Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Welcome back everybody. Afternoon, February 5.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: So we're

[Rep. Alyssa Black (Chair)]: pivoting to an issue that has come about recently and we've noticed it in both our budget adjustment and just today in in FY '27 budget. So I've asked Diva to come in and talk about this one issue in particular. And then we have some providers also that we have scheduled to provide feedback on this. So this is just sort of information gathering so that we really kind of understand this issue and what's going on. So Commissioner Gross, if you want to come up, And Grace, you want to come up too?

[Rep. Daisy Berbeco (Ranking Member)]: I appreciate it.

[Rep. Alyssa Black (Chair)]: Welcome back.

[Commissioner Gross (DVHA/AHS)]: Thanks for having me again. I should just schedule my whole day here.

[Rep. Alyssa Black (Chair)]: Good. You should.

[Commissioner Gross (DVHA/AHS)]: I want to thank the committee for having us today to talk about the applied behavioral health analysis and the implementations that we have done that have been implemented since January 1. I will say that there have been changes are in alignment with two let me wait for Grace.

[Rep. Alyssa Black (Chair)]: Okay. So

[Commissioner Gross (DVHA/AHS)]: Just so excited. I have

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: to figure out how to present in Zoom, which is, I will say, not my strong suit.

[Rep. Alyssa Black (Chair)]: Yeah. Okay.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Is it working?

[Rep. Alyssa Black (Chair)]: Yeah. You are doing better than 95% of it.

[Commissioner Gross (DVHA/AHS)]: Chinks her, she still has one more step. She's almost there.

[Rep. Alyssa Black (Chair)]: For the record, would be the worst of those ninety seconds. Appears to be working. Awesome, Grace. If you want to introduce yourself for the record.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: For the record, my name is Grace Johnson. I work as a policy analyst at the Medicaid Policy Unit at AHS. Thank you.

[Rep. Alyssa Black (Chair)]: All right.

[Commissioner Gross (DVHA/AHS)]: So we had to make these changes as a part of a compliance issue that we had identified and that we've realized that these impacts a number of providers and families. But we want to make sure that the things that I want to point out is that we're continually seeing if I can talk today, it's continuously monitoring our provider network that these policies changes are impacting. We're monitoring the monthly tier submissions to direct changes, and we're conducting a rate study later this year that will go over the ADA benefit and look at the rates there. So it's kind of

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I'm sorry. I did it, and now I'm not.

[Rep. Alyssa Black (Chair)]: That's perfect. Can you see me now? Yeah, Okay. So

[Commissioner Gross (DVHA/AHS)]: the Office of Inspector General at the Agency of Health and Human Services, so then at the federal level, has included audits in their ABA programs and their work plan. And so this is in our special unit investigation unit at DIVA has identified this as a risk for us. And so we have really thought about we reviewed our own program. We identified the vulnerabilities of the program. And one of them was that Diva currently had no written policy on concurrent billing. And so although we may allow that in a formal setting, there was no official written policy that we had. And that put us at risk of findings based on several patterns that we have saw. So our internal unit has required us to really clarify our policy and align with our correct voting policy as well.

[Rep. Alyssa Black (Chair)]: I just want to be clear that the US Department of Health and Human Services, we know, is specifically targeting these types of services, and we had not previously had written policy on this, and this was a vulnerability that we've got.

[Rep. Leslie Goldman (Member)]: Leslie, go ahead. This is kindergarten. What is an applied behavioral analysis?

[Commissioner Gross (DVHA/AHS)]: Sure. Grace, do you want to?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Yeah, sorry. No, that's all right. So Vermont Medicaid covers applied behavior analysis, which is ABA services for kids with autism. And we talk a little bit about what services specifically are impacted by this policy. But you're thinking largely of services that help children with autism, maybe things like toileting or dress themselves or enter classrooms or grocery stores in a way that is maybe more functional for them and for their families.

[Rep. Leslie Goldman (Member)]: So if I may, applied behavioral analysis is only applied to autism or anything having to

[Rep. Daisy Berbeco (Ranking Member)]: do with any kind of behavior?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: In this particular instance, we're talking about children with an ASD diagnosis, an autism spectrum diagnosis. And we

[Rep. Alyssa Black (Chair)]: are going to receive some testimony from providers of ABA services.

