BCBA's should only be allowed to supervise ABA cases. Typically, LMPH's do not have the clinical experience, oversight, or coursework to adequately implement effective ABA treatment programs. 

After the inital 6 month PA expires, our clients are receiving subsequent PAs covering only a 3 month period. Given the amount of paperwork involved in the reauthorization process (both for providers and Medicaid agencies), we feel that it would be beneficial to all involved to extend the period of time for these PAs to 4-6 months instead. It is also difficult to show significant progress in skills and programs with clients in such a short amount of time.

Our agency would be in favor of increasing the requirements for the staff providing the direct services.  Development of a category similar to QMHP, QIDP, or QSAP, for the practitioners of Behavioral Treatment services could be beneficial in improving the knowledge of those providing the direct services.   Requiring direct care staff to have specific experiences with the ID/D population and/or behavioral interventions would be consistent with what regulatory requirements exist in other program areas (e.g. Intensive In-Home, ID/D Crisis Stabilization).

Likewise, specific training developed and required by DMAS or DBHDS would also be welcomed, if offered in multiple sites and dates across the state.

We would not be in favor of requiring a BCBA to be the supervisor of Behavioral Treatment services rather than a LMHP.  In larger areas employing or contracting with a BCBA may be feasible, however this would essentially eliminate Behavioral Treatment Services in the Southwestern region of the state.  In addition, BCBA credentialing is an excellent professional license for Behavioral Interventions, but does not provide the same training in assessment of underlying Mental Health symptoms that are known to co-morbidly exist in the ASD and ID populations.

LMPH's do not have the clinical experience, oversight, or coursework to adequately implement effective ABA treatment programs.

LMHP’s are required to have coursework on Diagnosis and Treatment pertaining to all DSM diagnoses, including developmental and intellectual disabilities. There is an adequate foundation upon which to build the necessary knowledge of ABA via trainings/support. The Virginia Institute of Autism has offered wonderful trainings on ABA interventions as well as support for those who put forth the effort to provide Behavioral Therapy Services. There is no reason to believe that an LMHP cannot utilize such trainings/resources in order to implement an effective ABA program and, there is the added bonus of having someone who is clinically sound in mental health concerns that can address co-morbidity of the child and have the ability to offer support to parents as they may struggle in implementing interventions.

According to the Behavior Analyst Certification Board, there are only 364 registered BCBA’s in the state of Virginia. In running a search for providers within 50 miles of our service locations, the results range between 0 and 1 between the five counties and one city we cover. Based on this, I found ample evidence to agree with the previous statement that requiring a BCBA to supervise would essentially eliminate this very valuable service.

When asking for continuation of service there is a large amount of paperwork that must be done.  When the reauthorization is approved it is only approved for three months at a time.  For the reauthorizations, it would be beneficial for all involved to send in less paperwork such as a 90 day review of the behavior plan since the period being approved is so short.

Thank you,

Sara Williams, MSW, QMHP

LMHP's and LMHP-E's have been able to facilitate parent training and family systems therapy successfully within the EPSDT program. LMHP's and LMHP-E's have expertise in addressing family dynamics and building structure and the capacity within the family to embrace and sustain change. A solid understanding of Autism and other developmental disabilities, along with strong technical knowledge of ABA, should be requisites for any supervisors of the EPSDT program. We believe that both BCBA's and LMHP's/LMHP-E's have much to offer.

Thank you,

Monika Isip, LPC, ATR

Please provide guidance on the maintenance of data. The storage of raw data in files quickly fills charts. Within our agency, data is summarized in clinical case reviews, ISP reviews and updates, and reviewed in clinical supervision. Please clarify whether raw data sheets need to become a part of the permanent record. 

With the depth of documentation provided in regards to extension requests, we would like an extension of the approval period from 3 month to 6 month durations. This would provide a more appropriate time frame to demonstrate effectiveness of interventions, family involvement, case coordination, and significant progress. All extension requests could then be accompanied by a new letter of medical necessity.

 

Behavioral Therapy Services are most effective when provided by direct care staff with specific training in Applied Behavior Analysisand proven competencies.  Functional ability and mastery of activities of daily living, should be tracked through specific use of a task analysis for each skill and should be developmentally appropriate for each child. Independence should be documented through task analysis used by all on the treatment team, family members, and attendants or other care providers. 

