Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services


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9/20/21  9:52 am
Commenter: Hannah Robicheau, Compass Behavioral Solutions

This is going to hit hardest for Virginians who are people of color and/or have ASD

The task of standardizing codes so that billing for necessary ABA services, and hopefully decreasing the amount of administrative time, while increasing clarity, is a big but important venture. I think that some of the proposed changes open up some great options for families, such as more structured group therapy and more oversight over center-based programming. While there is potential for many positives, some of these proposed changes will also lead to poorer quality treatment (or lack of treatment) for Medicaid ABA therapy recipients.

That said, individualized treatment planning and data review for ethical providers providing appropriate treatment, can be extensive. The time that goes into ensuring that each ISP and supporting document for each individual client is not only appropriate and updated in a timely fashion, but written in a way that is able to be utilized by caregivers so that they can implement the strategies and we can develop capacity, can (and should) vary between clients. This ultimately leads to better, more efficient treatment, and a lower cost, across the life of the individual. Insufficent or capped treatment planning, results in further services, escalated interfering behavior, lower communication ability, and may result in requiring inpatient hospitalizations for clients over the long term, or a poorer quality of life for that individual and increased family stress. 

The biggest stressors for families of individuals who have ASD diagnoses is fear of the future, child behavior, treatment setbacks, getting treatment, exhaustion, and treatment disappointment, per Coping and Growing with Autism, IAN Research Repot #8 -April 2009: Family Stress.  - Part 1. Clinical research indicates that increases in these stressors are directly proportional to decreases in appropriate, individualized, and early treatment.

While an increased rate for LBA/LaBA services may assist in offsetting some of the cost of treatment planning, it wont be sufficient for appropriate (sometimes daily) individualization of services in the home, especially considering the variables to consider in planning treatment in the natural setting, and the training for family members necessary to ensure interventions are carried over outside of sessions. In addition, the lowered tech rate and lack of indirect supervision further undermines treatment integrity. Over time, if treatment planning and supervision is not included as a billable service, then center-based services will become the standard of care, reflecting on paper as mastery of skills, but skills that never generalize or are usable for clients with Medicaid outside of highly controlled settings. This also would prevent services for individuals in rural areas who cannot access center-based or telehealth treatment. Bear in mind that per the Virginia Poverty Law Center, 66% of Medicaid recipients are people of color in Virginia. This doesn't account for those that fall into the coverage gap, so that percentage is likely higher. These proposed changes favor individuals who are white, middle class, have numerous community supports, and are already physically healthy living in stable environments. Haven't we learned over the past year that we cannot allow this discrepancy to continue to happen?

Many other states have recognized this and kept H codes to cover the time that is spent to individualized programming. Think of the additional treatment planning time and supervision for parent training, and care coordination, that goes into ensuring that the parent of an individual with ASD, who has 2 jobs, a developmental delay or mental illness, and unstable housing, would need. That is simply not covered with a standardized code. The same code that a stay-at-home mom, with two kids, a nice well-kept stable home, would be applied.

What has resulted in practice from changes that cap or eliminate indirect services in other states is more center-based treatment, higher turnover of staff, fewer ethical treatment providers, poorer quality of services, poorer treatment integrity, poorer buy-in to treatment from caregivers, "canned" treatment informed only by assessments and "filling in the gaps" in an individual's skill assessment battery rather than individualization of programming, which impacts treatment efficacy and leads to higher costs overall, and no room for caregiver input (which impacts not just family buy-in to services, but ultimate maintenance of skills), and other short cuts to treatment. Individuals with developmental delays end up with less communication, more interfering behavior, more residential stays, lower family involvement, more restrictive treatment, and much, much higher costs to the family and the state. 

