RCG Behavioral Health Network appreciates DMAS’s efforts to clarify ABA medical-necessity and authorization requirements. We particularly support the proposed language requiring EPSDT review before the denial of services for a Medicaid member under age 21.

We are concerned, however, that the statement that ABA services “may not exceed 20 hours per week” could be interpreted by MCOs as a categorical benefit limit rather than an enhanced-review threshold. Treatment intensity should continue to be determined according to each youth’s individualized medical necessity. We recommend replacing this language with a requirement that requests exceeding 20 hours include enhanced clinical documentation and receive individualized EPSDT review.

DMAS should also clarify that EPSDT review is automatic before any adverse determination. Providers and families should not be required to initiate a separate EPSDT process after an initial denial, and an MCO should not reduce a request to 20 hours without first evaluating the complete clinical record and issuing an individualized medical-necessity determination.

RCG supports appropriate diagnostic evaluation, but access to qualified ASD diagnosticians remains limited in many areas of Virginia. Continued ABA services should not be denied or interrupted solely because a child remains on a diagnostic waitlist or because an external evaluator has not supplied appointment documentation, credential information, or a Type 1 NPI. When the provider documents continued medical necessity, clinical benefit, and reasonable efforts to obtain an evaluation, treatment should continue while that evaluation is pending.

We further recommend clarifying that ADI-R, ADOS, and CARS are examples rather than an exclusive list of acceptable instruments; permitting other validated evaluation methods, including clinically appropriate telehealth or hybrid evaluations; and allowing reasonable alternative documentation when information must be obtained from an independent evaluator.

Finally, we request adequate implementation protections. Existing authorizations should remain effective through their approved periods, the requirements should apply prospectively without retroactive recoupment, and providers and MCOs should receive standardized instructions and at least 90 to 180 days to implement the final requirements.

These revisions would preserve DMAS’s program-integrity objectives while reducing unnecessary treatment delays and ensuring that authorization decisions remain individualized, clinically driven, and consistent with EPSDT.