Virginia Medicaid's 20-hour ABA limit, as of October 2026

What changed, with the status first

Virginia has enacted a 20-hour weekly limit on Medicaid ABA services, and as of October 26, 2026 it is not in effect. Item 291.WW.2 of the 2026 Appropriation Act directs the Department of Medical Assistance Services (DMAS) to impose "a 20 hour per week cumulative limit per recipient on services provided under ABA, effective July 1, 2026," which "can be exceeded based upon documented medical necessity" under EPSDT. It also requires an autism spectrum disorder diagnosis before ABA is authorized, with a one-year provisional diagnosis allowed for children age 5 and younger, and says DMAS "shall implement this change upon federal approval." DMAS's bulletin, last updated July 31, 2026, says it is seeking CMS approval, that the effective date "will be announced in a subsequent notice," and that "no changes will be made to the current authorization process" until CMS approves and the Mental Health Services Manual update is final.^[1]

That manual update now exists as a proposal. Its comment forum on the Virginia Regulatory Town Hall closed October 21, 2026 with 62 comments, lists a planned effective date of October 22, and says: "The agency is considering feedback and has not yet made a decision to confirm or delay the proposed changes."^[2] DMAS's memos and bulletins page, read today, lists items through October 22, none of them an ABA notice.^[5]

What the draft manual says

The proposed Appendix D is marked "Revision Date: TBD."^[3] As drafted:

The limit. "Services are authorized based on medical necessity and may not exceed 20 hours per week, except as authorized under EPSDT review."^[3]

EPSDT review before any denial. "All service requests for ABA must be reviewed under EPSDT criteria prior to a denial." A request above 20 hours a week must include an individualized schedule of activities and how each one serves the treatment goals. In a clinic, "a general schedule of clinic-based activities is not sufficient."^[3]

Diagnosis documents on the initial request. One of three: an in-person comprehensive diagnostic evaluation by a licensed mental health professional (LMHP), using an evidence-based diagnostic tool and listing the evaluator's name, credential, and Type 1 NPI; for a child 36 months or younger, a provisional diagnosis with the diagnosing LMHP's name, credential, and NPI, a screening tool, and evidence of a scheduled evaluation or wait list placement; or, for a child 37 months to 5 years old, the same without the screening tool.^[3]

A clock on provisional diagnoses. If the full evaluation has not happened within the first six months of treatment, continued-stay requests need updated evidence of the appointment or wait list placement. A child 5 or younger at admission with no final diagnosis 12 months after admission is reviewed under EPSDT.^[3]

Who it affects

Virginia Medicaid ABA providers, fee-for-service and managed care. The draft addresses requests to "the FFS service authorization contractor or MCO," and its admission criteria require the member to be under 21.^[3] Those reviewers are Acentra Health and the Cardinal Care managed care organizations.^[4]

Not school-based behavior therapy. The Act's requirements "do not apply to behavior therapy provided by local education agency providers and reimbursed through the fee-for-service Medicaid school-based services program."^[1]

Not commercial plans. Nothing in the item or the bulletins addresses commercial insurance.

What to check this month

Which authorizations run above 20 hours a week. List the Virginia Medicaid authorizations above 20 hours (80 units) a week, with renewal dates. Under the draft, those renewals go through EPSDT review.^[3]

Whether that paperwork matches today's rule. The December 2025 bulletin already requires "significant detailed documentation and justification" above 20 hours a week, including an individualized schedule and, for clinic-based services, a split between therapeutic and non-therapeutic time.^[4] The draft asks for the same kind of schedule in an EPSDT request.^[3]

Diagnosis records in intake. For each family in intake or on the waitlist, check that the file holds the evaluation with the evaluator's name, credential, and NPI. Where a diagnosis is provisional, record the evaluation date or wait list placement where someone will see it at six and twelve months, when the draft asks for it again.^[3]

The notice itself. Watch the DMAS memos and bulletins page and the Town Hall forum.^[2] ABA policy questions go to [email protected].^[4] As with Indiana's ABA enrollment moratorium, the date that matters arrives in a notice, not in the law.

What is still open

CMS approval. DMAS said in July it was seeking it.^[1] I found no approval announced on its bulletins page.^[5]

The final manual text. Whether DMAS confirms the draft, changes it, or delays it.^[2]

The July 1 date. The Act prints both July 1, 2026 and "upon federal approval," and DMAS's bulletin says the authorization process does not change in between.^[1] To be clear, I cannot tell you how a final notice will treat that gap.

For what it's worth, I would track the diagnosis documentation first. The hour limit reaches authorizations above 20 hours a week. The diagnosis rules reach every new request.

Confirm before acting

This post describes the documents listed below as of October 26, 2026. It is not legal advice, and it does not say whether any particular authorization is affected. Confirm with DMAS, with the MCOs you bill, and with your counsel before acting on any of it.

Primary sources

1. DMAS bulletin, "Applied Behavior Analysis (ABA) Policy Changes," July 31, 2026.^[1]
2. Town Hall comment forum 2982, Appendix D, read October 26, 2026.^[2]
3. DMAS, proposed Mental Health Services Manual Appendix D.^[3]
4. DMAS bulletin, "ABA Policy and Regulatory Clarifications," December 16, 2025.^[4]
5. DMAS Medicaid Memos and Bulletins page, read October 26, 2026.^[5]