utilization thresholds, and considers appropriate flexibility in diagnostic requirements when clinically and legally permissible. Any policy changes should be evaluated for their potential effects on timely access to care, continuity of services, patient outcomes, and the ability of families to obtain medically necessary treatment.

As clinicians, our responsibility is to provide ethical, evidence-based care that meets the needs of each individual. Medicaid policy should support that goal rather than impose restrictions that may interfere with medically necessary treatment. Thank you for considering the perspectives of Virginia clinicians, the individuals we serve, and their families.

Justin Scroggins, BCBA, LBA

I am a Board Certified Behavior Analyst and LBA in Virginia. I have been practicing for almost four years. I have practiced in the home, clinic, and day care settings. I have also provided services In-person and via telehealth. I am writing to express concerns for the proposed updates in Appendix D.

First I want to express concerns regarding the 20 hour limit for services (page 28). It is  my clinical belief that the number of therapeutic hours be individualized to the child, and not based on a limit imposed by an external body. Treatment plans prepared by myself and my fellow BCBAs are done so after careful consideration, evaluation, and with respect to CASP guidelines. These hours consider the client and family’s ability to participate, their risks, deficits, strengths, and their support systems. At this time, I have multiple children on my caseload that require 15-25 hours of only direct (97153) services and this does not include the hours spent treatment planning, parent training, and supervising the direct care staff. If a limit is to be imposed; it is requested that this not be inclusive of parent training and supervision hours as these take away from the amount of direct therapy a child receives.

Should a child need additional hours, it is understandable that further review would be required and warranted to ensure appropriate use (Page 31). It is requested that this review should be completed by medical professional who is abundantly familiar such as a fellow BCBA/LBA with the field of ABA and in a timely manner so as not to further delay service delivery. I appreciate that many insurance carriers allow for peer to peer discussions to further justify the need for additional hours and this should continue to be the standard. It is my experience that these peer to peer reviews can at times be scheduled multiple weeks later which is time spent that a child could be making progress to reach functional independence.

Through my company, we service many children in rural areas in which there is not an in-person provider for more than 40+ miles. I have recently serviced a child who lives more than 30 miles outside of the closest major city (Roanoke) which is still fairly rural. These services are often paid through Medicaid and families are  unable to accommodate for extended drive times. In-person assessments should continue to be the priority, but when not possible due to limitations of availability, distance, or other barriers a virtual assessment should be accepted.

Early intervention is proven to be most beneficial to children diagnosed with Autism. These comments are intended to consider the need for additional documentation requirements to ensure ethical service delivery while also prioritizing the needs of the individuals that we serve thus improving quality of life, functional independence, and reduction of community/caregiver burden.

Thank you for your time and consideration of these comments.

Sarah Richter M.S. BCBA, LBA

1. Continue permitting telehealth diagnostic evaluations when clinically appropriate and conducted by qualified professionals.
2. Remove the proposed 20-hour-per-week limitation and all other predetermined hourly caps or utilization thresholds from the ABA Provider Manual.
3. Ensure that ABA treatment authorizations are based on individualized medical necessity reviews, supported by appropriate clinical documentation and professional judgment rather than arbitrary numerical restrictions.
4. Provide clear guidance to contracted MCOs that medically necessary ABA services must not be restricted through the application of predetermined hourly caps or utilization thresholds.

Our full comments will be emailed due to the character limit imposed by Town Hall.

The Virginia Association of Community-Based Providers (VACBP) submits these comments through its ABA Council. We recognize that the 20-hour limit and ASD requirement come from Item 291.WW.2 of the 2026 Appropriation Act; we ask DMAS to implement them clearly and protect continuity of care. A full letter has been sent to DMAS.

1. Eligibility (p. 24): Explain the clinical basis for ASD-only eligibility and what service DMAS recommends for youth with ADHD, ODD, conduct disorder, or Down syndrome/ID who benefit from ABA. State in the criteria that these youth may be approved via EPSDT.

2. Diagnosing professionals: Specify which license types may render ASD and provisional diagnoses, and distinguish administering a screening tool from making a diagnosis. Accept ASD diagnoses under all applicable F84 codes. Define "age 5 or under" as through the day before the 6th birthday.

3. Evaluations (pp. 28-29): Confirm prior evaluations using ADOS/CARS satisfy the requirement and current clients need not be re-evaluated. Evaluator waitlists are about one year; provide a grace period.

4. Provisional pathway (pp. 28-31): Name the ICD-10 code for provisional diagnoses. Define acceptable waitlist evidence (including family attestation or a DMAS form) since many families are waitlisted with no date. Define when the 12-month clock starts. No recoupment if a later evaluation does not confirm ASD; provide a transition period.

5. EPSDT and 20 hours (pp. 28, 31-32): EPSDT review should be automatic before any denial. Publish uniform elements, forms, and timeframes for all MCOs and FFS; continue services while review is pending. Accept schedules by session block, not unit by unit, and allow adjustments. Require reviewers with ABA expertise. List which codes count toward 20 hours, excluding assessment and family training. Use utilization data from all MCOs.

6. Assessment codes (p. 28): Direct MCOs that 97151, 97152, and 0362T need no prior authorization.

7. Implementation: Allow at least [90] days after the final manual is published. Apply new requirements to current youth only at their next continued stay. Provide training and FAQs before the effective date and coordinate MCOs for consistency.

8. Corrections: "Autism Diagnostic Review" should read "Autism Diagnostic Interview-Revised"; "evidenced based" should read "evidence-based"; use consistent age phrasing.

I am an Operations Manager at an ABA company serving children and families throughout the state of Virginia, most of them being covered by Medicaid. In my role, I work closely with the operational processes that support access to ABA services, including scheduling, authorizations, staffing coordination, and communication with families. I support DMAS’s goals of accountability, quality, and appropriate documentation. However, I am concerned that several of the proposed changes to Appendix D could create additional barriers to care, increase delays, and make it more difficult for families to access services that meet their children's individual needs.

Weekly Service Hours 

Children receiving ABA services have different needs, and the amount of treatment appropriate for each child should be determined through an individualized clinical assessment. I support many children under my purview who require thirty hours a week of therapy and have benefited greatly from it. I encourage DMAS to clarify that the 20-hour threshold triggers a review rather than functioning as a cap on services. I also suggest that only direct treatment hours count toward the threshold, excluding caregiver training, supervision, and assessment activities so that they don't use up the child's hours.

EPSDT Review and Continuity of Care 

Timely authorization decisions are essential to maintaining consistent services for children and their families. When requests for additional hours require further review without a clearly defined process, providers may face scheduling uncertainty, administrative backlogs, and difficulty maintaining continuity of care. I encourage that a BCBA or other ABA expert do these reviews within the standard 7- day timeframe and current service hours should continue while a timely request is being reviewed. 

In-Person Diagnostic Evaluations 

Requiring diagnostic evaluations to be completed exclusively in person will create additional obstacles for families who already experience long waitlists, transportation challenges, scheduling limitations, or limited access to qualified evaluators in their area. Many diagnostic practices I have spoken to have long waitlists, some of up to two years, requiring in person diagnostic evaluation will make these considerably longer. These barriers can delay the process of beginning appropriate services during the years where intervention is most important. I encourage DMAS to allow clinically appropriate telehealth evaluations when an in-person appointment is not reasonably available within an appropriate timeframe or distance. I ask that DMAS should also accept evaluations children already have.

Provisional Diagnoses for Young Children 

Allowing young children to access appropriate ABA services under a provisional diagnosis can help reduce barriers during a critical developmental period while additional diagnostic evaluation is pursued. Delays in obtaining evaluations can complicate intake, care coordination, and families' ability to access timely support. I therefore support letting children five and under start ABA services with a provisional diagnosis. I also recommend establishing a clear pathway for children older than five who encounter diagnostic waitlists to receive an individualized EPSDT review.

Family Participation 

Family involvement is an important part of ABA services, but many families may face circumstances that make consistent weekly participation difficult, including work schedules, transportation issues, medical emergencies, and other caregiving responsibilities. From an operational perspective, rigid participation requirements may place additional pressure on families who are already working to balance treatment with daily responsibilities. I encourage DMAS to require documented efforts to engage and support families before discharge is considered solely because of participation barriers, while allowing reasonable exceptions for extenuating circumstances.

I respectfully encourage DMAS to review the proposed provisions to ensure that accountability measures support, rather than unintentionally restrict, timely access to medically necessary ABA services for Virginia Medicaid beneficiaries.

Thank you for considering these comments and for your commitment to improving access to care for children and families across Virginia.

I am writing as a Licensed and Board Certified Behavior Analyst with a decade of clinical experience in Virginia, including eight years as a Registered Behavior Technician (RBT) and two years as a practicing BCBA. I currently oversee Applied Behavior Analysis (ABA) services for seven children across the Commonwealth, ranging from urban centers to extremely remote rural communities. The majority of these children rely on Medicaid.

