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.