I am writing to share significant concerns of the impacts the proposed changes to the Medicaid manual to LBAs, LABAs, and the clients and families receiving ABA services.  Implementing the manual as drafted would place significant strain on the Tier based model of services which could have a domino effect impacting both the mental health of clients and ABA staff in addition to the agencies providing services.  Please consider the following changes to the draft:

• BCaBa/LABAs have been providing supervision within their scope as outlined by the BACB & should continue to be able to bill supervision of unlicensed staff using supervisor billing codes.  Changing this could possibly close many agencies causing loss of services to many clients & families and straining the exiting supervisor load that could compromise to services.  ABA is designed to be a tiered model and LABAs meet significant criteria to attain their certification. 
• Clinical supervision of unlicensed staff on a weekly basis needs clarification.  Aligning with the RBT requirement of 5% supervision per month would match the BACB standards and help supervision occur at an appropriate amount based on unlicensed staff’s client hours.
• Removal of indirect billing codes could have far reaching ramifications to home based therapy.  Providing appropriate data driven direct ABA services needs to be balanced with the treatment planning, data review and required care coordination as appropriate to each individual client.  Without billing codes to support each of these critical activities without the presence of the client, when it is often not clinically appropriate, direct service hours would likely be reduced.  Families already struggle to meet hours requirements to fit in the direct services.

Thank you for the opportunity to comment.