Research and recommendations from CPT consultants, the BACB, ABA professional organizations, researchers, health care fund managers, and other non-profit organizations that have been looking at what is necessary to provide appropriate ABA services and have consistently come back to the following list as essential services for healthcare plans to cover: “If there is a question as to the appropriateness or effectiveness of ABA for a particular client, a review of treatment data may be conducted more frequently (e.g., after 3 months of treatment). 1. Assessment 2. Treatment Plan Development 3. Direct Treatment 4. Supervision (direct and indirect) 5. Parent and Community Caregiver Training 6. Consultation to Ensure Continuity of Care 7. Discharge Planning” per the BACB’s Health Plan Coverage Guidelines for ASD found here: This same source notes that proper assessment takes between 15-40 hours, solely for problem behavior assessment. Additionally, “On average, direct supervision activities comprise 50% or more of supervision; both direct and indirect supervision activities are critical to producing good treatment outcomes” (pg 28). The the Model Coverage Policy for Adaptive Behavior Services further supports this. This is not able to be accomplished with the proposed coding for DMAS behavioral therapy. It puts LBAs in a position in which instead of being able to plan appropriate treatment for a client, given the environment, family dynamics, location of the family, quality of the technician, and speed of the LBA in completing documents, we will have to make choices about which of these areas we attend to given a set amount of time, regardless of if the client regresses, progresses, or the environment changes.

Out of all of the states that I've worked in over the past 15 years, Virginia has been the most progressive in what we do to support individuals with ASD/ developmental diagnoses and his/her family through behavioral therapy/ABA, which overall increases the quality of life for individuals and families, and decreases the overall cost of treatment. Between the individualization of supports, the care coordination, and the focus of caregiver training and generalization of learned skills to help individuals with developmental diagnoses maintain skills, Virginia's Medicaid behavioral therapy program has been remarkable in that aspect. We as a state have an opportunity to keep this program remarkable.

For the sake of the community of families that only has access to proper and appropriate treatment because of Medicaid coverage, I urge you to consider the minimum of treatment planning, supervision (both direct and indirect) and care coordination being included in this proposal. Otherwise, these changes will result in a substantial hit to the quality of services for the population in our state that needs these services the most. Please make the decision to stand up for Virginians who do not have a voice to advocate for him/herself.


CommentID: 100038

9/20/21  10:42 am
Commenter: Kathleen O'Neil MS LBA - Compass

End of an era for home-based ABA?
I chose to build my career around providing ABA services specifically in a home environment, where many of the most socially significant skills are present and often most challenging, where I can help support families through their hardest moments, and where I can see the greatest lasting changes for the families I serve. When I first read the proposed changes to our Medicaid regs in the state of Virginia, I was floored, because it truly seems like the goal is to eradicate the possibility of providing home-based treatment for our consumers/clients.  Because of the way the draft regs are written, which look nice and lucrative if you are providing a clinic-based model, my fear is that more and more LBAs will choose to drift away from home-based work and move more toward clinic-based work only (or that companies' survival will be dependent on clinic-based work, thus eradicating home-based treatment altogether). As the draft regs have made clear, without an available supervisor/LBA/LMHP, services cannot occur, thus creating major limitations in the state of Virginia for the populations we serve.

I do see a few specific and major limitations that I would like to highlight: 

  • A clinic setting may provide a highly controlled environment in order to teach skills, however clients may not have a higher rate of generalization to their more natural home or community environments. I have seen this play out MANY times with clients transitioning from residential/center-based models to help with significant behavior reduction. In a center/clinic, the challenging behavior may have been reduced to near-zero rates, however upon re-entry into the home, the behavior change had not adequately generalized and the challenging behavior ends up re-emerging (at often dangerous rates). Home-based ABA is imperative to creating lasting, life-long behavior change in the most socially significant environment.
  • Home-based services allow for parent training opportunities to occur in the most natural environment. Part of the program description is to provide quality parent training opportunities. Quality, in my mind, should be in the most socially significant environment for the family, with the opportunity to provide the most trials available as well. This cannot adequately happen in the confines of a center program where you are limited to your time slot for parent training. However, home-based services allow parent training opportunities to happen at a higher frequency (think of using BST & coaching throughout an ENTIRE afternoon with a family -- game changer!) AND within the exact same environment where the behavior occurs (again...generalizable opportunities!). 
  • Families in more rural environments or those with a lower socioeconomic status may be limited in their ability to access center-based treatment. They may not have the ability to travel to appointments, or have to be dependent upon Medicaid or public funded transportation, which we all know is in very short supply right now. This creates an unnecessary barrier to treatment and may have accidental impacts on certain populations. I think of the radius I serve in - 1 hour from our home office - and how many families I serve without a car, driver's license, available transportation, or even basic self-advocacy skills, and I KNOW they will be the ones suffering at the hands of these Medicaid changes. If we can't provide home-based ABA in the state of Virginia, and they are unable to travel to a clinic that is an hour away, how do they get the help they need? 

