I am an Operations Manager at an ABA company serving children and families throughout the state of Virginia, most of them being covered by Medicaid. In my role, I work closely with the operational processes that support access to ABA services, including scheduling, authorizations, staffing coordination, and communication with families. I support DMAS’s goals of accountability, quality, and appropriate documentation. However, I am concerned that several of the proposed changes to Appendix D could create additional barriers to care, increase delays, and make it more difficult for families to access services that meet their children's individual needs.

Weekly Service Hours 

Children receiving ABA services have different needs, and the amount of treatment appropriate for each child should be determined through an individualized clinical assessment. I support many children under my purview who require thirty hours a week of therapy and have benefited greatly from it. I encourage DMAS to clarify that the 20-hour threshold triggers a review rather than functioning as a cap on services. I also suggest that only direct treatment hours count toward the threshold, excluding caregiver training, supervision, and assessment activities so that they don't use up the child's hours.

EPSDT Review and Continuity of Care 

Timely authorization decisions are essential to maintaining consistent services for children and their families. When requests for additional hours require further review without a clearly defined process, providers may face scheduling uncertainty, administrative backlogs, and difficulty maintaining continuity of care. I encourage that a BCBA or other ABA expert do these reviews within the standard 7- day timeframe and current service hours should continue while a timely request is being reviewed. 

In-Person Diagnostic Evaluations 

Requiring diagnostic evaluations to be completed exclusively in person will create additional obstacles for families who already experience long waitlists, transportation challenges, scheduling limitations, or limited access to qualified evaluators in their area. Many diagnostic practices I have spoken to have long waitlists, some of up to two years, requiring in person diagnostic evaluation will make these considerably longer. These barriers can delay the process of beginning appropriate services during the years where intervention is most important. I encourage DMAS to allow clinically appropriate telehealth evaluations when an in-person appointment is not reasonably available within an appropriate timeframe or distance. I ask that DMAS should also accept evaluations children already have.

Provisional Diagnoses for Young Children 

Allowing young children to access appropriate ABA services under a provisional diagnosis can help reduce barriers during a critical developmental period while additional diagnostic evaluation is pursued. Delays in obtaining evaluations can complicate intake, care coordination, and families' ability to access timely support. I therefore support letting children five and under start ABA services with a provisional diagnosis. I also recommend establishing a clear pathway for children older than five who encounter diagnostic waitlists to receive an individualized EPSDT review.

Family Participation 

Family involvement is an important part of ABA services, but many families may face circumstances that make consistent weekly participation difficult, including work schedules, transportation issues, medical emergencies, and other caregiving responsibilities. From an operational perspective, rigid participation requirements may place additional pressure on families who are already working to balance treatment with daily responsibilities. I encourage DMAS to require documented efforts to engage and support families before discharge is considered solely because of participation barriers, while allowing reasonable exceptions for extenuating circumstances.

I respectfully encourage DMAS to review the proposed provisions to ensure that accountability measures support, rather than unintentionally restrict, timely access to medically necessary ABA services for Virginia Medicaid beneficiaries.

Thank you for considering these comments and for your commitment to improving access to care for children and families across Virginia.