Re: Comments on Proposed Revisions to the Mental Health Services Manual, Appendix D — Applied Behavior Analysis Services

On behalf of Sparks, thank you for the opportunity to comment on the Virginia Department of Medical Assistance Services’ (DMAS) proposed revisions to the Mental Health Services Manual, Appendix D, governing Applied Behavior Analysis (ABA) services. Sparks has been providing ABA services in Virginia since 2018, and we currently support over 100 families.

Sparks appreciates DMAS’s efforts to clarify service authorization requirements, strengthen documentation of medical necessity, promote family involvement and care coordination, and support appropriate oversight of ABA services. We particularly appreciate the proposed pathway for authorizing services exceeding 20 hours per week through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) process, as well as the provisions addressing access to ABA for young children who are awaiting a comprehensive diagnostic evaluation.

We support efforts to ensure that Medicaid-funded services are medically necessary, appropriately documented, and delivered in accordance with generally accepted standards of care. We offer the following comments and recommendations to support effective implementation of the proposed policy while preserving access to individualized, medically necessary treatment for children and families enrolled in Virginia Medicaid.

1. Diagnostic Evaluation Requirements for Young Children

Sparks appreciates DMAS’s recognition that young children may experience delays in obtaining a comprehensive diagnostic evaluation for autism spectrum disorder (ASD) and that those delays should not necessarily prevent access to needed treatment. The proposed provisions establishing a pathway for children age 5 and younger to receive ABA services with a provisional diagnosis represent an important effort to address this challenge.

We request clarification regarding the proposed in-person comprehensive diagnostic evaluation (CDE) requirement. Given the limited availability of qualified diagnostic professionals in some communities, an in-person-only requirement could create an additional barrier for families already experiencing lengthy wait times. We encourage DMAS to clarify whether evaluations conducted through clinically appropriate telehealth modalities may satisfy this requirement when permitted under applicable professional standards and licensing rules.

We also recommend that DMAS clarify the documentation necessary to demonstrate that a comprehensive diagnostic evaluation has been scheduled or that a child is on a waiting list. Clear expectations would help providers and managed care organizations (MCOs) implement these provisions consistently and reduce avoidable administrative delays.

Finally, we recommend clarifying whether the diagnostic instruments identified in the proposed policy are illustrative rather than exhaustive. Language such as “including, but not limited to” would recognize that qualified diagnostic professionals may appropriately select other validated instruments or combinations of assessment methods based on the child's presentation, the professional's training and expertise, and the circumstances of the evaluation.

2. EPSDT Review and Authorization of More Than 20 Hours per Week

Sparks appreciates DMAS’s explicit recognition that ABA services may exceed 20 hours per week when medically necessary and authorized through EPSDT review. We support establishing a clear process through which providers can demonstrate the clinical rationale for requested treatment intensity.

We encourage DMAS to clarify that requestions over the 20-hour threshold warrant EPSDT review, and are not a firm  limitation on medical necessity of ABA services. Treatment intensity should be determined by each beneficiary’s unique clinical presentation, considering both behavioral excesses and skills in need of development. We encourage DMAS to ensure that EPSDT determinations remain individualized and that requests are not denied solely because a beneficiary is recommended to receive more than 20-hours per week.

The proposed requirement for an individualized schedule of activities for requests exceeding 20 hours per week is understandable as a means of demonstrating the therapeutic purpose of requested services, particularly during extended sessions in a clinic setting. Sparks supports documentation that explains how requested hours will be used and how planned activities relate to treatment goals. We agree that, in the absence of an identified treatment goal, activities of daily living are not billable services.  We recommend DMAS clarify that schedules are intended to describe the planned distribution of treatment activities throughout the day/week, rather than prescribe the exact activity that must occur during every discrete time period.

Generalization is a critical component of ABA services, and for many clients with ASD, it would be contraindicated to practice the exact same skills at the exact same time each day. Providers should retain appropriate flexibility to modify the order and presentation of therapeutic activities, to maximize client participation and progress. 