Thank you for considering these comments for the future of home-based ABA in light of the proposed Medicaid regulation changes. 

CommentID: 100041

9/20/21  10:43 am
Commenter: Kathleen O'Neil MS LBA - Compass

Lowered quality of treatment for home-based ABA

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.

CommentID: 100042

9/23/21  2:51 pm
Commenter: Lauren Fraedrich, LBA - Compass Behavioral Solutions

Impacts of Proposed Regulation Changes on Ability to Provide High Quality ABA Services


As a BCBA/LBA in Virginia who provides home-based services, the proposed changes in the Medicaid regulations gives me worry and concern about the feasibility and quality of home-based ABA services going forwards. Bigger picture, from the way that the drafted regulations are currently written, home-based services will be much more-costly to provide than clinic-based services, which will in turn lead to companies choosing to provide clinic-based services over home-based services and may lead LBAs to move away from providing home-based services, despite the continued need.  This will have a significant and direct impact on clients and their families, for whom ABA services are considered medically necessary. Individuals without access to transportation (especially those who live in more rural or remote locations and those with a lower socioeconomic status) will have increased barriers to accessing services. Additionally, this will impact client’s ability to learn and practice socially significant behaviors in their own environment, and parent’s/caregiver’s ability to participate as readily in services and parent-training. While I support and understand a need for change in the current Medicaid regulations, I worry that the proposed changes will unintentionally hurt those who are most in-need and work against creating lasting behavior change through a decrease in quality and feasibility of home-based services.


Changes in what LBAs are able to bill for and language allowing clinic-based services will lead companies/LBAs to provide services in the clinic, as it will allow for more billable activity (more lucrative) with increased convenience. In turn, this will impact:


  • Barriers to accessing services for low-income families and rural families
    • Transportation is a barrier for families due to distance, time, and cost. Some families (especially families with lower socioeconomic status) do not have access to transportation reliably. Others live up to one hour from our office locations and would have less time to dedicate to ABA services (leading to lower treatment outcomes) if they needed to travel to a clinic for services.
  • Quality Parent training:
    • Home-based services allow a greater magnitude for in-situation parent training and coaching in situations where the client is having the most difficulty. This includes support with changing the environment, using antecedent interventions during unique circumstances that occur in the home, and implementing behavior support plans in the clients natural environment.  By providing services in the home-setting, we are able to work with parents more frequently and for longer periods of time, doing repeated trials of BST on parent training objectives .
  • Generalization of skills and behavior decreases
    • Skills taught in a clinic setting may not access reinforcement in the client’s natural environment (due to a need for parent training and a significant difference in environment). Additionally, a major population that we serve (individuals with ASD) have challenges with generalization between settings and people.
  • Ability to practice skills that are unique to the home setting
    • Certain daily living tasks, sibling interaction, safety skills, etc. that are more appropriate to target in the client’s natural environment due to unique situations that cannot be replicated in a clinic setting
  • Quality of care
    • Loss of funding for treatment planning, frequent data analysis, and supervision of staff will lead to a lower quality of care in the home-based setting. While this is important in both the home and clinic setting for high quality ABA services, it impacts home-based services more greatly, due to the need for these to occur more frequently and extensively, as clinicians are practicing more remotely.
    • This could be offset with the addition of H codes (which other states have used successfully) that would allow for the additional individualization and extensive treatment planning and supervision that is necessary for high quality home-based services.
  • Longer wait-lists for clients due to lack of qualified staff
    • Changes in the rate of pay for clinician hours from $60 per hour to a lower hourly billable rate would greatly impact the ability to retain and hire qualified staff, especially for home-based ABA programs, due to travel expenses as well as increased health risk (especially during a pandemic) of being in other individual’s homes. This would lead to greater waits for clients to receive services due to lack of available staff.