While I fully support DMAS’s commitment to strong documentation and oversight, several provisions in the proposed Appendix D create administrative barriers that will delay or reduce medically necessary care for vulnerable children. Below are my specific concerns and actionable recommendations to ensure accountability without compromising patient care.

1. Service Hours Threshold (p. 28)

• Concern: The draft states that services "may not exceed 20 hours per week, except as authorized under EPSDT review." Treatment intensity must be dictated by individualized clinical assessments—not arbitrary numerical caps. A child with Level 3 severity requires significantly more intensive intervention than a child with Level 1 or 2 severity. Capping hours risks retarding progress, decreasing intervention efficacy, and prolonging the overall duration a child requires ABA services. Furthermore, CMS’s 2026 ABA Toolkit explicitly states that states may not apply hard limits to medically necessary services for children covered under EPSDT.

• Recommendations:

  • Clarify that the 20-hour mark functions strictly as a trigger for administrative review, not a clinical ceiling or hard cap.

  • Specify that only direct, face-to-face treatment time with the child counts toward this 20-hour threshold, ensuring that essential indirect care—such as supervision overlap, parent training, and assessments—does not reduce the child's direct therapy hours.

2. EPSDT Review Process & Continuity of Care (p. 31)

• Concern: While the draft promises an EPSDT review prior to any service denial, it lacks operational details regarding review timelines and provider qualifications. Delays in this process directly threaten service continuity.

• Recommendations:

  • Mandate that EPSDT reviews be conducted by a qualified BCBA or peer ABA expert.

  • Enforce a standard 7-calendar-day turnaround time for review decisions.

  • Guarantee that existing authorized service hours remain active throughout the review process to prevent gaps in medically necessary care.

3. In-Person Diagnostic Evaluations & Telehealth Flexibility (p. 28)

• Concern: Requiring strict, in-person diagnostic evaluations with zero exceptions creates severe access barriers for rural families. I regularly travel over two hours each way because my agency is the sole provider willing and able to cover certain rural areas. Families in these regions routinely wait months—sometimes years—for care. Mandating rigid in-person logistics introduces risks from weather delays, scheduling conflicts, and environmental factors. Furthermore, requiring external evaluators unfamiliar to the child can skew clinical results compared to assessments conducted by a primary BCBA who understands the child's baseline behaviors, family dynamic, and local care ecosystem.

• Recommendations:

  • Maintain in-person evaluations as the standard, but allow telehealth options when an in-person evaluator is unavailable within a reasonable timeframe or geographic distance.

  • Allow DMAS to accept existing, valid diagnostic evaluations that children have already completed, eliminating redundant administrative delays during critical developmental windows.

4. Provisional Diagnoses & Diagnostic Scope (pp. 24, 29)

• Concern: I support allowing children age 5 and under to begin services under a provisional diagnosis. Early intervention during these peak developmental years is critical. For example, I treat a child under age 5 who is currently making significant progress in ABA while specialists determine whether their presentation is Autism Spectrum Disorder (ASD) or another developmental condition. Losing access to care now would jeopardize those developmental gains. Furthermore, ABA methodology is clinically proven to benefit complex developmental conditions beyond ASD; limiting coverage solely to ASD restricts vital care for other vulnerable populations.

• Recommendations:

  • Authorize Nurse Practitioners (NPs) and Physician Assistants (PAs) to issue provisional diagnoses, aligning Appendix D with DMAS’s existing State Plan Amendment.

  • Establish a clear pathway via EPSDT review for children over age 5 on diagnostic waitlists to access provisional ABA services.

5. Family Involvement Requirements & Discharge Criteria (pp. 23, 26)

• Concern: Caregiver involvement is a cornerstone of my treatment plans. However, requiring rigid weekly participation under threat of discharge fails to account for real-world family circumstances. Many Medicaid families navigate extreme hardships—working multiple jobs, managing lack of childcare, or supporting multiple children with special needs. Imposing unrealistic participation quotas causes unnecessary anxiety, deters families from seeking care, and unfairly punishes children for their parents' structural barriers. Flexible engagement (e.g., telehealth check-ins, phone updates, tailored home goals) maintains effective care coordination without penalizing the child.

• Recommendations:

  • Incorporate extenuating circumstances provisions for caregiver participation requirements.

  • Permit discharge based on non-participation only after documented, multi-modal engagement efforts have been exhausted—matching the standard DMAS already uses for other youth services like Multisystemic Therapy (MST) and Functional Family Therapy (FFT).

ABA therapy yields the highest outcome measures when service intensity reflects individual clinical needs and families are supported by reliable, continuous care. I ask DMAS to preserve the accountability measures in this revision while implementing these essential adjustments so Virginia’s children do not lose medically necessary care to rigid caps, rural access barriers, or administrative delays.

Thank you for your time, leadership, and consideration of these comments.

Daria Ditzler, MS, BCBA, LBA

I am a Board Certified Behavior Analyst with over eight years of experience providing clinical oversight of ABA services. I currently oversee ABA treatment for more than eight children with autism in the Central Virginia region, most of whom receive services through Medicaid. I support the DMAS goals of accountability, quality assurance, and thorough clinical documentation; however, I am concerned that several provisions in the proposed Appendix D could delay access to or reduce medically necessary ABA services for the children I serve.

1. The proposed manual states that services “may not exceed 20 hours per week, except as authorized under EPSDT review.” Treatment intensity should be based on each child’s individualized assessment, clinical needs, safety risks, and response to treatment rather than a preset numerical threshold. I urge DMAS to state that a request of 20 hours triggers a clinical review rather than as a cap on medically necessary services.

A five-year-old child on a previous caseload required 30 hours of ABA treatment per week to address severe self-injurious behavior, aggression, and unsafe elopement. Within two months of intensive, individualized treatment, the child made progress in functional communication with caregivers, siblings, and ABA staff, alongside reductions in all tracked target behaviors. This example illustrates why treatment intensity should remain dependent on individual clinical needs.

I also request that DMAS clearly define which service components count toward the 20-hour threshold. Direct treatment hours should not be reduced by counting overlapping supervision, caregiver training, or assessment activities against the child’s direct treatment time. 

2.  The proposed manual references an EPSDT review before denial of services, but does not clearly identify who will conduct the review or establish a specific timeframe for completion. I request that reviews be conducted by a BCBA or another qualified professional with expertise in ABA and medical necessity determinations.  An expedited review process should be established for urgent clinical or safety concerns, with a maximum time frame of seven calendar days for routine reviews to promote timely, clinically appropriate decisions and minimize disruptions to medically necessary services. Current authorized service hours should remain in place while a timely request for review is pending to prevent interruptions in medically necessary ABA services. Services should not be reduced or discontinued until the review is completed and a determination is issued.

3. The proposed requirement for in-person diagnostic evaluations, without clearly defined exceptions, may create barriers to timely diagnosis and treatment. Families I serve have reported waiting more than ten months for an evaluation, and some live approximately 100 miles from the nearest available in-person evaluator. These delays can prevent children from accessing services during critical periods of early development.

I ask that DMAS retain in-person evaluations, but allow telehealth evaluations when in-person appointments are unavailable within a reasonable timeframe or accessible distance. DMAS should also accept existing diagnostic evaluations that meet clinical and documentation requirements to avoid unnecessary repeat assessments. These changes would reduce delays, travel burdens, and barriers to accessing services while maintaining appropriate diagnostic standards and ensuring timely access to medically necessary care.

4.  I support allowing children age five and younger to access ABA services based on an eligible provisional diagnosis while awaiting a comprehensive diagnostic evaluation. In my clinical experience, a three-year-old child began ABA treatment with a provisional diagnosis and made progress in functional communication, including requesting wants and needs, while experiencing reductions in tantrums and aggression. These improvements supported the child's ability to participate in school and community activities. This illustrates the potential benefits of early intervention and the importance of reducing delays in accessing medically necessary services while families pursue comprehensive diagnostic evaluations.

I ask that DMAS clarify that qualified nurse practitioners and physician assistants may provide provisional diagnoses when permitted under applicable state law and DMAS policy. 

5. Family involvement is essential to effective ABA treatment.  I incorporate caregiver training into treatment plans to promote generalization and consistency across settings; however, rigid weekly participation requirements and potential discharge may unintentionally penalize families facing work schedule changes, transportation difficulties, illness, or other circumstances beyond their control. For example, a parent on my caseload missed two weeks of scheduled participation due to unexpected work schedule changes, but parent guidance and support continued through brief weekly check-ins. I ask that DMAS allow exceptions for extenuating circumstances.  Discharge due to limited caregiver participation should occur only after documented efforts to engage the family, assess barriers, and provide reasonable accommodations when feasible.

ABA is most effective when treatment intensity aligns with each child’s clinical needs and families can rely on continuity of care. I ask DMAS to maintain accountability while ensuring these revisions do not create unnecessary barriers or delays that prevent children from accessing medically necessary services. Thank you for considering my comments.

Thank you for the opportunity to provide feedback on the proposed ABA policy updates. While we support DMAS's efforts to strengthen oversight and ensure appropriate utilization, we have several concerns regarding the potential impact on access to medically necessary services.

