Virginia's Draft ABA Manual Names the Diagnosis Rules. Comments Close October 21.

DMAS has published the draft Appendix D text behind its 20-hour limit and autism diagnosis requirement: named diagnostic tools, a Type 1 NPI, and six- and twelve-month clocks for provisional diagnoses. It plans an October 22 start.

Virginia's Department of Medical Assistance Services published its draft revision of the Mental Health Services Manual, Appendix D, in the Virginia Register on September 21. Public comment closes at 11:59 p.m. on October 21, and the Town Hall forum lists a planned effective date of October 22. That's 26 days to comment and 27 until the planned start.

The turn: the protocol we said was missing now exists

On September 1 we reported that Virginia's budget imposes a 20-hour cap and an autism diagnosis requirement, and that it "doesn't say what DMAS's provisional-diagnosis protocol will require." The draft answers that. DMAS has also filed state plan amendment 26-0018 with CMS, with a proposed October 1 effective date. We found no record of approval.

What's new against the current manual

  • Diagnosis: the current manual accepts any primary diagnosis correlating to a DSM diagnosis, or a provisional one. The draft requires "a diagnosis of autism spectrum disorder (ASD) (ICD 10 Code: F84.0)" by an LMHP. The only other route is a youth "age 5 or under" with a provisional ASD diagnosis.
  • Proof for the initial authorization is one of three:
    • an in-person diagnostic evaluation using a tool "such as" the ADI-R, ADOS or CARS, naming "the name, credential and Type 1 NPI of the evaluator";
    • for age 36 months or younger, a provisional diagnosis with the diagnosing LMHP's NPI, a screening tool such as the RITA-T or STAT, and proof of a scheduled evaluation or waitlist placement;
    • for 37 months to 5 years, the same without the screening tool.
  • Six months in: if the full evaluation hasn't happened "within the first six months of ABA treatment," the provider submits updated appointment or waitlist evidence.
  • Twelve months in: with no final diagnosis "12 months after admission," requests go to EPSDT review. That review needs three things: current appointment evidence "obtained directly from the evaluating entity," ASD indicators from the latest assessment addendum, and "documented evidence of ongoing clinical benefit."
  • Hours: services "may not exceed 20 hours per week, except as authorized under EPSDT review."
  • Denials: "All service requests for ABA must be reviewed under EPSDT criteria prior to a denial."

The limits

This is a draft, and DMAS's July 28 bulletin still governs: no change to authorizations until CMS approves and the manual is final. The individualized-schedule requirement above 20 hours is already in the current manual, not new. The SPA exempts school-based services billed through local education agencies from both the diagnosis rule and the hours limit. The rules bind ABA providers and diagnosing LMHPs in fee-for-service and in the Cardinal Care MCOs.

What you must know or do

  • Owners: list every Medicaid client whose diagnosis isn't F84.0. Those are the authorizations the draft would stop renewing unless the child is 5 or under with a provisional diagnosis.
  • Intake: check that your diagnostic reports name the tool used and include the evaluator's Type 1 NPI. Start collecting both now.
  • For clients 5 and under on a provisional diagnosis: record the evaluation appointment or waitlist date, and when each child reaches six and twelve months of treatment.
  • Clinical leads with a view on the rules: comment on the Town Hall forum (ID 2982) by October 21. The screening-tool requirement for children 36 months and under, and the three-item EPSDT test at 12 months, are the specific provisions to address.