Thank you for your considerations of these comments towards the proposed regulation changes.

CommentID: 100097

9/27/21  11:32 am
Commenter: Alea Finnemore, LBA (Compass Behavioral Solutions)

Impacting the Quality of ABA Services

As a BCBA/LBA providing in-home based services in the state of Virginia, I am writing with concern in regards to the current DMAS ABA therapy manual draft. As a company who primarily takes Virginia Medicaid, we at Compass have a unique understanding of how different the quality of in-home ABA therapy will be with the changes that are being proposed.


While we fully support and understand the need for fidelity in the behavioral therapy program and the need for uniformity through the usage of CPT codes, families who receive in-home therapy will be hit the hardest as the regulations promote clinic-based work which is often not as feasible for families who: live in more remote or rural areas, do not have easily accessible or reliable transportation, have working caregivers who cannot realistically take them to a clinic and/or for clients who require skills to be taught in the natural home environmental (versus in a clinic and then generalized to the home). Parent training, the most important component of what we do in providing ABA therapy, will also be the impacted. In addition to this broader concern, I have categorized some more specific concerns below:


1. Restrictive H Codes

The most urgent portion of the draft in need of revision is the removal of billable activities, such as care coordination, treatment planning/data analysis and supervision. While it is anticipated that a higher billing rate will help bridge the gap in the loss of the current billing structure, the quality of the ABA therapy provided (especially in-home) given the loss will most certainly be impacted. The nature of in-home work makes it extremely difficult to sit in someone’s home and conduct treatment planning and data analysis to ensure your technician has high quality interventions in place for therapy to be effective. Home based services, because of their remote nature, require more detailed treatment plans, frequent/daily complex data analysis and extensive supervision outside of the home. While none of these are unique to home-based ABA, both the ratio of time needed to achieve these services versus clinic-based services and the natural barriers of travel to these areas does create a discrepancy in the ability to bill for services by reinforcing services to be provided in a clinic setting versus in the home.


Other state Medicaid programs, such as Maryland, have created vital CPT codes that allow LBAs and LaBAs to provide sound and effective ABA therapy to clients and their families. Having this code in place still gives DMAS great visibility to service distribution and could be controlled by the MCOs based on service delivery model.


2. BCaBAs/LaBAs

According to the draft, BCaBAs/LaBAs now have limitations on billing. Although slightly less quantitatively, BCaBAs and LaBAs go through the same coursework and rigor to become credentialed and licensed in regards to the number of supervision hours and taking of the board exam. According to Virginia Licensure Laws and BACB guidelines for the practice of Applied Behavior Analysis, BCaBA/LaBA’s are qualified to provide supervision (CPT code 97155), parent training (CPT code 97156) and conduct certain assessments/analyze data (CPT code 97151), among others duties, under the supervision of a Licensed Behavior Analyst. In addition to the discrepancy this would cause, more importantly this change would be a detriment to many, if not all, ABA companies whom employ BCaBAs/LaBAs and to the families they serve.


3. Lowering Behavior Technician Rate

As we are already facing a significant reduction in our ability to hire qualified professionals to fill the position of behavior technician (particularly with in-home work), it is expected that lowering the rate will exacerbate this even further. In addition, by lowering the technician rate, we risk even longer wait list for individuals waiting to receive ABA services as well a reduction in the overall quality of care. Therefore, we are strongly encouraging the CPT codes for all services provided by behavioral techs remain at a minimum of $60 per hour when delivered in the home.


4. COVID-19

As we enter flu season and are still very much navigating COVID-19, it seems counterintuitive to change regulations at this time to require supervisors to obtain most of their billable hours by being face-to-face in the homes. Supervisors have upwards of 15 clients per case load versus technicians whose caseload is much smaller thus a much lower risk of spreading COVID-19 or other viruses. Supervisors, out of necessity, will need to move quickly from family to family each week putting our clients and families at an increased risk of getting sick.