[Rep. Brian Cina (Member)]: It isn't just children, it's adults as well.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: It is adults as well, yeah. In Vermont, our benefit primarily serves children.

[Rep. Leslie Goldman (Member)]: Keep going. Okay.

[Commissioner Gross (DVHA/AHS)]: Right. So as part of change of these changes, we have reviewed several different billing practices for the ABA, CPT codes, 97135 and 97155. And Viva has a number of resources that we use in terms of billing and our own coding team. And so what we have found is that in one of the resources that we've used, it says that the guidance clarifies that the Medicaid can only reimburse for the child's face to face time in receiving these services and that the two clinicians cannot bill for that same time period for that one child. And due to the scrutiny on the federal level and what we have identified internally as vulnerabilities, we needed to clarify where our policy was and have decided to no longer allow the concurrent billing of these two codes.

[Rep. Alyssa Black (Chair)]: Can we go back one slide? You sort of skipped over your fourth bullet point there. I thought it's about Wisconsin.

[Commissioner Gross (DVHA/AHS)]: About Wisconsin. Okay. Yeah. So a part of this I can get to that slide. So the inspector general identified in doing that audit in a situation with Wisconsin, they did not have a concurrent billing policy as well. And so that's where the feds have had to is now requiring them to pay $18,500,000 from the Medicaid program back to the feds.

[Rep. Alyssa Black (Chair)]: Is it Medicaid that's had to pay it back, or is it the providers that were paid previously under that, have they had to pay it back

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: as well? Yes. So as Daisyan said, there is similar to the fact pattern that we have here in Vermont, which is that the Office of Inspector General, as a part of this work series where they're doing the audits of the states, found that Wisconsin had $18,500,000 My understanding is that when the OIG finds an overpayment like that, not only is money recouped from the state Medicaid program, but the expectation is that those claims are also recouped from providers because they were found to be fraudulent or an overpayment.

[Rep. Leslie Goldman (Member)]: So a coding question? Are those codes providing different services from different people, or is it the same person providing the same service? Don't really know how that works. What's the thinking behind that? Absolutely.

[Commissioner Gross (DVHA/AHS)]: It's it's not the same person. So one code is for the train or for the non licensed, and the other one is for the supervisor. So they're they're in the meeting at the same time, and therefore, they are billing they're two different buttons. But Grace can Two defer to

[Rep. Leslie Goldman (Member)]: people Okay. So I understand. Two different people providing different, but at the same time, concurrent, but different services or not necessarily?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: So what had been happening prior to oneone is that you had both a licensed provider applied, an ABO provider, and a technician, someone who's not licensed, in the room with the kit at the same time. And what's interesting is that you were billing both 97,155 and $97,001.53 for that same hour of time. And the $97,001.55 is that licensed person, that qualified health professional that we're talking about. And then the other, the 9700153 is the tech. Diva, on 11/26, has determined that AMA correct coding doesn't really allow for both of those codes to be billed at the same time for the same kid for the same service. And in theory, what is happening or in practice now is that the technician's time is actually included in 97155. So instead of billing two codes for the same hour, the correct coding would say you can only bill one code for the same hour. And the tech may be hands on with the kid, and the licensed provider may be modifying the treatment plan at the same time. So you're talking about the same session with the kid, the same service being provided to the kid, but you have two providers. And the example that we provided here sort of outlines that a little bit, which is that you can have that tech and that provider at the same time. But really, it's for one hour. And correct coding rules indicate that it's really the child's time or the service time that is billed. You can't bill for the provider time. It has to be that hour of patient time. So even though you have two providers, it's one hour of service per AMA correct coding.

[Rep. Daisy Berbeco (Ranking Member)]: Could I ask you to go a little bit further and explain what those two service codes are doing? What are those services? Yes, 9700155.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: And I have it written down, but I'm going try to do it from memory because I can't access my notes when I'm presenting. The 9700155

[Rep. Daisy Berbeco (Ranking Member)]: is the, right here, is

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: the adaptive behavior treatment with protocol, administered by a licensed provider. The 9700153 is adaptive behavior treatment protocol administered by its clinician. Is that helpful?