We further recommend that DMAS clarify that activities must be related to a treatment goal, in order to be billable, rather than implementing a blanket prohibition on activities that appear recreational (in the absence of additional context). For example, many treatment goals are implemented during activities such as play, location transitions, and peer interactions. Such activities may serve important therapeutic purposes when incorporated into individualized treatment plans, linked to measurable objectives, and supported by appropriate data collection. The therapeutic nature of an activity should be evaluated based on its clinical purpose and documentation (or lack thereof) of treatment goals, rather than the name of an activity or setting. This clarification would help ensure that medically necessary treatment is not inadvertently excluded from authorization because of how an activity is categorized.

3. Continued Authorization for Children with a Provisional Diagnosis

Sparks appreciates the proposed provisions allowing continued consideration of ABA services for children age 5 and younger who have not obtained a definitive ASD diagnosis within 12 months of beginning services. The proposed pathway recognizes the importance of considering ongoing behavioral and developmental concerns, continuity of care, and efforts to obtain a comprehensive diagnostic evaluation.

We support a process that considers these factors together rather than making access to continued services dependent solely on the availability of an outside diagnostic appointment. We encourage DMAS to clarify how these provisions will be applied when families and providers have made reasonable efforts to obtain an evaluation but remain on a lengthy waiting list. We also recommend that the policy clearly distinguish between the documentation necessary to demonstrate ongoing efforts to obtain a CDE and the clinical information necessary to demonstrate continued medical necessity. This would promote consistent implementation and help prevent administrative delays when diagnostic access remains outside the family’s or provider’s control.

4. Family Participation and Caregiver Involvement

Sparks supports meaningful caregiver involvement with all of our clients. We recognize the value of caregiver education, training, and collaboration in supporting treatment progress and generalization. Despite our best efforts, there are circumstances in which a caregiver is not able to consistently participate in scheduled meetings or practice goals outside of session, particularly when there are multiple children with disabilities in the family and when a caregiver is navigating their own medical needs. Caregiver barriers should not interfere with a child’s access to medically necessary ABA services. 

We recommend that DMAS clarify how providers should address circumstances that limit caregiver participation, despite reasonable efforts to engage the family. The policy should permit individualized planning, alternative approaches to caregiver education and training when appropriate, documentation of barriers and engagement efforts, and clarification that failure to meet caregiver participation requirements should not be the basis for a denial of ABA services.

5. Care Coordination Requirements

Sparks supports coordination with primary care providers and other relevant treating professionals when appropriate and consistent with applicable consent and privacy requirements. We recommend that DMAS clarify that care coordination requirements are satisfied through documented, reasonable efforts when such communication depends on the response or cooperation of another provider. ABA providers cannot ensure that a primary care provider or other treating professional will respond to outreach or participate in coordination activities. The policy should require documentation of the efforts made to coordinate care and any barriers encountered, rather than making successful coordination a condition for continued service authorization. This approach would preserve the importance of coordinated care while recognizing circumstances outside the ABA provider’s control.

Conclusion

Sparks appreciates DMAS’s work to clarify Virginia Medicaid’s ABA service requirements and recognizes several constructive elements of the proposed revisions, particularly the pathway for authorizing services exceeding 20 hours per week through EPSDT review and the provisions addressing diagnostic access for young children.

We encourage DMAS to retain these access-oriented provisions while clarifying the implementation of diagnostic evaluation requirements, treatment schedules, documentation standards, family participation, and care coordination. We also encourage DMAS to ensure that ESDPT review requirements are applied in a manner that supports individualized medical necessity determinations and preserves appropriate clinical judgment.

Clear, consistent, and workable requirements will help providers demonstrate medical necessity, maintain appropriate clinical oversight, and deliver individualized treatment to children and families who rely on Virginia Medicaid.

Thank you for your consideration of these comments and for the opportunity to contribute to the development of this policy. Sparks welcomes continued engagement with DMAS as the Department finalizes the proposed revisions.

Sincerely,

Kayla Bagnato M.Ed., BCBA, LBA

Regional Clinical Director
Sparks