I have been a BCBA since 2013, have worked in the field of ABA since 2004, and am a former Virginia Association for Behavior Analysis board member. I am currently the Director of Developmental Services with Dominion Care. We currently provide ABA services throughout the state, and employ 10 BCBAs (LBAs) and 3 BCaBAs (LABAs). I am submitting these concerns on behalf of myself, my organization, and the clinicians I supervise.

We are concerned with these proposed changes to ABA services within 4 broad areas, outlined below:

1. Eliminating indirect work, such as supervision without a client present, care coordination, and materials development, from billable services.

This proposal requires additional care coordination, but does not consider it within a reimbursement framework. Indirect work is an integral part of ABA, as this is often how materials and programs are individualized, and continuity of overall service provision is provided and maintained with other service providers, and these services are not effectively completed while the client is present.

2. Disallowing LABAs from providing supervisory services.

Assistant Behavior Analysts are licensed by the Virginia Department of Health Professions and should be recognized within these regulations as licensed professionals. Both the DHP and the Behavior Analysis Certification Board allow that it is within the scope of practice for LABAs to complete all of the same duties as a Behavior Analyst, they just must receive supervision from a BCBA/LBA while completing those duties.

To disallow LABAs to provide these services places undue burden on practitioners of behavior analysis, and is more restrictive than mental health services, wherein a licensed-eligible clinician is able to provide services under supervision.

Our waitlist for Medicaid clients in one rural area in southwest Virginia is already 40 clients deep. If we were to remove one existing team from our structure because LABAs are no longer recognized as appropriate supervisors, they would no longer be able to manage their existing caseload, returning those clients to a waitlist. This would be detrimental to the consumers of ABA as they are already experiencing long waits for services, due to both a shortage of qualified professionals in the field and a staffing crisis due to the pandemic.

3. Increasing the supervision and documentation demands for ABA services.

These proposed requirements of unlicensed staff to occur weekly is a holdover from intensive in home, and should be replaced by the regulations of our credentialing body for 5% supervision per month. The addition of both 30-day ISP reviews and weekly treatment summary reports, on top of individual session notes is excessive and creates undue burden of activities that are, not only duplicative in nature but also not considered reimbursable.

Should these requirements remain, it is likely that our organization and others will need to limit the number of individuals served in order to meet increased administrative demands. Access to ABA services is already a challenge within the Commonwealth, and will only become more cumbersome as service providers are further limited in their ability to enroll clients into services.

We also support the comments outlined by Christy Evanko for VABA, and Gina Green for APBA.

These proposed changes to ABA services reflect a dramatic shift from current practices that will significantly impede our ability to provide services to clients in need. This rollout seems to exceed what is typically expected within a manual revision. As providers, we would have anticipated such changes to occur through a regulatory package including multiple opportunities for stakeholder involvement and comment.

We recognize that there is an immediate need to change the ABA billing codes. Given that need, we respectfully propose that codes be adjusted to reflect the move to CPT codes, while larger adjustments to service provisions wait until stakeholders are given sufficient input into their development, and then time to comment. In addition to the BACB guidelines, the Council of Autism Service Providers (CASP) has also made recommendations as to the provisions of ABA therapy to individuals with autism, and these should be reviewed and included prior to adopting new practices.

Meredith Eads, MEd., BCBA, LBA

Director of Developmental Services, Dominion Care