Again, while we fully support and understand the need for fidelity in the behavioral therapy program and the need for uniformity through the usage of CPT codes, I urge that the feedback and solutions that have been suggested within this comment, and the comments of others, be strongly considered by the state of the Virginia in support of LBA/LaBAs providing high quality care which directly effects the treatment that our vulnerable populations receive.


Thank you,


Alea Finnemore, LBA

CommentID: 100111

9/29/21  10:17 pm
Commenter: Stefania Fabbri, Licensed Clinical Psychologist, PhD (Compass)

The right thing to do vs the easy thing to do. Sessions in the home vs in clinic.

I appreciate the intention behind these new regulations and I believe some good things will come from them. 


As we take these regulations from paper to implementation in the real world, I can foresee a few issues playing out over time.


Fundamentally I would like to encourage a reflection upon “what do we know will lead to the best outcomes for the children and families we work with and whether these new regulations will make it more or less likely to achieve the best possible outcomes”


The right thing to do vs the easy thing to do. Sessions in the home vs in clinic. On paper having the opportunity to do both is great. Now in practice, we know that working in homes is way harder to do then working in a clinic, you face multiple challenges: more chaotic environment, less structure, less control, multiple people to work with and account for, family dynamics, driving etc.. …BUT we do it because we know it is the “right thing to do” and by that I mean working in the home is where we can have the most impact, it is the place where we can observe how behavior occurs naturally, it’s the environment the child operates in, it is where skills learned need to be generalized, its where we can support the parents at the hardest times.


Now going back to our original question -  Do we think that these new regulations will encourage/reinforce practitioners working in the home? If a practitioner is reimbursed the same for the “easy route” would we predict that, even with the best intentions and greatest intrinsic motivation to do the “right thing”, such practitioner, day after day, will continue to pick the hard road? Probably not. Most likely over time people will gravitate to what is easier and move away from providing services in the home. Companies that require more home based work will have a harder time hiring and retaining staff. 

Maybe these new regulations should find a way to either incentivize work in the home (eg: higher rate?) or somewhat restrict/put parameters around how much time is spent in the clinic and require a specific rationale for that, otherwise it is only a matter of time before witnessing an industry wide change that will no longer include the provision of services in the home.


Intentionality vs reactivity

The current regulation don’t include treatment planning, data review and analysis as its own billable entity. We know that treatment planning, case conceptualization, frequent data review and analysis is foundational to ensure we create plans that lead to the best possible outcomes. Treatment planning takes time and intentionality. It requires the opportunity to take a step back, think, plan vs reacting in the moment or improvising. Prompt and frequent data review and analysis is necessary for making timely and data driven adjustment to any given plan of care. 

Going back to our questions, do we think these regulations that cut down the amount of time that can be devoted to intentional planning and data review will increase or decrease the quality of care our clients receive? In the real world how do we think this will play out? Will it look like “cutting corners”? Using “one size fit all” plans and protocols? Will it look like multitasking and “reactively” adjust protocols or interventions while sitting in a session with a client and a technician? When you are treated by a physician, would you want that physician to spend time reviewing your records, exams, updated labs ahead of time or just try to improvise based on what he/she sees right there and then? 

If intentional and responsive treatment planning is so instrumental to best client outcomes should we not recognized it as its own entity just like face to face time? Should we not incentivize this foundational part of the work we do?


Collaboration vs isolation

Care Coordination and collaboration with other providers does not appear to be a reimbursable category in the current regs. Integrated care is something that our clients deserve and that requires REAL collaboration between professionals. Effective Care coordination is also extremely challenging mostly because it implies the recognition that we are not the experts of everything and that to look at the child as a whole we NEED to collaborate with other professionals.

Do we think that not reimbursing for Care Coordination will lead to better outcomes for our clients? How will this paly out in the real world? Would people mostly defaulted to sending a fax, or a quick email to “collaborate” with another providers/professional vs discussing, brainstorming, supporting eachother's work? Most likely it will lead to ineffective or completely absent collaboration, disjointed treatment efforts, isolation and providers working in their own “professional silos” and will in turn lead to poorer client outcomes.

CommentID: 100869