April 11, 2022

Agency for Health Care Administration
Bureau of Medicaid Policy
2727 Mahan Drive, Mail Stop #20
Tallahassee, FL 32308

Re: 59G-4.125, Behavior Analysis Services Coverage Policy

The Florida Association for Behavior Analysis would like to thank the Agency for Health Care Administration for working with FABA and providers of behavior analysis to make this transition to CPT codes as smooth as possible and to make certain that effective and ethical behavior analysis services are available to all Florida Citizens.

There are improvements in the proposed policy. One notable improvement is the emphasis
on parent involvement and the allowance for up to two hours per week of telehealth to allow for increased connection at times that are convenient to the recipient. However, as FABA and many others have discussed in prior meetings and in the workshop on 4/8/22, there are significant concerns with a number of aspects of the draft policy:

2.2 - Requires that the referral includes a comprehensive diagnostic evaluation (CDE) that recommends behavior analysis services. This is problematic in that some families are not able to find a provider to conduct a CDE in a timely fashion. FABA recommends that this be modified so that if a CDE has not yet been done but the recipient has a physician’s recommendation for behavior analysis, they would be eligible for services if a CDE was scheduled.

If is also the case that not every professional completing a CDE will recommend ABA. Perhaps ABA was not needed at the time the CDE was initially done, but was later deemed necessary out of concerns for safety, communication, or ability to perform major life activities. The CDE may have been completed in a state that did not have ABA services. FABA recommends that if the CDE did not recommend behavior analysis services but shows that the individual meets criteria for functional impairment, another physician, licensed profession or BCBA-D assess and make a recommendation the individual receive behavior analysis services.

4.2.1 – Requires two specific tools – The Vineland and BASC be administered with each prior service authorization request. These two tools are not sensitive to measuring improvements in recipient behavior, thus the benefit for their repeated use is unclear. The cost of purchasing the tests, obtaining training to administer and administering on a repeated basis are significant. FABA recommends that the pool of allowable assessments be expanded to include other tools such as the ABLLS, AFLS, PEAK, VB-MAPP and Essentials for Living. The professional conducting the assessment should select the tools most appropriate for the individual being assessed.

4.2.2 - The first paragraph indicates that the parent or guardian must participate in treatment. FABA supports the idea that parents participate in treatment, however, there are concerns over what “participate” means. There are also concerns about how this applies to situations when the recipient is over 18, lives in a group home, or has other primary caretakers. FABA recommends that the first paragraph of this section, and subsequent sections that address parents and guardians also include caretakers. Caregivers could be defined as person or personnel that must participate in treatment (e.g., grandparent, home staff, teacher, etc.). Consideration could also be given to providing specific activities that can demonstrate participation (assist with implementation, review data, etc.).

4.2.2 – The listing of procedures does not include all procedures on the fee schedule (e.g., T codes, supervision code. FABA recommends that all procedures on the fee schedule be defined in the policy.
4.2.2. - FABA continues to be concerned about the lack of modifiers when medically necessary treatment is implemented by BCBA, BCBA-D, BCaBA or FL-CBA.
4.2.3 - Supervision - FABA members have raised concerns about the requirement to bill a non-reimbursable code for supervision. For many providers, this will add additional administrative costs in generating and approving notes, entering into billing systems, etc. If supervision occurs in the middle of an RBT’s session, they will have to write 3 notes instead of one.
4.2.4 - Discharge – This section implies that individual would no longer be eligible to receive services if any of the items were true. For items three, four and five, this is problematic since the absence of maladaptive behavior should not be the only criteria for discharge. FABA recommends combining items 3-6 into one item such as “Data indicates the frequency and severity of maladaptive behaviors(s) or level of functional impairment no longer poses a barrier to recipient’s ability to function in their environment”
5.2. – Exclusion – FABA is concerned about the number of new exclusions added to this section. These exclusions will eliminate recipients from getting medically necessary services in environments where the behaviors occur, in situations that will allow the person to integrate into their communities and will interfere with ability to choose the most appropriate educational environment for their child. An unintended consequence of these exclusions will increase the delivery of services in clinics only, perhaps with only the those needing acquisition skills, leaving those bigger stronger, more violent recipients without any providers. Limiting provision of services in some setting will have an adverse affect on some families ability to work.

Concerns with specific exclusions:

• What is the definition of an Autism Specialty School? Why is the ASD diagnosis singled out?
• Recreational, leisure or educational camp? Although an RBT should not be used merely to provide 1-1 care in these settings, if these services are deemed medically necessary to treat severe or intense behaviors, or teach skills related to the recipients functional impairment, why is it excluded?
• Extracurricular activities – In some areas, this may be the best situation to train social skills rather than in contrived social situations.
• Caregiver of Childcare settings – This can be a valuable area to train skills and address challenging behaviors in integrated setting.

FABA recommends that the exclusions section be re-evaluated and concerns about the environments that services be provided be addressed through the prior authorization process. Perhaps some general guidance could be written into the policy.

6.2.2 This list is similar, but not identical to the Model Coverage Policy provided by the ABA
Coding Coalition. FABA recommends a number of items be modified:

• The third item requires a “Thorough Medical History…”. This seems excessive and goes beyond the scope of practice of behavior analysts. This should be modified to “Brief background information including available relevant medical history”
• The Supervision Plan requires the name of the person who is providing supervision. This should be modified to clarify that this is the plan for providing clinical oversight on this plan. Requiring the name of the actual person is problematic as it implies that the plan will need to be updated if there is turnover or coverage issues at the agency.

6.2.4. – FABA members have raised concerns about the practicality of session notes signed. It may not be clinically appropriate to get each note signed. Some electronic medical record systems allow for signatures, but the system do not show all the clinical items listed. It does not appear that this is a requirement for other Medicaid services. In lieu of requiring that each session note be signed, perhaps the parent, guardian or caretaker could sign a verification log that indicates the date, time in, time out, name and credentials of the provider. If the goal is to ensure parent/guardian/caregiver inclusion, the above verification log, along with parent training records, and signatures on assessments would appear to meet that objective.

FABA looks forward to working with AHCA to improve this policy. Please let us know if you
have any additional concerns.

Eric Prutsman – [email protected]
Tiki Fiol - [email protected]
Mary Riordan - [email protected]