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.