Dear DMAS Behavioral Health Team,

My name is Richard Gooden Jr., and I (along with my wife, Shelby) are the owners and founders of Boundless ABA, located in Roanoke, VA. I am writing to you today to provide insight into how the proposed changes will actually affect the families who are currently receiving services, as well as the many who are waiting to begin services. I would like to address one of the many proposed changes, and how implementing that change as currently written would be a disservice for the families who desperately need assistance. 

Proposal: Weekly hours (p. 28)
"May not exceed 20 hours per week." (Except under EPSDT review)
Goal: Reduce the number of hours a client can receive services to lower overall costs to Medicaid and help prevent over-prescription of hours by providers who are committing fraud.
Reality: Many families who receive services that they need will instead receive reduced or no services due to vague wording that may be interpreted as a hard-cap of hours by MCO's. Overall costs will increase as services are required for significantly longer time frames to make progress. Every hour invested now saves multiple hours of services later. Prevention and early intervention is always less expensive than continuous, ongoing services, which will also include costs into adulthood. The administrative burden will increase significantly, as every request over 20 hours will now go through a EPSDT review. This burden leads to additional costs and time delays for services. It should also be noted that the vague wording of this proposal needs to be clarified regardless of whether it is amended, changed, or removed. Does the 20 hour limit apply to any portion of the services provided, or only the direct services. The changes coming to ABA CPT codes in the near future would cause this 20 hour restriction to realistically only provide ~10 hours of service a week, as the remainder would need to be split to supervision, report writing, reassessment, and other currently non-reimbursable time spent supporting a client.
Comment: I fully support the effort to reduce fraud and over-prescription of hours by providers. I do not pretend that every provider and company is making decisions based off of medical necessity only, and not the financial incentives that they may perceive from those actions. However, many clients do require significant support to make progress towards independence. The reality many parents face is that the options offered in public schools or other federally funded sources are not adequate to support the medically necessary needs of their child. Additionally, they face constant suspensions, expulsions, classroom disruptions (affecting their peers), and direct service professionals to support them. This limit will not save money, even in the short term, as the cost of services will merely be passed to other support systems with worse outcomes. Over time, the additional costs of continued services, or other, more expensive support systems into adulthood, will increase the total costs to the budget.
Solution: Remove, or clarify the wording of this proposal to be clear that it is a guideline, and not a hard limit applied to every applicant. Increase monitoring and investigations into possible fraud - remove the bad actors while maintaining medical services when it is appropriate. 

Proposal: Weekly hours (p. 28)
"May not exceed 20 hours per week." (Except under EPSDT review)
Goal: Reduce the number of hours a client can receive services to lower overall costs to Medicaid and help prevent over-prescription of hours by providers who are committing fraud.
Reality: Many families who receive services that they need will instead receive reduced or no services due to vague wording that may be interpreted as a hard-cap of hours by MCO's. Overall costs will increase as services are required for significantly longer time frames to make progress. Every hour invested now saves multiple hours of services later. Prevention and early intervention is always less expensive than continuous, ongoing services, which will also include costs into adulthood. The administrative burden will increase significantly, as every request over 20 hours will now go through a EPSDT review. This burden leads to additional costs and time delays for services.
Comment: I fully support the effort to reduce fraud and over-prescription of hours by providers. I do not pretend that every provider and company is making decisions based off of medical necessity only, and not the financial incentives that they may perceive from those actions. However, many clients do require significant support to make progress towards independence. The reality many parents face is that the options offered in public schools or other federally funded sources are not adequate to support the medically necessary needs of their child. Additionally, they face constant suspensions, expulsions, classroom disruptions (affecting their peers), and direct service professionals to support them. This limit will not save money, even in the short term, as the cost of services will merely be passed to other support systems with worse outcomes. Over time, the additional costs of continued services, or other, more expensive support systems into adulthood, will increase the total costs to the budget.
Solution: Remove, or clarify the wording of this proposal to be clear that it is a guideline, and not a hard limit applied to every applicant. Increase monitoring and investigations into possible fraud - remove the bad actors while maintaining medical services when it is appropriate. 

While this proposal is mine (and others) largest concern, there are many other proposed changes that just don't make sense - especially the implementation timeline. Everyone involved needs time to make the drastic changes to how services are monitored, managed, and provided and the requirement to do that in a few short months (since the bill was proposed) to days (since the bill goes into effect) are just not possible. We ask that everyone is provided a realistic time frame to implement any and all the changes. I strongly urge your team to consider the actual outcome of the changes that have been proposed. Every medical service should be based on medical necessity, and not the limits suggested by politicians or driven by financial decisions. 

Sincerely,

Richard Gooden Jr, Founder and Owner, Boundless ABA

richard@boundlessaba.com · 540.212.4069