To the Department of Medical Assistance Services:
I am writing as  a Licensed Behavior Analyst / a provider serving families across the state to comment on the proposed revisions to the ABA diagnostic and service authorization requirements. I support DMAS’s goal of making sure ABA reaches children who truly need it. However, several of the proposed changes would delay or block medically necessary care for Medicaid-enrolled children, especially families in rural Virginia. I respectfully ask DMAS to revise them before adoption.
1.  The in-person requirement for the comprehensive diagnostic evaluation should be removed.
The revised Initial Service Authorization section requires a comprehensive diagnostic evaluation “conducted in-person” using a tool such as the ADI-R, ADOS, or CARS. The same requirement appears in the continued stay criteria for children under age 5. This requirement is not clinically necessary. Validated telehealth diagnostic methods for autism are now widely used. The ADI-R itself is a structured caregiver interview that does not depend on the child being in the room. Many qualified evaluators in Virginia have adopted telehealth assessment since 2020, and DMAS already recognizes telehealth for other behavioral health services through its Telehealth Services Supplement.

A competent diagnosis should be judged by the qualifications of the evaluator and the validity of the method, not the physical location of the appointment. I ask DMAS to accept comprehensive evaluations delivered in person or by telehealth when a qualified LMHP uses a validated diagnostic tool or method.
2.  Virginia does not have enough diagnosing providers to meet this requirement on a reasonable timeline.
Families across the Commonwealth already wait over a year an autism evaluation. Qualified evaluators, including developmental-behavioral pediatricians, child psychologists, and others trained in standardized ASD instruments, are concentrated in a few metro areas and academic centers. Many of them do not accept Medicaid or have closed waitlists.

Requiring in-person evaluations will shrink the available evaluator pool even further. It will lengthen waits for every family, including those who are not on Medicaid. Research consistently shows that early intervention produces the strongest outcomes. Each month a young child waits for a diagnosis is a month of lost developmental opportunity.
3.  Rural families will be disproportionately harmed.
For families in Southwest Virginia, the Southside, the Shenandoah Valley, and the Eastern Shore, an in-person evaluation can mean 8 hours of round-trip travel, often more than once, since many evaluations span several appointments. Parents must miss work, often without pay. They must arrange childcare for siblings, pay for gas, and sometimes pay for an overnight stay. Medicaid transportation can help, but it does not cover lost wages, and it does not make a waitlist shorter. These barriers fall hardest on the low-income families that Medicaid is designed to serve. The likely result is that rural children will be diagnosed later and start services later, or not at all.
4.  The provisional diagnosis pathway should be expanded, not time-limited.
I appreciate that DMAS created a provisional diagnosis pathway for young children. As written, though, it has gaps:

It ends at age 5. A 6-year-old who is on a waitlist has no provisional option. That child can reach ABA only through EPSDT review. Waitlists do not stop at a child’s fifth birthday, so the provisional pathway should be available to any youth under 21 who has a documented scheduled appointment or waitlist placement.

The 6- and 12-month deadlines penalize families for a shortage they cannot control. If a family can show they remain on a waitlist, services should continue without added review burden.

Requiring documentation “obtained directly from the evaluating entity” adds an administrative step that busy diagnostic clinics may be slow to complete. Families or providers should be able to submit appointment confirmations or waitlist letters they already have.

The screening tools named for children 36 months and younger (RITA-T and STAT) require specific training and are not routinely available in many rural primary care practices. Please clarify that other validated screeners commonly used by pediatricians, such as the M-CHAT-R/F, are acceptable.
5.  Technical corrections.
The ADI-R is the Autism Diagnostic Interview–Revised, not the “Autism Diagnostic Review.” Please also confirm that diagnoses from physicians, such as developmental-behavioral pediatricians, are accepted under the LMHP diagnostic requirement.

Summary of requests:
•  Allow comprehensive diagnostic evaluations by telehealth or in person.
•  Extend the provisional diagnosis pathway to all youth under 21 with a documented waitlist or scheduled appointment.
•  Allow services to continue without added review while a family remains on a documented waitlist.
•  Accept family- or provider-submitted waitlist documentation.
•  Broaden the accepted screening tools.

Thank you for considering these comments. Virginia’s Medicaid-enrolled children with autism, particularly those in rural communities, deserve timely access to diagnosis and treatment. The diagnostic rules should not add barriers beyond the provider shortage they already face.

Respectfully,

Annie Taggart, BCBA, LBA