1. In-Person Diagnostic Requirements

We strongly encourage DMAS to reconsider requiring diagnostic evaluations to be conducted in person. Families across Virginia already face extremely long waitlists for autism evaluations, and this requirement would create additional barriers and further delay access to critical early intervention services.

This would particularly impact families in rural and underserved communities where qualified diagnostic providers are limited.

We recommend continuing to allow telehealth diagnostic evaluations when clinically appropriate and performed by qualified professionals.

2. 20-Hour EPSDT Documentation Threshold

We recommend that the proposed 20-hour threshold for enhanced EPSDT documentation apply specifically to direct treatment hours (CPT 97153) rather than total ABA service hours.

Clinical supervision (97155) and caregiver training (97156) are essential components of treatment and should not count toward this threshold.

Including these services would effectively reduce the amount of direct treatment a child can receive before additional documentation requirements are triggered, creating unnecessary administrative burdens.

3. Clarification of the 20-Hour Limitation

We are particularly concerned with the proposed wording that ABA services "may not exceed 20 hours per week."

This language could be interpreted by Medicaid managed care organizations (MCOs) as an absolute benefit cap rather than a threshold requiring additional clinical review.

The CMS State Medicaid & CHIP ABA Toolkit, released August 4, 2026, specifically states on page 123 that utilization thresholds and authorization limits "should not operate as absolute caps" when additional medically necessary services are required.

CMS further recognizes that treatment intensity should be individualized based on each child's clinical needs, consistent with federal EPSDT requirements.

We recommend replacing the proposed language with:

"Requests exceeding 20 hours per week of direct ABA treatment (CPT 97153) shall require enhanced clinical documentation and individualized medical necessity review under EPSDT. This threshold shall not constitute an absolute service limitation, and additional medically necessary hours may be authorized based on the individual needs of the child."

DMAS should also explicitly instruct MCOs that requests exceeding this threshold must receive individualized review rather than automatic denial.

Conclusion

We appreciate DMAS's commitment to improving ABA services in Virginia. However, these changes should not create additional barriers for families already struggling to access care.

We respectfully request that DMAS maintain flexibility for diagnostic evaluations, apply the 20-hour documentation threshold specifically to direct treatment, and clearly establish that treatment intensity must be determined by individualized medical necessity rather than an arbitrary hourly cap.

Thank you for your consideration!

I have two children that are level 3 nonverbal. My 5-year-old has been doing ABA therapy for 2 years now, 5 days a week and 8 hours a day. When he first started, he did not communicate at all and was eloping. Those were our two main goals starting out. Fast forward two years later, we rarely have an issue with eloping, he can communicate by stating "I want ____" and can answer yes or no to questions. He even was learning to potty train which was going amazing. At the begging of this year, he was sick and had to miss a few days. Even in that short period of time, you could see the decline. More recently, I had a lapse in insurance because I accidentally missed a renewal (never received in mail). Which this halted a hard stop to therapy for him. I had to re-apply and needless to say, he missed three months of therapy due to the process. In a very short period of time, he started regressing huge. Not wanting to communicate, refusing to try and use the potty, and his behavior declined quickly. He just went back about two weeks ago for 5 days for 8 hours a day. Unfortunately, we received a full denial for ANY therapy. so, after a full week, we then had another hard stop which is currently happening right now. The center is trying everything they can to appeal this decision.

I also have a son that will be 3 in October. We were in the process of getting him in ABA when the lapse started. Unfortunately, he only got approved for 25 hours and started today. I saw all the progress my 5-year-old made over the course of two years and that really was defeating that my 3 year old gets half of what my 5 year old received. Some therapy is better than none, I guess. But these kids require consistent therapy and 4 hours a day is nothing. Early intervention is a joke and a waste of time. He had a therapist come twice a month for 1 hour and there was absolutely 0 progress. I honestly didn't even know the point because my child would have to get to know her all over again each time. When they are in therapy consistently, they grow a bond with their tech and therapist which creates trust and a comforting environment for them to be able to thrive in daily living. Which is essential for autistic children. Autistic children do not magically grow out of this diagnosis; they learn to adapt with skills that they are taught consistently with their tech and therapist and the ongoing medical care that is absolutely necessary. 

As parents of autistic children, WE LIVE THIS EVERY DAY. For an insurance company to say my child no longer needs services or doesn't need the number of hours that has been helping them tremendously, is absolutely absurd. Not to mentioned, my 5-year-old has been approved with little to no issues for TWO YEARS. Why all of a sudden does insurance companies feel the need that these young children no longer need it? We do not have "normal" children. We have children that have to fight hard every day to do the things a "normal" child would have no issue with doing or understanding.  We have to live with this for the rest of our lives, and we do not know what the future holds. Will my child be able to be independent one day and live a normal life to the best they can be are questions I ask myself every day. But to know they have the opportunity to get help as young as they are, can make all the difference in the world to our futures. 

Re: Comments on Proposed Revisions to the Mental Health Services Manual, Appendix D — Applied Behavior Analysis Services

On behalf of Sparks, thank you for the opportunity to comment on the Virginia Department of Medical Assistance Services’ (DMAS) proposed revisions to the Mental Health Services Manual, Appendix D, governing Applied Behavior Analysis (ABA) services. Sparks has been providing ABA services in Virginia since 2018, and we currently support over 100 families.

Sparks appreciates DMAS’s efforts to clarify service authorization requirements, strengthen documentation of medical necessity, promote family involvement and care coordination, and support appropriate oversight of ABA services. We particularly appreciate the proposed pathway for authorizing services exceeding 20 hours per week through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) process, as well as the provisions addressing access to ABA for young children who are awaiting a comprehensive diagnostic evaluation.

We support efforts to ensure that Medicaid-funded services are medically necessary, appropriately documented, and delivered in accordance with generally accepted standards of care. We offer the following comments and recommendations to support effective implementation of the proposed policy while preserving access to individualized, medically necessary treatment for children and families enrolled in Virginia Medicaid.

1. Diagnostic Evaluation Requirements for Young Children

Sparks appreciates DMAS’s recognition that young children may experience delays in obtaining a comprehensive diagnostic evaluation for autism spectrum disorder (ASD) and that those delays should not necessarily prevent access to needed treatment. The proposed provisions establishing a pathway for children age 5 and younger to receive ABA services with a provisional diagnosis represent an important effort to address this challenge.

We request clarification regarding the proposed in-person comprehensive diagnostic evaluation (CDE) requirement. Given the limited availability of qualified diagnostic professionals in some communities, an in-person-only requirement could create an additional barrier for families already experiencing lengthy wait times. We encourage DMAS to clarify whether evaluations conducted through clinically appropriate telehealth modalities may satisfy this requirement when permitted under applicable professional standards and licensing rules.

We also recommend that DMAS clarify the documentation necessary to demonstrate that a comprehensive diagnostic evaluation has been scheduled or that a child is on a waiting list. Clear expectations would help providers and managed care organizations (MCOs) implement these provisions consistently and reduce avoidable administrative delays.

Finally, we recommend clarifying whether the diagnostic instruments identified in the proposed policy are illustrative rather than exhaustive. Language such as “including, but not limited to” would recognize that qualified diagnostic professionals may appropriately select other validated instruments or combinations of assessment methods based on the child's presentation, the professional's training and expertise, and the circumstances of the evaluation.

2. EPSDT Review and Authorization of More Than 20 Hours per Week

Sparks appreciates DMAS’s explicit recognition that ABA services may exceed 20 hours per week when medically necessary and authorized through EPSDT review. We support establishing a clear process through which providers can demonstrate the clinical rationale for requested treatment intensity.

We encourage DMAS to clarify that requestions over the 20-hour threshold warrant EPSDT review, and are not a firm  limitation on medical necessity of ABA services. Treatment intensity should be determined by each beneficiary’s unique clinical presentation, considering both behavioral excesses and skills in need of development. We encourage DMAS to ensure that EPSDT determinations remain individualized and that requests are not denied solely because a beneficiary is recommended to receive more than 20-hours per week.

The proposed requirement for an individualized schedule of activities for requests exceeding 20 hours per week is understandable as a means of demonstrating the therapeutic purpose of requested services, particularly during extended sessions in a clinic setting. Sparks supports documentation that explains how requested hours will be used and how planned activities relate to treatment goals. We agree that, in the absence of an identified treatment goal, activities of daily living are not billable services.  We recommend DMAS clarify that schedules are intended to describe the planned distribution of treatment activities throughout the day/week, rather than prescribe the exact activity that must occur during every discrete time period.

Generalization is a critical component of ABA services, and for many clients with ASD, it would be contraindicated to practice the exact same skills at the exact same time each day. Providers should retain appropriate flexibility to modify the order and presentation of therapeutic activities, to maximize client participation and progress. 

