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