On June 29th, the Virginia governor and members of the GA finalized the budget, which will go into effect on July 1. Throughout the recent General Assembly, we let you know about some concerning language in the drafted budget that could result in restricted access to Medicaid-funded Applied Behavior Analysis (ABA) services. Here is what you need to know:
What Passed: The ABA Utilization Cap
The governor’s office and members of the General Assembly were largely unmoved by our advocacy efforts to strike the weekly 20-hour cap on ABA recipient hours and the requirement that services be restricted to a diagnosis of autism spectrum disorder.
This provision, found in Item 291.WW.2, originated in the outgoing Youngkin administration’s budget proposal rather than as a new initiative from Gov. Spanberger or the current General Assembly. That distinction did not change the outcome: the fiscal realities of Medicaid spending growth made this a difficult provision to dislodge once budget negotiations were underway, and our advocacy was not enough to move the new administration or the General Assembly to strike it this session.
This is the budget language signed into law by Gov. Spanberger:
“The Department of Medical Assistance Services (DMAS) shall impose a 20 hour per week cumulative limit per recipient on services provided under ABA, effective July 1, 2026; such limit can be exceeded based upon documented medical necessity under early and periodic screening, diagnostic and treatment (EPSDT). The department shall require a diagnosis of autism spectrum disorder prior to authorizing ABA services. DMAS shall have the authority to amend the state plan under Titles XIX and XXI of the Social Security Act to effect these changes. DMAS shall provide guidance to ABA providers and facilities on required ABA documentation and shall coordinate with managed care organizations (MCO) to perform periodic pre- and post-payment reviews of ABA payments. DMAS shall require specific reporting from each MCO that can be analyzed across MCOs, by region, by provider, and at a statewide level. The requirements in this amendment do not apply to behavior therapy provided by local education agency providers and reimbursed through the fee-for-service Medicaid school-based services program. The department is authorized to promulgate emergency regulations to implement this change within 280 days or less from the enactment of this act. The department shall implement this change upon federal approval and prior to the completion of any regulatory process undertaken in order to effect such change.”
What We Secured: Two Key Amendments
However, we did find success with two amendments we advocated for.
Item 291 #18c added a provision stating that: “Children age 5 and younger may receive a provisional diagnosis for one year utilizing a protocol designated by DMAS.” This means that children who present with developmental delays but do not have a formal diagnosis of ASD have a pathway to receive Medicaid-funded ABA services while pursuing a comprehensive evaluation.
Item 291 #13c obligates DMAS to establish an ABA workgroup, where VABA will have a seat at the table to better educate policymakers about nuances within ABA practice, offer solutions to disincentivize practice that does not meet well-established standards within our field, as well as propose improved ways for DMAS to oversee this benefit—especially towards identifying better efficiency that could result in more clarity for providers, better care for service recipients, and taxpayer savings. This is the language for Item 291 #13c:
“The Department of Medical Assistance Services (DMAS) shall convene an ABA benefit Utilization Workgroup for the purpose of examining Medicaid expenditures and utilization trends for this service and identifying strategies to control costs while still preserving access to care for those in need of the therapy. The workgroup shall: (i) identify utilization trends, including trends among those with different diagnosis acuity levels; (ii) examine different delivery methods of ABA services and their impact on utilization; (iii) review utilization and service authorization criteria including standard assessment tools and diagnostic criteria taking into account differing service intensity and duration requirements; (iv) evaluate utilization management tools that align with national clinic practice guidelines promulgated by independent national nonprofit organizations; (v) define medical necessity criteria taking into account behavioral factors, ability to learn, age and development, and skills development including clear criteria for eligibility, scope of services and documentation requirements; (vi) review provider qualification recommendations related to ABA practitioner certification and licensing; and current supervision requirements and standards to help ensure appropriate clinical oversight; (vii) evaluate the appropriateness of ABA services for children with diagnoses other than ASD; and (viii) review the MCO annual reporting data to identify any areas of potential improvement to the delivery of services and any needed changes in regulations or policies from DMAS. The workgroup shall include stakeholders, including ABA service providers, including center-based models and home-based models, representatives from managed care organizations serving Medicaid patients, Virginia licensed behavioral analysts, and a child or adolescent psychiatrist. The workgroup meetings shall be open to the public and offer opportunities for public input.”
What’s Next: The SPA Process
One key next step in this process involves DMAS filing a State Plan Amendment (SPA) with the Centers for Medicare and Medicaid Services—the federal agency that manages and oversees all things Medicaid, among other things. When a state is planning to make a change to its program policies or operational approach, states send SPAs to CMS for review and approval.
While VABA’s Public Policy Committee is not optimistic that CMS will reject Virginia’s SPA outright, rejection remains possible given potential compliance issues under federal law (e.g., the Mental Health Parity and Addiction Equity Act and Early and Periodic Screening, Diagnostic, and Treatment requirements).
The Policy Committee and VABA Board of Directors will continue to monitor the status of the SPA filing and keep our membership updated.
If you have any questions or need support, please contact us at admin@virginiaaba.org. Interested in becoming more involved with the policy committee around this or other issues? Email policy@virginiaaba.org