Virginia Won't Pay for Clinic-Based ABA Unless the Plan Says Why It's in a Clinic

Virginia's Department of Medical Assistance Services opened a December 16, 2025 bulletin by saying it “has been made aware of actions that are not in compliance with existing ABA rules,” and that non-compliance “may result in negative consequences, including retraction of Medicaid payments.” It then told its authorization contractor, Acentra Health, and the Cardinal Care plans to build five clarifications into both authorization and program integrity reviews.

It's called a reminder. The instruction to reviewers is what makes it an enforcement document, and it has been in force for nine months.

The turn: three rules aimed at one model

Read together, three of the five are about the clinic or center-based program.

• The setting needs a reason. “Services provided in a clinic or office setting without documented clinical justification for the location in the Individual Service Plan (ISP) are not covered.” Continued authorization also needs a summary of progress toward generalization “in multiple settings.”
• Families have to be in it. For clinic, office or center-based services, “Direct family involvement in the treatment program is required at a minimum of weekly and must be documented in the ISP,” and “Family training (97156, 97157) is required,” with the youth present unless it's clinically appropriate otherwise.
• Clinic schedules have to be individual. Requests over 20 hours (80 units) a week need a schedule tying each session to treatment goals. “A general schedule of clinic-based activities is not sufficient,” and the schedule has to separate therapeutic time from “recreational and non-therapeutic activities,” such as naps and meals unrelated to goals.

Who can supervise, and how assessment starts

• Only LBAs, LABAs and licensed clinical psychologists have delegation authority over non-licensed staff. LCSWs and LPCs “do NOT have delegation authority,” and LMHP residents and supervisees “shall not supervise ABA services.” Technician-level services by staff who don't meet the manual's criteria are “not reimbursable to Medicaid and subject to retraction.”
• Initial assessments must be in person, with the youth and family, by an LBA, LABA or LMHP, include a functional assessment with validated tools, and be updated at least annually.
• Telemedicine needs an ISP schedule of when services are remote and when in person, clinical evidence the modality fits, and a plan for in-person care when needed.

The limits

The bulletin restates the Mental Health Services Manual. It isn't a new rule, and it names no new effective date. Its own boilerplate says Cardinal Care plans “may utilize different guidelines” than fee-for-service, even as the body directs them to apply these clarifications. And it's separate from the 20-hour cap we covered on September 1. DMAS said on July 28 that the authorization process won't change until CMS approves that cap and the manual is updated, so this bulletin is the documentation standard for requests over 20 hours today.

What you must know or do

• Clinical directors: open every clinic or center-based ISP and find the sentence that justifies the setting. If there isn't one, add it before the next authorization.
• For each clinic client, find the weekly family involvement entry and 97156 or 97157 in the plan. A week without one is the gap a retraction review will find.
• Owners: list every RBT or unlicensed staff member with their supervising clinician. Any supervisor who is an LCSW, LPC or resident has to be replaced by an LBA, LABA or licensed clinical psychologist.
• Replace any generic clinic timetable in over-20-hour requests with an individual schedule that marks therapeutic and non-therapeutic time.
• Check that initial assessments since December were done in person and say so in the record.