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.