We further recommend that DMAS clarify that activities must be related to a treatment goal, in order to be billable, rather than implementing a blanket prohibition on activities that appear recreational (in the absence of additional context). For example, many treatment goals are implemented during activities such as play, location transitions, and peer interactions. Such activities may serve important therapeutic purposes when incorporated into individualized treatment plans, linked to measurable objectives, and supported by appropriate data collection. The therapeutic nature of an activity should be evaluated based on its clinical purpose and documentation (or lack thereof) of treatment goals, rather than the name of an activity or setting. This clarification would help ensure that medically necessary treatment is not inadvertently excluded from authorization because of how an activity is categorized.

3. Continued Authorization for Children with a Provisional Diagnosis

Sparks appreciates the proposed provisions allowing continued consideration of ABA services for children age 5 and younger who have not obtained a definitive ASD diagnosis within 12 months of beginning services. The proposed pathway recognizes the importance of considering ongoing behavioral and developmental concerns, continuity of care, and efforts to obtain a comprehensive diagnostic evaluation.

We support a process that considers these factors together rather than making access to continued services dependent solely on the availability of an outside diagnostic appointment. We encourage DMAS to clarify how these provisions will be applied when families and providers have made reasonable efforts to obtain an evaluation but remain on a lengthy waiting list. We also recommend that the policy clearly distinguish between the documentation necessary to demonstrate ongoing efforts to obtain a CDE and the clinical information necessary to demonstrate continued medical necessity. This would promote consistent implementation and help prevent administrative delays when diagnostic access remains outside the family’s or provider’s control.

4. Family Participation and Caregiver Involvement

Sparks supports meaningful caregiver involvement with all of our clients. We recognize the value of caregiver education, training, and collaboration in supporting treatment progress and generalization. Despite our best efforts, there are circumstances in which a caregiver is not able to consistently participate in scheduled meetings or practice goals outside of session, particularly when there are multiple children with disabilities in the family and when a caregiver is navigating their own medical needs. Caregiver barriers should not interfere with a child’s access to medically necessary ABA services. 

We recommend that DMAS clarify how providers should address circumstances that limit caregiver participation, despite reasonable efforts to engage the family. The policy should permit individualized planning, alternative approaches to caregiver education and training when appropriate, documentation of barriers and engagement efforts, and clarification that failure to meet caregiver participation requirements should not be the basis for a denial of ABA services.

5. Care Coordination Requirements

Sparks supports coordination with primary care providers and other relevant treating professionals when appropriate and consistent with applicable consent and privacy requirements. We recommend that DMAS clarify that care coordination requirements are satisfied through documented, reasonable efforts when such communication depends on the response or cooperation of another provider. ABA providers cannot ensure that a primary care provider or other treating professional will respond to outreach or participate in coordination activities. The policy should require documentation of the efforts made to coordinate care and any barriers encountered, rather than making successful coordination a condition for continued service authorization. This approach would preserve the importance of coordinated care while recognizing circumstances outside the ABA provider’s control.

Conclusion

Sparks appreciates DMAS’s work to clarify Virginia Medicaid’s ABA service requirements and recognizes several constructive elements of the proposed revisions, particularly the pathway for authorizing services exceeding 20 hours per week through EPSDT review and the provisions addressing diagnostic access for young children.

We encourage DMAS to retain these access-oriented provisions while clarifying the implementation of diagnostic evaluation requirements, treatment schedules, documentation standards, family participation, and care coordination. We also encourage DMAS to ensure that ESDPT review requirements are applied in a manner that supports individualized medical necessity determinations and preserves appropriate clinical judgment.

Clear, consistent, and workable requirements will help providers demonstrate medical necessity, maintain appropriate clinical oversight, and deliver individualized treatment to children and families who rely on Virginia Medicaid.

Thank you for your consideration of these comments and for the opportunity to contribute to the development of this policy. Sparks welcomes continued engagement with DMAS as the Department finalizes the proposed revisions.

Sincerely,

Kayla Bagnato M.Ed., BCBA, LBA

Regional Clinical Director
Sparks

• 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.

• 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.

The most important considerations in this effort to contain costs while assuring access to appropriate services are the appropriateness of this service, the concerns expressed by adults who received this service, and what is lost when hours and hours are spent in therapy that is based on rewards and consequences without sufficient attention to what is happening in the nervous system. While ABA continues to be promoted as evidence-based, the original research does not meet today’s criteria. Most of the research is generated by the industry itself. However, other research paints a different picture.

• Regarding effectiveness:  the TRICARE study regarding ABA: https://therapistndc.org/aba-is-not-effective-so-says-the-latest-report-from-the-department-of-defense/  Here is a follow-up to concerns expressed by the ABA industry to that report:  https://therapistndc.org/rebuttal-to-critique-of-dod-aba-report/
• Evidence of Increased PTSD Symptoms in Autistics Exposed to Applied Behavior Analysis: https://www.emerald.com/aia/article-abstract/4/1/19/39360/Evidence-of-increased-PTSD-symptoms-in-autistics?redirectedFrom=fulltext
• Mental health outcomes associated with applied behavior analysis in a US national sample of privately insured autistic youth: https://journals.sagepub.com/doi/10.1177/13623613251390604

• In a 2022 survey of 11, 212 (7491 who were autistic), nearly 90% of autistic people (and almost 60% of non-autistic professionals) disagreed with the use of ABA on autistic children, (almost 80% and over 40% respectively disagreeing strongly). https://autisticnotweird.com/autismsurvey/#aba

• A Preliminary Investigation into the Presence of Woozles in Applied Behavior-Analytic Publications  https://repository.stcloudstate.edu/items/b6006788-0072-41af-a3f5-eee13b08ecd8
• The Gold Standard Fallacy of ABA: A Reference Guide for Therapists, Educators, & Parents, by Julie Roberts (Available on Amazon and elsewhere)
• The Autism Industrial Complex: How Branding, Marketing, and Capital Investment Turned Autism into Big Business, by Alicia A. Broderick

ABA ignores the extensive body of research and experience about behaviors that are not chosen, that is, behaviors in response to unconscious stimuli that trigger automatic protective responses (fight, flight, freeze, for example), as well as the impact of nervous system state.

Hours spent in “therapy” (often provided by individuals with only forty clock hours of training) are hours that are not available for everyday learning activities, for neuro-affirming therapies including Occupational Therapy, Speech and Language Therapy, and Augmentative and Assistive Communication Services.

CPB Behavioral Therapy and Advocacy Services, LLC thanks DMAS for the opportunity to comment. As an ABA provider, we operate in a rural area, which presents its own unique challenges. Below, are our main concerns with the ABA provider manual changes.

We support 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.

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.”

We appreciate 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.

We request 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.

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. We recommend 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. We recommend 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.

We recommend 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): 

1. 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.
2. 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.
3. 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.
4. 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.

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. We support 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.

We recommend 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.

DIAGNOSTIC TOOLS SHOULD BE IDENTIFIED AS EXAMPLES, NOT AN EXCLUSIVE LIST

• 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 addition, our families have trouble finding diagnosing providers. In many cases, our wait lists for ABA assessments are 6-18 months long. Some of our diagnosing facilities, cut off the diagnostic age at 8 years old, which makes it difficult for our older families to get diagnoses and/or be revalidated. In addition, this becomes a barrier to care. While telehealth evaluations aren’t ideal, this is oftentimes, the only option for our rural families. Losing access to these assessments could become the difference between accessing help and not accessing help.

Lastly, with being in a rural area, access to services are already limited. By moving to an autism only diagnosis, this will prevent those children without an autism diagnosis to go without any sort of services in rural areas. This is an area that potentially needs to be addressed as our children may be left with even less options for services overall.

Respectfully,

Crystal Peterson Barker, BCBA, LBA

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

My name is Sarah Coffey. I have been a BCBA for 15 years and currently serve as Vice President of Operations at Behavioral Innovations.

Behavioral Innovations provides center-based ABA to children with autism. We operate three centers in Virginia, in Chantilly, Fredericksburg and Manassas, with a fourth opening in Woodbridge in 2027. We also operate more than 120 centers across five other states. Most of the children we serve in Virginia are covered through Medicaid managed care, so we are invested in continuing to provide individualized services that produce meaningful outcomes and support children transitioning to less restrictive environments.

There is a great deal in this draft we support. Every ABA request being reviewed under EPSDT criteria before a denial is a stronger protection than exists in most states where we operate. Separating authorization requirements into initial, continued stay and EPSDT requests answers an existing problem. We also agree a provisional diagnosis is a legitimate basis for beginning treatment, given long wait times for a comprehensive evaluation.

There are some provisions in this draft that make a child's access or continued access to treatment, dependent on factors outside of what DMAS is trying to solve for. In some places it is documentation produced by a professional who is not treating the child; in others a caregiver's availability, a calendar interval, or a fixed threshold on service hours in advance of any individualized assessment. What these provisions have in common is access to care and the adequacy of the benefit, and where the benefit is delivered through managed care they also engage the Commonwealth's mental health parity obligations.

We are not asking the Department to remove a utilization management threshold, but rather to consider how DMAS reviews requests for services above 20 hours a week.  Our comments go to how that review is defined, published and applied, because a standard not stated in advance cannot be met in advance.

