Treatment fidelity and the alignment of CPT codes with commercial managed care are but two reasons that an update to these regulations are understandably in order. The reimbursement for group treatments and clinic-based services broaden service options for children and their families. The requirement of weekly parent/caregiver participation is another welcome addition that is likely to increase the sustainability of client gains. 

I am asking that consideration be given to areas of this draft proposal that unintentionally threaten the ability to both provide and maintain the quality of home-based ABA services and discourage the provision of home-based services. Directly supporting clients and their parents in their homes with observation, analysis, education, behavior skills training, skill building, behavior reduction, and the support of care coordination helps to set them up to enjoy longer term and more widespread gains. It is arguably more challenging to provide home-based services than clinic-based. Nonetheless, home-based services are critical for the generalization of gains across settings. The skills acquired by parents and their child are often necessary to sustain the child’s placement in the home. Further, home-based services allow access to clients who are unable to access other services due to their remote location. Of course, many of these benefits also serve to reduce the overall long-term healthcare costs for these members. For these reasons and others, I urge you to consider some concerns relative to this draft proposal as noted below.

• The elimination of previously billable work in critical areas of home-based treatment (weekly supervision of technicians, data analysis, and treatment planning) will have a significant adverse impact on the quality of treatment. The variability of the home environment renders data analysis and treatment planning far more challenging and complex than in the more restricted and controlled environment of a clinic. Supervision is also more challenging as direct observation of the technician is not as readily available as it is in a clinic. 
  • Proposed solution: With consideration to the increased challenge and complexity, provide H codes specific to home-based services that allow billing for the required non-face-to-face tasks of supervision, data analysis, and treatment planning. Providing such H codes is not foreign to Medicaid programs, still requires providers to account for service distribution, and could be managed by MCOs.

• For home-based services, the elimination of non-face-to-face billable work in critical areas of treatment planning and provision will make it even more difficult to hire LBAs/LaBAs. LBAs/LaBAs would need to increase their frequency of travel and extend their work day into the evenings (when clients are home after school) which, in turn, would effectively make it far more challenging than it already is to hire LBAs/LaBAs willing to provide home-based services over clinic-based. Again, clinic-based services may seem the only viable business model when considering these challenges and/or significantly fewer clients could be served.
  • Proposed solution: Same as above.

• There is a rumored intention to lower technician rates. In a hiring climate where clients are often left waiting for services because, among other things, there are far more attractive jobs from which to choose (higher pay, more predictable and convenient schedules, less or no travel, more on-site support), lowering the rate is moving in the wrong direction.  The provision of home-based services is arguably costlier than clinic-based services.
  • Proposed solution: Keep the technician rate at $60 per hour for home-based services.

Thank you for considering this commentary.