As an ABA in home counselor that went on to pursue my BCBA in order to best develop programming and interventions, I have been disheartened by EPSDT’s withdrawal of approval for BCBA provided assessment and supervision.  In order to provide quality services to the children of Virginia I make the following points:

BCBA’s are well equipped to provide oversight to quality treatment services.  They are well trained in behavior techniques, building communication, data collection and interpretation, task analysis to build independent living skills, discrete trial, and many other techniques.

BCBA’s will not have an incentive to work for Medicaid funded agencies according to the current limitations.  Other states offer more opportunities and higher reimbursement rates.

As a behavior counselor and BCBA, I have benefited greatly from supervision and insight offered from a LMHP or LMHP-E, so I would strongly suggest not limiting supervision to BCBA’s alone.

We feel that behavioral therapy can best be provided by counselors with specific training and demonstrated competency regarding the practice of Applied Behavior Analysis.

Other considerations that affect programming:

The three month turnover rate for extension requests adds a significant burden to direct care staff

Quality Assessment is key to program development. We would like the option to provide a total of 7-10 hours for administration and interpretation of the VB-MAPP to children with emerging language development.

Grafton would like to see regulations that are consistent with the Behavior Analyst Certification Board’s guidelines and standards.  The Behavior Analyst Certification Board articulates sound, clear direction on all aspects of ABA treatment, including assessments, expected duration of services, a recommended tiered service delivery model, case load sizes, and discharge/transition activities.

We support the position that a Board Certified Behavior Analyst (BCBA) or Board Certified Assistant Behavior Analyst (BCaBA) under the supervision of a BCBA is ultimately be responsible for a client’s ABA treatment, whether providing the service directly or through the supervision of a trained Behavior Specialist.  The requirements for these positions and supervision expectations are defined by the Behavior Analyst Certification Board.

We believe more time should be permitted and compensated, as needed, for assessment (up to 10 hours).

Re-authorization periods should be longer than 3 months; we recommend 6-month periods.

A differential rate of payment is needed between BCBAs (a higher rate) and Behavior Specialists.

Expand the Supervision Regulations

To include both LMHP/LMHP-Es (with ABA experience/expertise) and LBA/BCBAs. Our agency has benefitted greatly from contracting an LBA to train our staff and oversee program development in addition to our licensed supervisor. Yet this LBA is not permitted to supervise in our EPSDT program because we are licensed under the Intensive In-Home license despite her eight years of experience working directly with this population. This setup is not congruent with “knowledge to practice.” By requiring additional training for all supervisors in the program, and credentialing behavior analysts to provide supervision and assessments, we believe that it would raise the standard of supervision provided to clinicians working in the program and enhance the quality of services provided to families.

Increase the Standard of Training

Behavioral therapy can best be provided by counselors with specific training and demonstrated competency regarding the practice of Applied Behavior Analysis. The ABA Outpatient track more consistently prepares staff to meet the needs of the population serviced through behavioral therapy by requiring 40 hours of specialized training. This same standard of training should be expected of staff working in programs provided under Intensive In-Home track as well. The same clients are being serviced under these two programs, but staff qualifications vary drastically. It is essential to the children and families that we work with to bring regulations more in accordance with one another so that the same quality of service is being provided by all agencies.

Clarification of Covered Services

As the regulations read now, some things appear to be mentioned twice under “Covered Services” (for instance, clinical supervision). We feel that it leaves room for interpretation by the provider in some instances. As a provider, we would like to be sure that we are billing responsibly and feel that can be achieved more effectively with further clarification in this section.

The Virginia Office for Protection and Advocacy frequently represents parents and children in their quest for behavioral therapy services (including Applied Behavior Analysis (ABA)) through Medicaid’s EPSDT program.  Our office is hopeful that new regulations will make it easier for our clients to find appropriate behavioral therapy services.  To that end, we offer the following two comments as suggestions for the content of the proposed regulations, based on our office’s experiences with requests for behavioral therapy services for children.

First, the new regulations should ensure appropriate licensure and certification of providers of behavioral therapy services to children.  Recently, the Commonwealth of Virginia began licensing Board Certified Behavior Analysts (BCBAs).  Identification and enrollment of those newly licensed BCBAs as providers will help ensure ABA services are appropriate, available, and standardized.  Of course, other qualified providers should be authorized to provide other behavioral therapy services.

Second, the regulations should include a mechanism for an evaluation or development of a plan of care before the provider requests service approval through the Letter of Medical Necessity process, to ensure the child’s behavioral therapy needs are appropriately addressed.