This summary is limited by the comment field. Our full comment, twelve items and fifty-one recommendations with the supporting provision text, is being provided to the Department's Regulatory Coordinator and should be considered part of this submission.

The Four Items that Matter Most

1. The new weekly limit of 20 hours

The draft provides that services "may not exceed 20 hours per week, except as authorized under EPSDT review." The current Appendix D contains no limit on authorized hours; it refers to 20 hours only as the point above which a schedule of activities must be submitted. The effect is an ordinary authorization request above 20 hours carrying extra documentation becomes reachable only through EPSDT review.

We read the EPSDT clause as the Department intending 20 hours to operate as a utilization management threshold rather than a ceiling, and we think that intent is right. Our concern is the words. "May not exceed" is the language of a limitation, and the exception is written as an exception rather than the ordinary route for a child whose assessment supports more intensive care.

This reaches us principally through managed care. Each Virginia health plan builds its own criteria from the Department's and is bound to a definition of medically necessary services no more restrictive than the state's. A manual that states 20 hours as a limit gives every plan a limit to implement.

The code scope is unstated and it changes the number materially. The Department's 28 July 2026 bulletin describes a cumulative weekly limit. Read cumulatively, protocol modification and caregiver training consume part of the 20 hours and a child's ceiling for direct treatment is lower. Read as direct treatment only, the same child may receive supervision and caregiver training above it. A provider cannot build a treatment plan without knowing which applies.

The figure also sits below what CMS describes as appropriate for the children this benefit admits. CMS's August 2026 toolkit for state Medicaid agencies states there are no established metrics for what counts as a low or high intensity intervention and "no consensus on a set number of hours recommended for treatment." To formulate appropriate frequency and intensity, "providers consider the patient's level of ASD severity, which the DSM-5-TR defines using three levels from least (Level 1) to most (Level 3) severe." CMS illustrates: "Best practice is that the number of hours detailed in the ITP be aligned with these levels; for example, 10, 20, and 30 hours for children in levels 1, 2, and 3, respectively." Almost no child at level 1, and few at level 2, meet medical necessity for ABA. The children admitted to this benefit sit at the levels for which CMS illustrates 20 and 30 hours, and a single figure of 20 is set at the lower.

The same chapter reports that intensity is not correlated with improvement in outcomes, and we do not read the two passages as being in tension. CMS's point in both is that the number of hours belongs to the individual child rather than to a figure set in advance.

Texas operates the model CMS describes. Texas’ Medicaid manual states its frequency tiers "are guidelines," that "frequency and duration should be based upon the functional goals of treatment," and that its highest tier, "greater than 20 hours/week," may be delivered "without requiring additional submission of documentation or review by a physician for medical necessity."

Our own authorizations point the same way. Of 27 children in active treatment in Virginia today, roughly 80 percent are authorized at or above 20 hours a week of direct treatment under 97153 alone, before protocol modification or caregiver training. Those are hours the Department and its plans have already approved as medically necessary. We offer it as one provider's snapshot, and the Department can test the question against its own authorization data. If the figure operates as a limit, exception review becomes the ordinary route for this population, a volume of review neither the Department nor providers are set up to absorb.

We ask the Department to:

• Replace "may not exceed 20 hours per week" with language that authorization requests at/above 20 hours are subject to the additional documentation and review described in the manual and are authorized where medical necessity supports them.
• State that the figure is a utilization management threshold and not a limitation on the amount of medically necessary ABA that may be covered.
• State what the figure is intended to address and the basis on which it was set.
• Confirm requests above the threshold are decided based on the child's clinical presentation, functional impairments, ASD severity level, treatment goals and response to treatment.
• Publish the documentation expected above the threshold and issue that guidance to contracted plans, confirming a plan may not require more than the manual states.
• Confirm the Department has considered the figure in the parity analysis it maintains for its managed care delivery system under 42 C.F.R. 438.3(n) and subpart K, and state where that documentation is posted.
• Confirm the threshold applies to direct treatment under 97153 and 97154, and that 97155, 97156 and 97157 do not count toward it.
• Confirm a child may be authorized above the threshold at initial authorization, state the decision timeframe, and provide that a child keeps authorized hours while a continued stay request is under review.

2. The provisional diagnosis pathway is newly limited to children five and under

The current criteria carry no age limit. The draft admits a child on a provisional diagnosis only where "the youth is age 5 or under." A child of six or seven with a provisional diagnosis, waiting for a comprehensive evaluation, can be admitted today and could not be under the draft.

The children affected are not a marginal group. Diagnosis after age five is common, particularly for girls and for children whose presentation is less overt. We understand the concern that a provisional diagnosis should not become an indefinite basis for treatment. The draft's own six and twelve month checkpoints already address it. The age limit does not add a safeguard. It closes a door that is open today.

We ask the Department to remove the age limit from admission criterion 2(b); to apply the same continued stay and EPSDT review mechanisms to any child admitted on a provisional diagnosis; and, if an age limit is retained, to extend the documentation route in item 2(c) to children above five and accept evidence of a scheduled evaluation or active waitlist placement.

3. The functional impairment criteria for admission

Admission requires a second showing beyond the diagnosis. Four of the manual's five criteria correspond to the diagnostic domains for autism. The fifth, frequent intense outbursts that are self-injurious or aggressive, is not a diagnostic criterion. It is an associated feature, present in some children and absent in many.

The criteria are also written to a severity the diagnosis does not require. The diagnostic criteria ask whether social deficits are persistent; the manual asks whether impairment is severe. The diagnostic criteria ask whether repetitive behaviors are present; the manual asks whether they are disruptive. A verbal child with a confirmed diagnosis, whose deficits are persistent but not severe and whose routines are rigid but not disruptive, can fail two of five. The Department accepts that child's diagnosis and declines to allow the child to access care.

The criteria also point a reviewer toward problem behavior as the marker of medical necessity, when the treatment that follows is largely skill acquisition.

We ask the Department to align the functional impairment criteria with diagnostic domains; to confirm that "severe" and "disruptive" describe the presentation rather than set a threshold above the diagnosis, or to remove those qualifiers; and to confirm a child who meets the diagnostic criteria at the lowest severity level is admissible where the assessment supports medical necessity.

4. The new diagnostic documentation requirement

The requirement itself is reasonable. The open questions are what happens to children already in treatment and whether a school-based evaluation counts.

We ask the Department to confirm that an authorization in effect on the effective date remains valid for its approved period and to state the first request at which the new requirement applies; to apply it prospectively, deferring it for children already in treatment to the first continued stay request at least six months after the effective date, or until changes from the Department's ABA workgroup are reflected in the manual; to add licensed school psychologists to the qualifying professionals; to communicate the requirement directly to evaluators through the Department's own bulletins, so the obligation does not reach them first through the ABA provider; to confirm the provider may supply the evaluator's Type 1 NPI; to accept a comprehensive evaluation completed by telehealth using a validated instrument; and to accept any validated autism screening instrument under item 2(b), including one completed by the child's primary care provider.

Comments on remaining items

5. Evidence obtained directly from the evaluating entity: The clause carries two readings. If it means the document must originate with the evaluator, say so and we will comply. If it means the evaluator must transmit it to us, a child's treatment becomes contingent on an office outside the treatment relationship that neither family nor provider can compel. We ask that the evidence originate with the evaluating entity but may be submitted by the provider, the family or the evaluator; that where the evaluator does not respond within a stated period, the family's documentation plus the provider's documented efforts suffice and services may not be denied on that basis alone; and that a documented waitlist placement carry forward on the family's confirmation that it remains active.

6. The twelve-month diagnostic checkpoint: Retain the twelve months measured from admission. Provide that EPSDT review may not result in denial or reduction where the only outstanding item is an appointment controlled by a third party and the child continues to meet medical necessity and show documented benefit, and that a documented active waitlist placement satisfies the requirement while it remains active. Clarify that the comprehensive evaluation in continued stay item 1 is submitted once completed and that until then items 2 and 3 govern; as drafted it carries no timing and could be read to apply ahead of the checkpoints the draft sets for the same children. Carry the age distinction the draft makes at initial authorization into the continued stay criteria, or state the basis for a single interval.

7. Discharge where a caregiver is unable to participate: A caregiver's work schedule is not a clinical finding, and the draft treats it as one by placing caregiver participation among discharge criteria that are otherwise clinical determinations. This is the provision most likely to end treatment for a child who still needs it, and it will fall hardest on families with inflexible hours, single-caregiver households and families without reliable transportation. We ask that caregiver participation be removed from the discharge criteria and addressed through the ISP; that providers instead establish an individualized participation plan, document efforts and barriers, and modify training methods, format or scheduling where clinically appropriate; that services not be terminated or reduced solely for barriers to participation where the provider has made and documented reasonable efforts and the child continues to benefit; or in the alternative that the criterion be limited to a caregiver who declines to participate after documented efforts, removing "or is unable." We also ask what direct family involvement "at a minimum of weekly" requires, including whether it is satisfied by documented contact or a specified duration, whether it is separately billable, and whether telehealth satisfies it. A requirement carrying a discharge consequence should be stated precisely enough to be met.

