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