My name is Nate, and I serve as the Virginia State Director for Total Care ABA. My work involves helping families access treatment, recruiting qualified clinicians, and expanding exceptional care into communities that have been underserved for far too long. Virginia presents a unique challenge: while some communities have access to major healthcare systems, others are hours from the nearest qualified professional. In healthcare, workforce shortages are not merely an operational inconvenience. They determine whether a child receives care at all.

I have spoken with parents waiting 18 months or longer for an autism evaluation, assuming they can even secure a place on a waiting list. Once they finally receive a diagnosis, many begin another search for treatment. In parts of Virginia, available BCBAs are separated by hundreds of miles. Our own clinicians have driven more than five hours (each way) to conduct an in-person assessment because there was a child at the other end of that drive who needed help. I have heard parents break down on the phone after months or years of searching, exhausted and unsure where else to turn. These are not hypothetical challenges. They are the realities families face before the proposed changes to Appendix D are even considered.

I recognize the importance of clinical accountability, appropriate utilization, and responsible Medicaid oversight. However, the proposed requirements must be evaluated against the realities of an already strained system. The 20-hour weekly limit, even with EPSDT protections, may create additional delays for children requiring intensive treatment. In-person assessment and diagnostic evaluation requirements present substantial challenges in communities where qualified professionals are hours away. Narrower diagnostic eligibility risks further delaying care, despite provisional allowances for younger children. Increased documentation requirements must remain clinically meaningful and manageable for an already limited workforce. Individually, these provisions may appear reasonable. Together, they risk creating additional barriers for children who have already waited far too long. I am particularly concerned about caregiver participation and continuity-of-care requirements. We serve children involved with DSS, children in foster care, and children who have experienced unsafe or unpredictable home environments. Some have already endured more instability than any child should have to experience. For these children, consistency is not simply a clinical consideration; it may be something they have rarely known. Somewhere amid changes in homes, caregivers, and the people they depend on, there is a clinician who continues to show up. A familiar face, a predictable routine, and a relationship built slowly through trust. For some of these children, our team may be one of the few constants in their lives. That is why the 31-day discharge provision deserves particular scrutiny. When treatment is interrupted by staffing shortages or circumstances beyond a family's control, requiring a new assessment and authorization risks prolonging the disruption. We should be making every reasonable effort to preserve those relationships, not allowing administrative processes to become another source of uncertainty. A child who has spent much of their life adjusting to people leaving should not have to lose another source of stability because the system could not keep up.

I urge DMAS to examine the cumulative impact of these requirements and establish meaningful safeguards: timely access to medically necessary care under EPSDT, practical assessment options for underserved communities, protections against diagnostic delays, reasonable caregiver accommodations, workable documentation standards, and continuity-of-care protections when interruptions are beyond a family's control. I would welcome the opportunity to meet with DMAS leadership, share what we are witnessing firsthand, and contribute to solutions that uphold clinical accountability without sacrificing access to care.

Behind every regulation is a family that must live with its consequences. Behind every authorization is a child who cannot afford another year of waiting. Virginia already has an access problem. We have a responsibility to solve it, not make it harder for families to overcome.

Our clinicians have driven more than five hours to a child who needed someone to show up. I hope that same child can count on the people making these decisions to show up for them, too.

Respectfully,

Nate

757-578-1996