8. Discharge after a 31-day lapse: Allow an exception where the provider documents the cause of the interruption and the clinical basis for resuming the existing episode of care, permit resumption on an addendum rather than a new assessment and plan, and confirm that an absence documented in advance in the ISP does not start the period.

9. The ten-day transition period: Allow up to 30 days where clinically necessary and transition efforts are documented, and allow extension where the receiving provider's authorization is pending, so a child is not discharged into a gap created by a second review.

10. Schedules required above 20 hours: Confirm the schedule describes the structure of the treatment day and the therapeutic purpose of each portion, and does not fix the specific intervention delivered in each timeframe, which remains clinical judgment during the session. State the requirement to distinguish therapeutic from recreational and non-therapeutic time as a general one applying to every setting in which ABA is delivered, or remove it; as drafted it reaches clinic-based services alone and the draft gives no reason for the difference. Confirm that play, meals, toileting and transitions count as therapeutic time where they target plan goals and progress is measured. For young children a substantial part of teaching happens in those moments, and a standard reading them as non-therapeutic would misdescribe the intervention.

11. Care coordination with the primary care provider: As drafted the requirement describes an outcome rather than an effort, so a record can fall short for a reason the provider does not control. We ask that providers make and document reasonable efforts to coordinate with the primary care provider and other treating professionals, consistent with consent and privacy requirements, and that a family's decision not to authorize an exchange of information be a documented barrier rather than a provider deficiency.

12. Supervision and direction are used interchangeably: The manual requires observation and supervision monthly and clinical supervision twice monthly, and uses the two terms in overlapping ways. They are different activities. Clinical direction means working alongside the technician and adjusting the protocol; supervision required by the health regulatory board is a separate obligation; the administrative supervision tied to the RBT credential is a third. We ask that they be distinguished and each described consistently with the scope of practice of the professional performing it.

Implementation 

We ask that DMAS issue implementation guidance to contracted plans covering the effective date, authorizations already in place, the 20-hour threshold and the EPSDT pathway, and each new documentation requirement. State a single effective date for this appendix and confirm how it relates to any corresponding state plan amendment. Confirm, for the manual as a whole, that a plan's criteria and documentation requirements may be no more restrictive than the Department's. Allow a defined period between publication of the final manual and enforcement.

Recommended Corrections

The CPT code set should be updated. The manual references Category III codes 0362T and 0373T, which the AMA deletes effective 1 January 2027 and replaces with 97148 and add-on 97149, and 97159 and add-on 97160.

The diagnostic instrument listed as "Autism Diagnostic Review (ADI-R)" should read Autism Diagnostic Interview-Revised, in both locations where it appears.

The age boundary for the provisional diagnosis pathway is stated four ways across admission criterion 2(b), item 2(c) of the Initial Service Authorization Request, and the Additional Continued Stay Criteria. We ask that one formulation be used throughout, and that the Department confirm whether a child who has turned five but not six is included.

Summary

As highlighted above, four items matter most, and all four determine whether a child receives the service at all rather than how it is documented. The weekly limit should be written as the threshold the Department appears to intend, because every plan will build its criteria from whichever word the manual uses. The age limit closes to children over five a route open to them today. The functional impairment criteria ask for a second showing beyond the diagnosis the Department has already accepted. Lastly, the caregiver criterion makes a family's schedule a basis for discharge.

Each can be addressed without weakening the Department's utilization management, and our full comment proposes language that does so. Thank you for the opportunity to comment, and we welcome the chance to discuss our comments with the Department!

We respectfully request that DMAS revise the draft manual section governing Autism Spectrum Disorder (ASD) diagnostic documentation for ABA services. Our primary concern is that the proposed requirements would force ABA providers to retroactively evaluate and potentially question valid, established diagnoses based on assessment instruments, formatting, or telehealth delivery. Once a qualified LMHP acting within their scope of practice establishes a diagnosis, that diagnosis should be accepted for accessing ABA services.

Key Concerns:

• Retrospective Evaluation of Diagnoses: Requiring ABA providers to audit the original clinician’s diagnostic methodology, formatting, or tools creates an improper administrative burden, strays outside the scope of ABA treatment planning, and departs from how established diagnoses are treated throughout medicine.

• Invalidation of Existing & Telehealth Diagnoses: Diagnostic practices vary across settings, timeframes, and geographic locations. Individuals diagnosed in the past or out-of-state should not be penalized. Crucially, Virginia Medicaid currently reimburses diagnostic evaluations conducted via telehealth. Disqualifying diagnoses obtained through a Medicaid-covered service delivery method is contradictory and leaves families without a clear path forward.

• Duplicative Costs and Barriers to Care: Autism diagnostic slots in Virginia are already extremely limited, with long waitlists at participating hospital systems. Forcing individuals to 

• Undergoing Repeat Evaluations: This creates unnecessary, duplicative costs for the Medicaid program, places administrative strain on MCOs and providers, and causes harmful delays in access to care.

If DMAS seeks to enforce specific diagnostic standards, those rules should apply prospectively to evaluators at the time of assessment, not retroactively to members seeking treatment.

We recommend that DMAS revise this section to require ABA providers to document the existence of a qualifying ASD diagnosis and the credentials of the professional establishing or attesting to that diagnosis, rather than independently verifying the original diagnostic methodology.

Proposed Language:

a. A diagnostic evaluation confirming the diagnosis of Autism Spectrum Disorder (ASD) by an LMHP acting within their scope of practice. ABA providers shall document the name and credential of the evaluator; or the name and credential of the primary care provider attesting to the Autism Spectrum Disorder diagnosis.

b. For youth 36 months of age or younger, documentation of a provisional diagnosis of Autism Spectrum Disorder may be utilized for the approval of ABA services. A provisional diagnosis may be provided by an LMHP acting within their scope of practice. ABA providers shall document the name and credential of the LMHP providing the provisional diagnosis.

We respectfully request that DMAS revise the draft manual section governing Autism Spectrum Disorder (ASD) diagnostic documentation for ABA services. Our primary concern is that the proposed requirements would force ABA providers to retroactively evaluate and potentially question valid, established diagnoses based on assessment instruments, formatting, or telehealth delivery. Once a qualified LMHP acting within their scope of practice establishes a diagnosis, that diagnosis should be accepted for accessing ABA services.

Key Concerns:

• Retrospective Evaluation of Diagnoses: Requiring ABA providers to audit the original clinician’s diagnostic methodology, formatting, or tools creates an improper administrative burden, strays outside the scope of ABA treatment planning, and departs from how established diagnoses are treated throughout medicine.

• Invalidation of Existing & Telehealth Diagnoses: Diagnostic practices vary across settings, timeframes, and geographic locations. Individuals diagnosed in the past or out-of-state should not be penalized. Crucially, Virginia Medicaid currently reimburses diagnostic evaluations conducted via telehealth. Disqualifying diagnoses obtained through a Medicaid-covered service delivery method is contradictory and leaves families without a clear path forward.

• Duplicative Costs and Barriers to Care: Autism diagnostic slots in Virginia are already extremely limited, with long waitlists at participating hospital systems. Forcing individuals to 

• Undergoing Repeat Evaluations: This creates unnecessary, duplicative costs for the Medicaid program, places administrative strain on MCOs and providers, and causes harmful delays in access to care.

If DMAS seeks to enforce specific diagnostic standards, those rules should apply prospectively to evaluators at the time of assessment, not retroactively to members seeking treatment.

We recommend that DMAS revise this section to require ABA providers to document the existence of a qualifying ASD diagnosis and the credentials of the professional establishing or attesting to that diagnosis, rather than independently verifying the original diagnostic methodology.

Proposed Language:

a. A diagnostic evaluation confirming the diagnosis of Autism Spectrum Disorder (ASD) by an LMHP acting within their scope of practice. ABA providers shall document the name and credential of the evaluator; or the name and credential of the primary care provider attesting to the Autism Spectrum Disorder diagnosis.

b. For youth 36 months of age or younger, documentation of a provisional diagnosis of Autism Spectrum Disorder may be utilized for the approval of ABA services. A provisional diagnosis may be provided by an LMHP acting within their scope of practice. ABA providers shall document the name and credential of the LMHP providing the provisional diagnosis.

VIA Centers for Neurodevelopment

Public Comment Regarding Proposed Updates to the Mental Health Services Manual, Appendix D – Applied Behavior Analysis

VIA Centers for Neurodevelopment (VIA) appreciates the opportunity to comment on the Virginia Department of Medical Assistance Services' (DMAS) proposed updates to Appendix D of the Mental Health Services Manual (DMAS, 2026).

VIA is a Virginia nonprofit organization providing services across the lifespan, including clinic-based Early Intensive Behavioral Intervention (EIBI) for children with autism and other neurodevelopmental disabilities. Our programs serve individuals with significant developmental, behavioral, communication, and adaptive needs through comprehensive, individualized Applied Behavior Analysis (ABA) treatment.

