Trade groups, clinics and parents urged DMAS to make 20 hours a review trigger, count only direct treatment and honor existing autism diagnoses.
Key Takeaways
- A diagnosis gate with defined proof: DMAS’s proposed Medicaid ABA manual requires an in-person evaluation by a Licensed Mental Health Professional, using a tool such as the ADOS, ADI-R or CARS, before ABA is authorized.
- A limit most young children already pass: DMAS data show more than half of children 4 and under in Virginia Medicaid ABA had weeks of 20 or more hours in 2025, and the draft routes every request above 20 hours to EPSDT review.
- What providers asked for: Commenters urged DMAS to call 20 hours a review threshold, define which codes count, allow telehealth evaluations and accept diagnoses children already have.
- What is still unknown: DMAS has not posted a final manual, and CMS has not publicly acted on the state plan amendment Virginia filed August 7.
Virginia’s Department of Medical Assistance Services (DMAS) listed October 22 as the planned effective date for a rewrite of the Medicaid manual section that governs applied behavior analysis. The proposed update to Appendix D of the Mental Health Services Manual would require an autism spectrum disorder diagnosis before ABA can be authorized, define how that diagnosis must be documented, and write the 20-hour weekly limit from Virginia’s 2026 budget into the service authorization rules.
The public comment period on the Virginia Regulatory Town Hall closed at 11:59 p.m. on October 21 with 62 comments. As of October 22, DMAS had not posted a final version, and the state plan amendment Virginia sent to CMS on August 7 to carry the same changes showed no federal approval. Acuity has requested comment from DMAS.
Acuity reported in July that Virginia’s budget directed DMAS to cap Medicaid ABA at 20 hours a week and require an autism diagnosis, and in September that the state had moved its diagnosis line into statute as CMS urged states to draw the same line. The proposed manual is the first detailed look at how DMAS intends to run both requirements in daily authorization, and the comments filed against it, from national and state trade groups, provider organizations, behavior analysts and parents, are the field’s first formal response.
What Virginia’s Proposed Medicaid ABA Manual Requires
The current Appendix D admits a youth under 21 who meets criteria for a primary ICD diagnosis that correlates to a DSM diagnosis, or who has a provisional psychiatric diagnosis from a Licensed Mental Health Professional (LMHP) when no definitive diagnosis has been made. The word autism does not appear in those criteria. The proposed version strikes that language and replaces it with two paths: an autism spectrum disorder diagnosis (ICD-10 code F84.0) by an LMHP acting within their scope of practice, or, for youth 5 and younger, a provisional autism diagnosis from an LMHP.
The functional criteria stay the same. A youth must still show at least two of five listed impairments, covering functional communication, social interaction, intense behavioral outbursts, repetitive or ritualized behaviors, and sensory integration, and a family member or caregiver must be available to take part.
What changes most is the paperwork at the front door. For an initial authorization, a provider would submit a comprehensive diagnostic evaluation, conducted in person, that confirms the autism diagnosis and uses an evidence-based tool such as the Autism Diagnostic Interview-Revised (ADI-R), the Autism Diagnostic Observation Schedule (ADOS) or the Childhood Autism Rating Scale (CARS). The evaluation must name the evaluator and list their credential and Type 1 National Provider Identifier.
Who Can Diagnose Autism for Virginia Medicaid ABA
Virginia would accept a diagnosis from an LMHP acting within their scope of practice. Virginia’s regulations define the LMHP category to include, among others, physicians, licensed clinical psychologists, Licensed Professional Counselors, Licensed Clinical Social Workers, Licensed Marriage and Family Therapists and licensed substance abuse treatment practitioners. The state plan amendment uses broader language, requiring an evaluation by a licensed professional with expertise in autism evaluation, as defined by DMAS, and allowing a provisional diagnosis by a qualified prescriber or licensed practitioner.