[Rep. Daisy Berbeco (Ranking Member)]: Yes. I think that, yeah,

[Rep. Alyssa Black (Chair)]: just go ahead. Per one hour, both of them are per one hour.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I actually think they're both perfect Okay. But yeah, for the same

[Rep. Alyssa Black (Chair)]: unit Two of minutes for an hour. Okay.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I would have to check that. It might be an hour, but

[Rep. Alyssa Black (Chair)]: I can't think it's fifteen minutes. So

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: the change to alignment correct coding is the first change that we made, that 97055, 97053. The other large change that you might be hearing about is the telehealth change. So in the review that Diva did of our program, we also identified some need to change the method of delivery for some of the services we were providing. And largely during COVID-nineteen, we opened up a handful of these codes to be delivered via telehealth in order to ensure access to service. But review is determined that that might not be the most clinically appropriate method of delivery. And so in that review, the things that I mentioned before, like toileting or dressing, is we've determined to be more clinically appropriate to be done in person instead of via telehealth. And while we also wanted to recognize the benefit of some of these services being provided via telehealth, we settled on a hybrid model. And so they have three codes that are going to continue to be allowed via telehealth, and the rest of the codes will now be delivered in person. Part of the reason for this telehealth delivery model was that we really wanted to make sure those initial assessments were done in person, that a person was meeting with that client. We're talking largely here about neurodivergent children. We're talking about children who might have varying degrees of ability to interact with a screen. And so we felt like it was important to move some of those services to be in person delivery only. We also really Oh, sorry.

[Rep. Leslie Goldman (Member)]: So when you say we determined, is there a professional assessment? Like how that determination get done?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Yeah, sorry. When I say we, I mean the agency.

[Rep. Leslie Goldman (Member)]: Yeah, there are professionals involved in evaluating that it's not appropriate for telehealth for children to get dressed, whatever.

[Rep. Alyssa Black (Chair)]: Yeah, absolutely. Yeah, so

[Commissioner Gross (DVHA/AHS)]: we clinicians who are ADA specialists. And then we have coders as well. It's part of our clinical unit who are able to review these changes and determine best practices and clinical standards.

[Rep. Leslie Goldman (Member)]: So that's a process you have throughout your system Yes. And it's something

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: we use often. Yeah, in this particular instance, we also consulted with licensed ABA providers to make sure that we were getting multiple views, as well as our deeper clinical team and our deeper coding team to really look at those codes, some of the codes mentioned in person specifically. And so we really wanted to look at how those codes were being used and what the purpose of those codes might be. Sorry, I thought I saw a question coming.

[Rep. Alyssa Black (Chair)]: Did you have a question? No, just thinking.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: That's all right. Just wanted to make sure I didn't cut you off. So really looking at those initial assessments, making sure you have proper supervision of a technician, and then really ensuring, like I talked about, that you're receiving high quality care, that it's the most clinically appropriate, and that if there is any fraud, waste and abuse, that we're reducing opportunities for fraud, waste and abuse.

[Rep. Alyssa Black (Chair)]: We also want to talk a

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: little bit about the projected policy impact. Vermont Medicaid served three twenty unique members in 2025 who received ADA services. Providers on average will see a 12% decrease in hours eligible to be counted in their tier payments as a result of these changes. When I talk about the counted in a tier payment, Vermont Medicaid doesn't pay for the AVA benefit in a fee for service. We pay for it in a value based tier system. So it gets a little confusing when I talk about it that way. But for the purposes of this change, it actually sort of relates the 12% decrease in eligible hours also results in a 12% decrease in income for these providers. The range is between 016%. The average is 12%. That is really the result of the concurrent billing. The telehealth in total will see a 0.8% of all of the Vermont Medicaid ABA hours. So both telehealth and in person hours will be restricted by limiting telehealth to those three codes. Nearly 80% of the telehealth that is occurring today will continue without sort of any impact to those claims. And many providers won't see a change to any of their telehealth practices. We see only six of 20 providers have any impact to their telehealth claims. And largely 91% of all of the telehealth impact falls to one.

