As a Board Certified Behavior Analyst (BCBA) and Clinical Director with approximately eight years of experience working with children with autism, I am deeply concerned about Virginia’s proposed implementation of a 20-hour-per-week limit on Applied Behavior Analysis (ABA) services.

Throughout my career, I have worked with children who have significant communication deficits, severe behavioral challenges, and difficulties with essential daily living skills. I have also witnessed firsthand the incredible progress that can occur when children receive consistent, individualized, medically necessary treatment.

ABA is not a one-size-fits-all treatment, and neither should the number of hours a child receives be. Some children may make meaningful progress with 10–20 hours per week, while others require 25–40 hours to appropriately address their clinical needs. Treatment recommendations should be based on comprehensive assessments, individualized goals, behavioral severity, and ongoing clinical data, not a predetermined number of hours.

Many of the children we serve struggle with behaviors such as aggression, self-injury, and elopement, which can present serious safety concerns. Others have significant communication and adaptive skill deficits that require consistent intervention across environments and daily routines. Arbitrarily restricting treatment hours risks limiting opportunities to develop functional communication, independence, social skills, and safer alternatives to challenging behaviors.

I am also concerned about the additional barriers this could create for families. Parents already navigate lengthy diagnostic processes, insurance authorizations, and difficulties accessing services. Requiring additional justification to exceed 20 hours could result in treatment delays, unnecessary administrative burdens, and disruptions in care, particularly for children with the most significant needs.

While I recognize that the proposed policy includes an exception for documented medical necessity under EPSDT, it is essential that this process be clear, timely, accessible, and consistently applied across insurance providers. Children should not have to experience interruptions or reductions in medically necessary treatment simply because their needs exceed an established threshold.

Additionally, I strongly encourage clarification regarding whether the 20-hour limit includes only direct treatment or also encompasses BCBA supervision, treatment planning, and caregiver training. These services are essential components of effective ABA treatment and should not come at the expense of a child’s medically necessary direct intervention hours.

I understand the importance of responsible healthcare spending and appropriate utilization of services. However, reducing access to early, individualized intervention may create greater challenges for children and families in the long term.

Medical necessity should determine treatment intensity, not an arbitrary weekly limit.

I strongly urge Virginia policymakers and DMAS to preserve individualized treatment recommendations, ensure meaningful access to medically necessary services beyond 20 hours, and involve practicing clinicians and families in decisions that directly affect the children we serve.

These decisions have real consequences for real children and families. Every child deserves access to the level of care necessary to develop meaningful skills, improve their quality of life, and reach their fullest potential.