That is a wider door than Kansas is building. Under KMAP General Bulletin 26140, Kansas Medicaid will accept autism diagnoses for ABA from November 1 only from doctoral-level psychologists and a list of qualified physicians. Alabama’s pediatrician referral rule remains paused, Michigan’s Bulletin MMP 26-18 kept a broad diagnostic list, and Texas added Nurse Practitioners and Physician Assistants as diagnosticians this summer for its state-funded Children’s Autism Program.
Virginia’s in-person requirement is the tighter piece. The proposed text asks for a comprehensive evaluation conducted in person to support a full diagnosis, which on its face excludes evaluations done entirely by telehealth.
Provisional Autism Diagnosis Rules for Children 5 and Younger
The budget allowed children 5 and younger to receive ABA on a provisional diagnosis for one year under a protocol DMAS would designate. The proposed manual sets out that protocol in two age bands. For children 36 months or younger, a provider would submit the name, credential and NPI of the LMHP who made the provisional diagnosis, results from an autism screening tool such as the Rapid Interactive Screening Test for Autism in Toddlers (RITA-T) or the Screening Tool for Autism in Toddlers and Young Children (STAT), and evidence of a scheduled diagnostic appointment or a place on a waitlist. For children 37 months through 5 years, the same documentation applies without the screening tool.
Two checkpoints follow. If a full evaluation has not been completed within the first six months of ABA, the provider must submit updated proof of the appointment or waitlist placement along with evidence of continued medical necessity. If the child still has no final diagnosis 12 months after starting ABA, further requests move to review under EPSDT, Medicaid’s benefit for children and youth under 21, and must include current, dated proof of the appointment or waitlist placement obtained directly from the evaluating entity, documentation of continued indicators consistent with autism, and evidence that ABA has produced clinical benefit.
The 20-Hour Weekly ABA Limit and EPSDT Review
The proposed manual states that ABA services are authorized on medical necessity and may not exceed 20 hours a week, except as authorized under EPSDT review. As Acuity reported in August, a December 2025 DMAS bulletin already required substantial justification above 20 hours; the rewrite turns that threshold into a stated limit.
Requests above 20 hours would need an individualized schedule of the activities that structure each session and a description of how each activity advances the treatment goals. Clinic-based schedules would have to separate time spent in therapeutic interventions from recreational and non-therapeutic time, and a general schedule of clinic activities would not be enough.
The proposal also adds a protection. All ABA service requests would be reviewed under EPSDT criteria before any denial, including requests for youth who do not meet the diagnostic criteria and requests above 20 hours. The state plan amendment exempts services delivered by local education agencies through the school-based program from both the diagnosis requirement and the 20-hour limit.
What DMAS Data Shows About ABA Hours in Virginia
DMAS’s own numbers show how many children the 20-hour line would reach. At the first meeting of the state’s ABA Utilization Workgroup on September 22, the agency reported that children 4 and under and children 5 to 10 make up about 90 percent of the children receiving ABA. According to the meeting’s slide deck, 55 percent of the 3,563 children 4 and under served in 2025 received between 20 and 38 hours in a week, and about 16 percent received 38 hours or more. Among the 6,152 children ages 5 to 10, the figures were 43 percent and about 10 percent. DMAS noted that a child could be counted in more than one band.
The same deck reported that 88 percent of children who received ABA in 2025 had an autism diagnosis. Sentara Health Plans, presenting its own claims, said autism accounted for 87.8 percent of its 2025 ABA spending, or $80.7 million, and that the largest non-autism categories were led by combined-type ADHD at $2.09 million. Sentara cautioned that diagnosis codes on claims do not by themselves establish whether the treatment was clinically indicated. A utilization slide in the managed care section of the deck reported that, over the 12 months ending in March 2026, providers requested an average of 22.9 hours a week while delivering 14.28 hours across all service codes.
Mariel Fernandez, Vice President of Government Affairs at the Council of Autism Service Providers (CASP), presented the trade group’s practice guidelines at the same meeting. Her slides describe focused treatment as typically under 25 hours a week and comprehensive treatment as typically more than 25, and state that soft caps are permissible as a utilization tool but may not function as a de facto hard cap. The question of how intensity relates to outcomes is one Acuity examined when seven providers benchmarked their own results.