[Rep. Alyssa Black (Chair)]: Yes. Where are those six providers located or who do they serve?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Good question. We did an analysis. I can pull it up in my notes. I don't remember all the counties, but it is not concentrated to one particular geographic region. We did do an analysis of whether or not the impact would fall to one region or the other, and largely, all of the claims that we know will be impacted fall within across the whole state. There isn't one area that tends to be more impacted than others.

[Rep. Daisy Berbeco (Ranking Member)]: I'm a Chittenden County legislator, so I'm curious if I have any providers here or if it's just folks that mainly serve rural areas.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I can pull it up. I don't want to misspeak on the counties, but I can't while I'm sharing my screen, so I can pull it up for you. But I'll have to go out of this view. Might also be in there.

[Rep. Alyssa Black (Chair)]: Can I ask a question real quick? You said that ninety one percent of those affected by the telehealth is one provider? Yeah. How many of these three twenty unique members does that one provider serve?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: So I can't answer that, but I can tell you one hundred and fifty four kids total will be affected by the telehealth changes. I would have to look at the exact number of those that fall to that one provider. It's one hundred and fifty four.

[Rep. Alyssa Black (Chair)]: One hundred and fifty four. And if one provider is 90%, then that one provider would

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: So what we see is that a lot of individuals go to one provider and maybe get an assessment and then end up receiving their services elsewhere from a different provider. So even though 154 individuals may see their services in person via telehealth now, for each kid, the maximum number of hours impacted are 7% of hours. So at most, a child would see 7% of their hours move from telehealth to in person. So it's mainly concentrated to one provider. And even in that being true, those kids that might see their service delivery change, it's a very small portion of their overall ABA hours that are changed by that telehealth to in person.

[Rep. Alyssa Black (Chair)]: Robert and then Daisy. Just so I can put this to bed,

[Rep. Brian Cina (Member)]: the changes to align with clinical best practice, the last thing you say there is why certain codes are removed from telehealth, the last thing you say is to reduce fraud, waste and abuse. I hear about this a lot from people that are actively involved in the autism system. Is that an admission that there is fraud and abuse here in Vermont?

[Commissioner Gross (DVHA/AHS)]: I mean, I think there there is fraud ways and abuse in the system. It's just every part of our job is to kind of figure out and that's why we have special investigations units and the audits that we do to find to kind of find those areas and those vulnerabilities sent to do something. So yeah, so, yeah, there there is possibility of fraud wakes abuse, and that's part of what we're working on doing. Jill, do you wanna

[Jill Wilson, Medicaid Health Assistant Director]: I just wanna add something. Yeah. Of course. Jill Wilson, Medicaid health assistant director.

[Rep. Alyssa Black (Chair)]: I guess what I would

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: say is those

[Jill Wilson, Medicaid Health Assistant Director]: are scary words for a range of things that happen. So sometimes waste really means coding things incorrectly by accident and even when you're meaning to do things correctly. So it's a broad range of behaviors in the term for other ways to abuse. And so our job is to essentially make it difficult for people to make mistakes or for people to do things on purpose. And that is the range of things that happen

[Rep. Alyssa Black (Chair)]: and pay attention to that across the whole system, not just

[Jill Wilson, Medicaid Health Assistant Director]: in this part of the provider community,

[Rep. Alyssa Black (Chair)]: but really all parts of the provider community.

[Rep. Brian Cina (Member)]: Well, the reason I ask that question is because constituents of mine have said there is fraud going on and that their kids and their adult children are not getting the services that they need because of that. So, that is why I asked the question. Thank you.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: And then the counties, I can I have the counties for you written down? Didn't have to

[Rep. Daisy Berbeco (Ranking Member)]: take It may play into a larger answer to this question, which is kind of two parts. One is, I guess I'm having a couple reactions. I'll try to turn them into questions. One is that it sounds like we have three twenty unique members served. And you said that 154 are going to be impacted by these changes. And that aside from this one provider who only represents 9% of total ADA hours built. Is that right? I'll tell you my concern. My concern is that people in our urban areas have greater access to these services. And by cutting telehealth, we're going to have tons of people in rural areas who do not have help toileting. And we're doing it because perhaps the special investigations unit isn't effective. That's my concern.

