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:

• Access to 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 of 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.