In addition to my initial concern regarding the eradication of home-based ABA, I have chosen to speak to another issue with the limitations on adequate treatment planning for ABA services. IF home-based ABA continue even with the proposed Medicaid changes, home-based providers will be once-again fighting an up-hill battle with in regarding to treatment planning, analyzing data, and making data-based decisions for home-based clients due to the restriction on billable activities for providers. I do see a direct correlation between a loss of billable activities and a substantial impact on quality of care for clients. 

Home-based treatment, due to the remote nature of this type of work, does require more intentional, thorough, and frequent treatment planning, data analysis, and external supervision with staff. These are clearly areas that are needed in clinic-based work as well, however home-based treatment does require more time due to some of the natural barriers involved (like traveling to remote locations). 

As LBAs are some of the required providers for this type of work, it is also our ethical obligation, per our BACB ethics code, to engage in a quality provision of behavior analysis through individualized treatment and assessment. In our ethics code:

• 2.09 states that our clients have a right to effective treatment and we, as BCBAs, have the obligation to advocate for appropriate treatment. I am fearful that, with a potential eradication of home-based treatment, we will not be able to adequately advocate for appropriate treatment if that treatment modality is home-based. 
• 3.01 states that we must conduct assessments prior to making recommendations or writing any programs, and we also need to graphically display our data to support our treatment recommendations. The current draft regulations are eliminating ongoing assessment, data analysis, and treatment planning. How can we ethically provide treatment for clients and families without the provision to complete such a foundational component of our job?
• 4.03 discusses the need for INDIVIDUALIZED behavior change programs. As mentioned above, home-based ABA treatment does require more access to ongoing assessment, data analysis, and treatment revision due to 1) the remote nature of this environment, and 2) due to the ever-present changing variables that occur in a home setting. Again, how can we ethically provide quality care when these are the types of services that have been eradicated from the draft Medicaid regs? 

While this is not a comprehensive list, it does pose some major concerns regarding QUALITY assessment, treatment, and data analysis for home-based providers. I am terrified of the day I can no longer spend time thoroughly designing a behavior change program for a family based on their needs, unique situation, environment, and changing variables.

I encourage the state of Virginia to look to neighboring states, such as Maryland, who added provisions for external supervision and the addition of up to 4-hours of treatment planning per month for all clients. This small adjustment will substantially help us better promote and enact the science of ABA. Additionally, this provision will support home-based ABA providers and the work that we do and ensure that this necessary service is not eradicated in the state of Virginia. Please take this into consideration so that home-based ABA treatment may continue to exist and function in an optimal manner. 

https://health.maryland.gov/regs/Pages/10-09-28-Applied-Behavior-Analysis-Services-(MEDICAL-CARE-PROGRAMS)---1227-4504.aspx