[Commissioner Gross (DVHA/AHS)]: I see your concern, But I also want to push back there in that we're not one, these are three codes that we're getting rid of because we determined that it was not clinically did not meet our clinical standards. And then two, we're still allowing the telehealth in those other areas. And so while we are and that is part of what we're looking at in our monitoring plan is to see where does this create an access issue. And so we will continue to monitor that and see if did our decision disproportionately affect the rural areas and vice versa.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Yeah. Which I think goes into what we're doing to monitor and make sure that that doesn't happen. We've projected that there aren't disproportionate impacts based on where someone's geographically located, but we're also continuing to monitor that. We're not just taking what that projection is and leaving it there. Do you want to talk about the impact?

[Commissioner Gross (DVHA/AHS)]: So yeah, so we're closely monitoring it. And then act 14, which lays out which rates studies Diva has lined up, we do have an ABA benefit that is due before July 26 this year. And to look at those payment rates to see whether or not the rate is adequate and if access if access plays a part in that as well. And so there are things there that we are looking at. And that we are also asking if we go to the providers to submit information that we really need them to help us identify these issues. And that's where the rate study will help us in determining if the rate is appropriate, if there are any or there needs to be any changes moving forward. And it's not always an increase. I will say it doesn't guarantee an increase. Sometimes we have seen rate studies actually say that there's a decrease in the rate. But that's also about the information that we have from those providers.

[Rep. Alyssa Black (Chair)]: Did you say oh, I'm sorry. Go ahead. Did you say we're doing this in direction of the inspector general's office, or is this something that you've gone ahead on your own to get ahead of it?

[Commissioner Gross (DVHA/AHS)]: It's not by the direction of the Office Inspector General. We are being proactive given the fact pattern that we have that other states have had to pay them. Thanks.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I think also just to speak to not only are we doing the rate study, which is occurring right now and will include extensive provider engagement and making sure that the rate that we have is sustaining access to these services, We also, because of the way that we pay for ABA services, have sort of insight every month into what services are being provided, the number of hours, what kids are being served. And so we're already sort of monitoring whether or not we see any decreases in any of that. And so that will continue as well in addition to the rate study to help us make sure that we're not seeing any decreases in any specific areas, whether it relates to either providers or to members.

[Rep. Alyssa Black (Chair)]: I need to go back slides. I

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: just figured this out so I

[Jill Wilson, Medicaid Health Assistant Director]: can go back and forward.

[Rep. Leslie Goldman (Member)]: Six.

[Rep. Alyssa Black (Chair)]: Tell me a little bit more about how they're paid. Tell me like the tier payments. So they're not fee for service. So they're not directly being They're billing those particular codes and in some cases concurrently. But you don't actually pay on a fee for service basis, you're paying them like a bulk rate based on the number of hours that somebody is served. Based upon the codes that they submit? And you tally up the time of the codes and then they get a tier payment for? So yeah, this is, I might not be the perfect person to speak to this, so we might have to

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: get you a write up on a little bit more about this because I'm not involved in the reconciliation of the tiers. But my understanding of what occurs is that providers come to Deva and at the end of a month or the time period, they say we provided X number of hours of services. Deva provides payment for those hours of services. Then providers submit, like we call them like shadow claims or zero pay claims to support. These are actually the number of hours we provided. And then through the process, we have an entire dedicated team that works through the reconciliation. And if providers ended up providing more services than they claimed, we reconcile that difference. Or if they claimed more than we reconcile downward. But it sort of works on a prospective, which is that they say we fall in this tier for those number of hours this month. And then it sort of is on the back after the shadow claims are submitted because providers have time to submit those claims. We sort of make sure that that's all reconciled and that the services provided were paid for.

