In reviewing the proposed changes to the billing codes for ABA services, several concerns for the feasibility of continuing quality in-home ABA services, especially for those in rural communities, arose for me and many of my colleagues. These include limited opportunities for supervision, treatment planning, care coordination, and the creation of resources in support of clients’ treatment goals. I’m also greatly concerned about the incredibly short timeline in which providers will be asked to make these significant changes should what is currently being proposed become a definitive set of standards as of 12/1/2021, especially during the midst of a global pandemic. As Covid-19 cases continue to remain at significant levels, especially in rural populations with a small percentage of people who are vaccinated, it will be difficult to navigate these changes and require home-based supervisors to increase time working in clients’ homes, which increases the risk of spreading the virus to clients, families, and staff.

• Supervision: The quality of in-home ABA services depends, in great part, on the technicians working directly with families. Because these individuals are often working in isolation (without the presence of a supervisor or other technician), ongoing supervision is necessary to support the correct implementation of ABA interventions as well as support the individuals in these positions in a broader capacity. The rate of turnover in this field (in-home ABA services) is high relative to many other professions, one such factor being the emotional and physical toll of providing ABA services, especially to families with low socioeconomic status. By limiting what is considered billable supervision to only live supervision with clients, there will likely be an impact on the frequency and quality of contact between a supervisor and their supervisees as well as the ongoing support that many technicians I’ve worked with have cited as being the reason they’ve remained in an in-home ABA technician position. The proposed billing codes also eliminate the opportunity to bill for engagement in clinical discussion and behavior skills training without a client being present, which likely will impact the ability to engage in these activities in an environment with few distractions that supports errorless learning. The expectation that my colleagues and I hold technicians to during sessions is that their time should be spent actively engaging with the clients and their families throughout the course of sessions rather than engaging in conversations or trainings with their supervisor, therefore, only being able to bill for live supervision with a client would limit the time a supervisor is able to work one-on-one with their supervisees and impact the quality of supervision. There would also be limited time available to review data and graphs with supervisees as well as review changes to protocols outside of sessions. Additionally, the reduced billable rate for technicians will likely impact the ability to hire qualified candidates, which is already a significant concern in the midst of a global pandemic.
• Treatment planning: Again, the quality of in-home ABA services depends in great part on having adequate time and resources to develop a comprehensive treatment plan and review data on an ongoing basis in order to make changes to the treatment plan, as needed. Without the necessary billing codes to support this, it is likely that supervisors will engage in less frequent data review and analysis, which is a foundational element of ABA and directly impacts the development and modification of treatment plans.
• Care coordination: Coordinating care with other providers is listed as a required activity in the proposed regulations, however, there is no billing code to support this, which will likely impact the frequency of this activity, especially for clients with many different service providers and those who live in more rural communities.
• Resource development: A staple of ABA services is the development of individualized resources for clients that supports their learning. There is an abundance of evidence that suggests visual supports for a number of activities can impact behavior for the better. For technicians, whose days are typically filled with client sessions and drive-time to and from those sessions, or supervisors, whose days are typically filled with supporting their supervisees, treatment planning, care coordination, and many other activities, to create these resources without being able to bill will impact the quality, individualization, and overall creation of resources that are clinically appropriate and often necessary for effective treatment.
• Timeline of these changes: As I noted above, the timeline of these changes is incredibly short and would not give providers (especially those providing in-home ABA services) adequate time to prepare for the changes that will impact services at every level. 

I appreciate your serious consideration of these comments and hope that they provide an understanding of the significant impact these changes will likely have on the well-being of clients, the livelihood of technicians, and the quality of in-home ABA services.