What Providers Told DMAS in 62 Public Comments
Most of the comments concerned the 20-hour language. In its filing, CASP recommended that DMAS state that 20 hours a week “is a utilization-management threshold, not a limit” on medically necessary ABA. The Virginia Association for Behavior Analysis (VABA) asked DMAS to define how hours are counted, noting that a week of 20 treatment hours that includes two hours of concurrent clinical direction would register as 22 and trigger review. VABA recommended counting face-to-face time with the youth once, regardless of how many staff bill, and asked DMAS to confirm it has completed, or will complete, the comparative analysis federal parity rules require for limits of this kind.
Providers described what the language would mean in practice. Callie Plattner, Chief Clinical Officer of Mosaic Pediatric Therapy, which operates eight clinics in the Richmond region and Southwest Virginia, wrote that Virginia providers report at least one managed care organization already issues at least partial denials on every request above 20 hours. “The current standard asks whether more hours are medically necessary,” she wrote. “The proposed standard presumes they are not.” Sarah Coffey, Vice President of Operations at Behavioral Innovations, which runs three centers in the state, wrote that roughly 80 percent of its 27 Virginia children are authorized at or above 20 hours a week of direct treatment under code 97153 alone.
The diagnostic rules drew the next largest share. Several behavior analysts, including staff at Paragon Autism Services, filed identical comments arguing that once a qualified LMHP establishes a diagnosis, “that diagnosis should be accepted for accessing ABA services,” and that providers should not have to audit how an existing evaluation was done. The Virginia Association of Community-Based Providers put evaluator waitlists at about one year and asked DMAS to confirm that children already in treatment will not need re-evaluation. Behavioral Innovations noted that the current manual places no age limit on provisional diagnoses. “The age limit does not add a safeguard,” Coffey wrote. “It closes a door that is open today.”
Many individual comments repeated shared language, and several came from staff of the same organizations, including at least eight connected to Golden Steps ABA. Parents filed some of the most personal entries. Luvey Evans, the mother of a nonverbal 3-year-old with Level 3 autism, wrote that medical necessity should set treatment intensity, “not a predetermined number of hours established for administrative purposes.” Parents and providers also objected to the manual’s weekly family-involvement requirement and its discharge rule after a lapse of more than 31 days. Not every comment favored more ABA. One commenter questioned the therapy’s evidence base, citing a survey in which most autistic respondents opposed its use with children, and argued that time spent in ABA displaces speech, occupational and communication therapies.
Several filings also credited DMAS. RCG Behavioral Health Network said it particularly supported requiring EPSDT review before any denial, and Behavioral Innovations called that protection stronger than what exists in most states where it operates.
What Comes Next for Virginia Medicaid ABA Providers
DMAS told providers in a July bulletin that it would announce the effective date for the ABA changes in a later notice, after CMS approves them and the manual update is complete. The planned October 22 date on the Town Hall listing marks DMAS’s target for the manual. It does not by itself confirm federal approval. Federal rules give CMS 90 days from receipt of a state plan amendment to approve it, disapprove it or request more information.
The workgroup is the other venue. The budget directs it to evaluate the appropriateness of ABA for children with diagnoses other than autism, and VABA asked DMAS to treat the hour-counting and documentation provisions as interim until the workgroup reports. Commenters including CASP and VABA also flagged that the draft still references Category III codes 0362T and 0373T, which the 2027 CPT code set deletes on January 1, a change Acuity covered in its report on the coding coalition’s guidance for 2027.
For providers, the practical demand is evidence on file: an in-person evaluation, a named evaluator with an NPI and a validated tool for new referrals, and appointment or waitlist proof that stays current for provisional cases. The proposed text does not say whether youth already authorized under the current criteria must submit new diagnostic documentation at their next continued-stay request, or which codes count toward 20 hours. Those two answers, more than the effective date, will decide how much of the change lands on children already in care.