VIA supports DMAS's efforts to strengthen documentation, utilization review, medical necessity determinations, and program integrity. Our primary concern is that the proposed 20-hour-per-week cumulative limit could become a categorical restriction on clinically necessary care if the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) exception is not implemented consistently across managed care organizations (MCOs).

1. The 20-hour limit should not become a de facto hard cap

VIA recognizes that the 2026 Appropriation Act establishes a 20-hour-per-week cumulative limit, subject to an EPSDT exception when additional services are medically necessary (Commonwealth of Virginia, 2026, Item 291.WW.2). Our concern is ensuring that this exception is meaningful, consistently applied, and based on individualized medical necessity.

The proposed manual appropriately requires EPSDT review before denying ABA services, including requests exceeding 20 hours. Federal EPSDT requirements provide eligible children and youth under 21 access to medically necessary Medicaid-coverable services to correct or ameliorate identified conditions (Centers for Medicare & Medicaid Services [CMS], 2026).

DMAS should clarify that:

• The 20-hour threshold does not substitute for an individualized EPSDT determination.
• Reviews must evaluate the full amount of services requested and supported by clinical documentation, rather than treating 20 hours as the presumptive maximum.
• Authorizing fewer hours than requested constitutes a partial denial requiring appropriate individualized EPSDT consideration.
• MCOs must apply consistent substantive criteria when evaluating requests exceeding 20 hours.

An EPSDT exception has limited practical value if providers and families must pursue additional reviews or appeals simply to obtain consideration of the medically necessary level of care.

2. The EPSDT exception should apply based on individual medical necessity, not service model

VIA encourages DMAS to clarify that the EPSDT exception is not limited to EIBI, a particular age group, or a specific clinical presentation.

When more than 20 hours of ABA services are requested, medical necessity should be evaluated based on functional impairments, treatment goals, behavioral and safety needs, response to treatment, progress, caregiver needs, and the clinical rationale for the requested intensity. This approach aligns with professional practice guidelines and federal Medicaid guidance emphasizing individualized treatment planning (Council of Autism Service Providers [CASP], 2024; CMS, 2026).

The 20-hour threshold should prompt appropriate EPSDT consideration rather than establish a presumption that additional services are clinically inappropriate.

3. DMAS should establish a consistent EPSDT framework across MCOs

Differences in MCO utilization-management processes could result in unequal access to medically necessary ABA services for individuals with comparable clinical needs.

VIA recommends statewide guidance establishing:

• Consistent documentation and medical necessity criteria for requests exceeding 20 hours;
• Clear review procedures, decision timelines, and clinical explanations for reductions or denials;
• Appropriate clinical expertise among reviewers, particularly when evaluating treatment intensity, consistent with CASP guidelines and CMS recommendations concerning experienced behavior analysts in utilization review (CASP, 2024; CMS, 2026);
• Timely reconsideration and appeal procedures; and
• Oversight mechanisms to identify meaningful differences in MCO authorization decisions.

DMAS should also clarify that MCO-specific requirements may not be more restrictive than applicable Medicaid benefits or DMAS requirements (CMS, 2026).

4. Treatment intensity should remain individualized and informed by clinical evidence

Treatment intensity is an important clinical variable in ABA, including EIBI. Research identifies associations between treatment intensity and outcomes while demonstrating that these relationships are complex (Eldevik et al., 2026; Sandbank et al., 2024). Professional guidelines and CMS guidance emphasize individualized treatment planning and clinically appropriate intensity (CASP, 2024; CMS, 2026).

VIA is not advocating that more hours are inherently better or that every individual should receive a particular number of hours.

Appropriate intensity depends on developmental functioning, communication and adaptive skills, behavioral and safety needs, treatment goals, progress, and opportunities for generalization. It may also change over time as skills develop or clinical needs evolve.

DMAS should preserve individualized clinical decision-making rather than allowing 20 hours to become a practical maximum regardless of documented need.

5. The evidence base and clinical model are particularly important for EIBI

One area of VIA's particular expertise is clinic-based EIBI for young children with autism who have significant developmental, behavioral, communication, and adaptive needs.

EIBI is an evidence-supported comprehensive intervention associated with improvements in intellectual functioning, adaptive behavior, and autism-related symptoms (Eldevik et al., 2026). The American Academy of Pediatrics also recognizes EIBI as a comprehensive treatment model for children with autism (Hyman et al., 2020).

A 2026 individual-participant data meta-analysis identified meaningful improvements in adaptive behavior, intellectual functioning, and autism symptom severity, as well as associations between treatment intensity and outcomes. These findings should be interpreted in light of the methodological limitations of the included studies (Eldevik et al., 2026).

This evidence does not establish one appropriate number of hours for every child. Rather, it supports comprehensive, individualized treatment informed by clinical needs and response to intervention.

Developmental timing is particularly important for young children receiving EIBI. CMS recognizes that some children may require higher-intensity ABA for a period of time based on functional needs, safety concerns, or treatment goals (CMS, 2026). Utilization review should allow clinicians to demonstrate when that intensity is medically necessary.

6. Comprehensive ABA is more than a number of direct treatment hours

Comprehensive ABA includes direct intervention, clinical supervision, treatment modification, data analysis, caregiver training, treatment planning, generalization, and coordination of care.

These components serve complementary clinical functions. CASP identifies ongoing case supervision, treatment modification, and caregiver involvement as important elements of effective treatment, with supervision adjusted according to individual needs (CASP, 2024).

A cumulative-hour limit that does not adequately account for these components could incentivize providers to prioritize direct treatment hours at the expense of clinical oversight and caregiver participation.

DMAS should ensure that utilization-management requirements support the full treatment model rather than inadvertently reducing its effectiveness.

7. The cumulative-hour calculation should be clearly defined

The proposed cumulative-hour limitation requires additional clarification regarding which ABA services and activities count toward the 20-hour threshold (DMAS, 2026).

Direct treatment, clinical supervision, treatment modification, caregiver training, assessment, and treatment planning are not interchangeable.

CASP identifies one to two hours of case supervision for every ten hours of direct treatment as a general standard of care, while emphasizing individualized supervision needs. CMS similarly distinguishes clinical oversight from direct treatment and other service components (CASP, 2024; CMS, 2026).

If supervision and caregiver training count toward the same 20-hour threshold as direct treatment, an individual receiving 20 hours of direct intervention may have little or no remaining capacity for these other clinically necessary services.

Reducing one component to satisfy a numerical limit does not eliminate the clinical need for that component.

VIA requests that DMAS clearly identify the applicable service codes and activities, explain how each component is counted, and clarify the treatment of concurrent or overlapping services in calculating cumulative weekly hours.

8. Appeals should not be the primary mechanism for obtaining timely access to medically necessary ABA

Meaningful appeal rights are important, but appeals cannot substitute for appropriate initial utilization-management determinations.

In Virginia, providers frequently undertake substantial administrative work to appeal service denials or reductions, including preparing documentation, participating in peer-to-peer discussions, and navigating multiple review levels. However, children and families bear the greatest consequences when services are delayed or interrupted.

This is especially concerning for EIBI. Children do not pause development while authorization disputes are resolved. Missed opportunities to develop communication, adaptive, social, and functional skills cannot necessarily be restored following a successful appeal.

VIA encourages DMAS to require meaningful consideration of the full requested level of care during initial review and establish timely processes that minimize interruptions in medically necessary services, particularly for individuals already receiving treatment.

9. Clinic-based ABA should continue to be evaluated based on individualized clinical need

Clinic-based EIBI can provide important advantages for children with significant support needs, including structured teaching environments, specialized clinical supervision, opportunities for social learning and generalization, and consistent treatment implementation.

Service setting should be determined by individual clinical needs and treatment goals, not assumptions that one setting is inherently preferable. CASP recognizes that ABA may be appropriate in clinic, home, school, and community environments depending on the individual's needs (CASP, 2024).

VIA encourages DMAS to preserve individualized consideration of clinically appropriate treatment settings.

10. Diagnostic requirements should not unnecessarily restrict medically necessary ABA for children without an ASD diagnosis

VIA encourages DMAS to clarify how the proposed diagnostic requirements apply to children with significant clinical needs who do not have an autism spectrum disorder (ASD) diagnosis.

Our clinical experience includes children with genetic disorders, feeding disorders, behavioral disorders, and other developmental disabilities for whom ABA may be clinically appropriate to address functional impairments, challenging behaviors, adaptive deficits, communication needs, and feeding difficulties.

The CMS State Medicaid & Children's Health Insurance Program Applied Behavior Analysis Toolkit recognizes applications of ABA beyond ASD and specifically discusses services for individuals without an ASD diagnosis (CMS, 2026, Appendix C).

VIA supports appropriate diagnostic and eligibility requirements but requests clarification regarding how medical necessity and coverage are evaluated for children with other diagnoses under applicable Medicaid benefits and EPSDT requirements.

