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:
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:
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:
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