EMG Consulting appreciates the opportunity to comment on the draft revisions to Appendix D. EMG is a clinician-owned behavior analytic practice founded in 2008 and based in Virginia Beach. We serve families across the Commonwealth through ABA services under Appendix D and through Therapeutic Consultation under the DD Waivers, and much of our work is with individuals with intellectual and developmental disabilities and significant behavioral needs. That work gives us a clear view of who these revisions will affect, and of the gaps they may fall into.
EMG supports DMAS’s goals of clear medical necessity documentation, consistent administration across MCOs, and meaningful family involvement. We endorse the comments submitted by the Council of Autism Service Providers (CASP) and the Virginia Association for Behavior Analysis (VABA) and will not repeat their analysis here. Instead, we offer what we see in practice.
Youth Without an ASD Diagnosis
We understand that Item 291.WW.2 requires an ASD diagnosis before DMAS authorizes ABA. Many of the youth who will fall outside that requirement have intellectual or developmental disabilities with severe self-injury, aggression, or pica. Left untreated in childhood, these behaviors tend to worsen and become harder to change with age.
Through our work providing Therapeutic Consultation under the DD Waivers, we see what happens when behavioral needs go unaddressed early. Individuals and families come to rely on waiver services, crisis supports, and more restrictive settings to manage behavior that might have been reduced years earlier. The waiver system itself faces real challenges, including limited slots for those without the highest-priority status and a shortage of qualified providers. Those challenges hit hardest on families whose needs have grown over the years. Access to ABA services under Appendix D during childhood is one of the most effective ways to prevent that path.
The draft states that EPSDT will review all ABA requests before denial, and we support that safeguard. For it to work, providers and MCOs need to know what a complete request looks like for a youth without an ASD diagnosis. We join VABA in asking DMAS to state the minimum documentation required for these requests, so that families with the same clinical needs get the same answer regardless of their health plan.
Continuity of Care
We ask DMAS to address youth already in active treatment without an ASD diagnosis when the revised manual takes effect. They should continue receiving services under EPSDT review while their authorizations are evaluated, rather than face a gap in care. An abrupt stop to effective treatment for severe behavior puts the youth, their families, and sometimes their placements at risk.
Diagnostic Access
Waits for a comprehensive autism evaluation in Virginia often run many months, and longer outside major metro areas. A child whose diagnosis is delayed by a waitlist should not also wait for treatment. We support the draft’s provisional diagnosis pathway and ask that DMAS keep it flexible enough to bridge those waits.
Points We Want to Underscore
Of the recommendations CASP and VABA have made, EMG wants to emphasize three:
The 20-hour threshold should trigger additional review, not cap medically necessary care. The number of hours requested should never, by itself, be a basis for denial.
Services should not be reduced or terminated because of barriers to caregiver participation when the provider has documented its efforts to engage the family and the youth continues to benefit. Many of the families who need these services most are single parents, shift workers, caregivers of several children with disabilities, or families far from services.
Care coordination should be satisfied by documented good-faith efforts. Providers cannot make another practice respond.
Closing
EMG shares DMAS’s commitment to services that are medically necessary, well documented, and consistently administered. We appreciate the Department’s consideration and would welcome the chance to share our perspective on ABA and DD Waiver services as these provisions are finalized.
Respectfully submitted,
Elizabeth Matthews, Ed.D., BCBA, LBA
Chief Executive Officer
EMG Consulting