The proposed manual includes ASD-specific diagnostic requirements, including comprehensive evaluation and evidence-based diagnostic tools. DMAS should clarify whether these requirements apply exclusively to ASD-related ABA services or could affect access to medically necessary behavioral services for children with other conditions.

In particular, VIA requests clarification regarding whether and under what circumstances ABA-specific services may be authorized for children without ASD, including through EPSDT or other applicable Medicaid coverage pathways.

Diagnostic requirements should support appropriate clinical decision-making without inadvertently restricting consideration of medically necessary services for children with other qualifying conditions.

11. Provider documentation requirements should be clear, clinically meaningful, and consistently applied

VIA supports documentation standards that allow DMAS and MCOs to evaluate medical necessity, treatment progress, and appropriate service utilization.

DMAS should provide consistent statewide expectations and examples addressing initial authorization, requests exceeding 20 hours, continued-stay reviews, treatment-plan updates, caregiver training, clinical supervision, treatment modification, objective progress measures, and changes in treatment intensity.

Clear expectations would reduce administrative inconsistencies across MCOs and help ensure that decisions reflect clinically meaningful information.

12. Implementation should protect continuity of care

VIA encourages DMAS to establish transition protections that minimize disruption for individuals already receiving medically necessary ABA services.

CMS guidance emphasizes individualized reauthorization decisions informed by progress, current functioning, ongoing clinical needs, and continuity of medically necessary treatment (CMS, 2026).

Providers, families, and MCOs need sufficient time and guidance to implement revised requirements. DMAS should clarify that existing authorizations will be honored through their approved periods unless an individualized determination supports a medically necessary change.

Individuals should not experience treatment interruptions solely because of changes in administrative interpretation or implementation.

Conclusion

VIA supports DMAS's efforts to strengthen oversight, program integrity, documentation, and individualized medical necessity determinations.

Our primary concern remains that the 20-hour cumulative limit could become a de facto hard cap if MCOs apply inconsistent interpretations of the EPSDT exception or treat the threshold as a default maximum.

Summary of Requested Clarifications and Recommendations

VIA respectfully requests that DMAS:

1. Ensure the 20-hour limit does not become a categorical clinical maximum and that the EPSDT exception remains meaningful.
2. Require individualized EPSDT review of the full amount of services requested, including partial denials.
3. Establish consistent MCO review standards, processes, and expectations for clinical expertise.
4. Apply the EPSDT exception based on medical necessity rather than service model, age, or clinical presentation.
5. Prevent MCO requirements from being more restrictive than applicable DMAS requirements.
6. Clearly define the services and activities included in the cumulative-hour calculation.
7. Recognize clinical supervision, caregiver training, treatment modification, and other essential components of comprehensive ABA.
8. Preserve individualized clinical decision-making regarding treatment intensity and setting.
9. Clarify diagnostic and documentation requirements, including access to medically necessary services for children with qualifying non-ASD diagnoses.
10. Provide adequate implementation guidance, transition time, and protections for existing authorizations.

VIA appreciates DMAS's consideration of these comments and its efforts to improve the quality, accessibility, and accountability of Medicaid-funded services across Virginia.

Sincerely,

Katie Kariel, M.T., BCBA, LBA
Director of Pediatric ABA Services
VIA Centers for Neurodevelopment

References

Centers for Medicare & Medicaid Services. (2026, August). State Medicaid & Children's

Health Insurance Program applied behavior analysis (ABA) toolkit.

https://www.medicaid.gov/medicaid/benefits/autism-services

Commonwealth of Virginia. (2026). 2026 Appropriation Act, Item 291.WW.2.

https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/

Council of Autism Service Providers. (2024). Applied behavior analysis practice guidelines for

the treatment of autism spectrum disorder: Guidance for healthcare funders,

regulatory bodies, service providers, and consumers (3rd ed.) [Clinical practice

guidelines]. https://www.casproviders.org/asd-guidelines

Eldevik, S., Strømgren, B., Eikeseth, S., Fields, A., Goetz, C. M., & Titlestad, K. B. (2026).

Clinically significant outcomes of early intensive behavioral intervention for children

with autism spectrum disorders: An individual participant data meta-analysis. Autism

Research, 19(1), Article e70169. https://doi.org/10.1002/aur.70169

Hyman, S. L., Levy, S. E., Myers, S. M., & Council on Children With Disabilities, Section on

Developmental and Behavioral Pediatrics. (2020). Identification, evaluation, and

management of children with autism spectrum disorder. Pediatrics, 145(1), Article

e20193447. https://doi.org/10.1542/peds.2019-3447

Sandbank, M., Pustejovsky, J. E., Bottema-Beutel, K., Caldwell, N., Feldman, J. I., Crowley

LaPoint, S., & Woynaroski, T. (2024). Determining associations between intervention

amount and outcomes for young autistic children: A meta-analysis. JAMA Pediatrics,

178(8), 763–773. https://doi.org/10.1001/jamapediatrics.2024.1832

Virginia Department of Medical Assistance Services. (2026). Mental health services manual:

Appendix D—Applied behavior analysis [Proposed guidance document]. Virginia

Regulatory Town Hall. https://townhall.virginia.gov/l/Comments.cfm?GDocForumID=2982

I am a Board Certified Behavior Analyst and Licensed Behavior Analyst with 12 years of experience. I have overseen ABA for up to 15 children with autism in 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.” 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. 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, 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 ask that a BCBA or other ABA expert do these reviews within the standard 7-day timeframe. Current hours should continue while a timely request is reviewed.

In-person diagnostic evaluations (p. 28). The draft requires evaluations to be done in person, with no exceptions. Families I work with wait about 3-4 months for an evaluation, and some live 50-60 miles from the nearest in-person evaluator. 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.  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. 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.

Kristin Kaschub, BCBA, LBA

EMG Consulting appreciates the opportunity to comment on the draft revisions to Appendix D. EMG is a clinician-owned behavior analytic practice founded in 2008 and based in Virginia Beach. We serve families across the Commonwealth through ABA services under Appendix D and through Therapeutic Consultation under the DD Waivers, and much of our work is with individuals with intellectual and developmental disabilities and significant behavioral needs. That work gives us a clear view of who these revisions will affect, and of the gaps they may fall into.

EMG supports DMAS’s goals of clear medical necessity documentation, consistent administration across MCOs, and meaningful family involvement. We endorse the comments submitted by the Council of Autism Service Providers (CASP) and the Virginia Association for Behavior Analysis (VABA) and will not repeat their analysis here. Instead, we offer what we see in practice.

Youth Without an ASD Diagnosis

We understand that Item 291.WW.2 requires an ASD diagnosis before DMAS authorizes ABA. Many of the youth who will fall outside that requirement have intellectual or developmental disabilities with severe self-injury, aggression, or pica. Left untreated in childhood, these behaviors tend to worsen and become harder to change with age.

Through our work providing Therapeutic Consultation under the DD Waivers, we see what happens when behavioral needs go unaddressed early. Individuals and families come to rely on waiver services, crisis supports, and more restrictive settings to manage behavior that might have been reduced years earlier. The waiver system itself faces real challenges, including limited slots for those without the highest-priority status and a shortage of qualified providers. Those challenges hit hardest on families whose needs have grown over the years. Access to ABA services under Appendix D during childhood is one of the most effective ways to prevent that path.

The draft states that EPSDT will review all ABA requests before denial, and we support that safeguard. For it to work, providers and MCOs need to know what a complete request looks like for a youth without an ASD diagnosis. We join VABA in asking DMAS to state the minimum documentation required for these requests, so that families with the same clinical needs get the same answer regardless of their health plan.

Continuity of Care

We ask DMAS to address youth already in active treatment without an ASD diagnosis when the revised manual takes effect. They should continue receiving services under EPSDT review while their authorizations are evaluated, rather than face a gap in care. An abrupt stop to effective treatment for severe behavior puts the youth, their families, and sometimes their placements at risk.

Diagnostic Access

Waits for a comprehensive autism evaluation in Virginia often run many months, and longer outside major metro areas. A child whose diagnosis is delayed by a waitlist should not also wait for treatment. We support the draft’s provisional diagnosis pathway and ask that DMAS keep it flexible enough to bridge those waits.

Points We Want to Underscore

Of the recommendations CASP and VABA have made, EMG wants to emphasize three:

1. The 20-hour threshold should trigger additional review, not cap medically necessary care. The number of hours requested should never, by itself, be a basis for denial.

2. Services should not be reduced or terminated because of barriers to caregiver participation when the provider has documented its efforts to engage the family and the youth continues to benefit. Many of the families who need these services most are single parents, shift workers, caregivers of several children with disabilities, or families far from services.

3. Care coordination should be satisfied by documented good-faith efforts. Providers cannot make another practice respond.

Closing

EMG shares DMAS’s commitment to services that are medically necessary, well documented, and consistently administered. We appreciate the Department’s consideration and would welcome the chance to share our perspective on ABA and DD Waiver services as these provisions are finalized.

Respectfully submitted,

Elizabeth Matthews, Ed.D., BCBA, LBA
Chief Executive Officer
EMG Consulting