[Rep. Alyssa Black (Chair)]: That makes it so you pay it on a prospective basis. That is my understanding. So like, say a child was sick for a week or two and didn't receive any services, then that would get reconciled at the end of the next month because there wouldn't be that tally of Sorry, I

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: used perspective in that we don't wait for the claims, but not perspective in that a provider would come to us at the January and say, I did provide this many services. So they're not like, if they went in today, it wouldn't be the services they're anticipating to provide in February. It would be what they did provide in January. Then like, usually it ends up being very close with the reconciliation. Just has to press up to get shadow claims in. And then sometimes there's a change in what someone's eligibility or something like that. But it's not prospective in the future. It's just before the claims come in to support that.

[Rep. Alyssa Black (Chair)]: Very administratively burdensome for all of you.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I believe that it is. But I'm on board.

[Rep. Daisy Berbeco (Ranking Member)]: I've

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: heard that it is intensive for everyone. Yeah.

[Rep. Brian Cina (Member)]: Is that

[Rep. Alyssa Black (Chair)]: done manually? I believe so.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I believe a large portion of it is done manually by staff. There's obviously the claims go through our MMIS system, but the reconciliation and working with providers to get things in is all a manual process. And

[Rep. Alyssa Black (Chair)]: did you say all the counties had someone involved or Yeah,

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: the providers that'll see the most impact to the counties were Newport, Rutland, Chittenden, Montpelier and Bennington.

[Rep. Alyssa Black (Chair)]: Alright, keep going. Was that it?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I think that was it for us.

[Rep. Alyssa Black (Chair)]: Think, yeah. Okay. Leslie, and then I just had one other question. Maybe you don't want

[Rep. Leslie Goldman (Member)]: to answer this, but you brought it up, but you can say not today, or someone else say later. Because you brought up the idea of reducing fraud, waste, and abuse. And I know that you were specifically talking about these particular codes, but I'm wondering about how big an operation is Indiva that is looking at fraud, waste and abuse.

[Commissioner Gross (DVHA/AHS)]: Yeah, we can give I can't give you exact numbers today, but there are several units who do look at there are different units that look at different perspectives of of the payment or not the payment, but, like, across the program. So I can give you that, but that's kind of a broad it's a diva wide thing, but I can give you the exact numbers.

[Rep. Leslie Goldman (Member)]: It's like a billion dollar operation, right? Something like plus or minus. And I'm just wondering, that's a very interesting idea that you have to do that, but how much does it cost and how much you're actually saving and the effectiveness of that. You brought up broad based abuse and that's where my mind went.

[Rep. Alyssa Black (Chair)]: Okay, there are 20 providers that provide these services across the state of Vermont.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: That was the number as of December 2025, yes. Okay.

[Rep. Alyssa Black (Chair)]: So you have in here that there's a 12% decrease in the hours, which should equate to a 12% decrease. What is the dollar amount of that? How much money are we talking? Yes. Across 20 providers, and I do realize not equal. For concurrent billing, it's $1,400,000 Okay. And that's just the concurrent billing piece. 1.4. And then the telehealth is only impacting 0.8%. 0.8. So how much does that equate to?

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Don't anticipate that those services will switch delivery, but we don't anticipate

[Rep. Alyssa Black (Chair)]: loss of services. Okay, so no loss of services. So that means no loss of reimbursements. You see, you're talking about $1,400,000 by 20 providers, I mean, that's just assuming that they're all equal, which means they're not going to be. That's a lot of money for one provider to absorb. Are we worried about that? We're mandated to provide these services, correct? Yes. I mean, this is

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: a benefit that Vermont Medicaid has. It's a benefit that under EPSDT we provide.

[Rep. Alyssa Black (Chair)]: It's What an essential again is the timeline of when you're going to have an analysis of the effects of this and

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: The rate study will be concluded by July 2026, but we are monitoring it ongoing.

[Rep. Alyssa Black (Chair)]: So what if July 2026 rolls along in a few months and you've done the rate study, new rates don't go into effect usually typically until January 1 next year, which means that theoretically $1,400,000 hit to providers in one year. That could really place these services at risk, particularly in some of our more rural areas. And as we know, once you lose a service, you're not getting that. Be prepared to July 1 when we realize that with the rate study that we need to do something? Are we prepared to raise rates in July and then come back to us in the BAA and with an up?

[Commissioner Gross (DVHA/AHS)]: That is one solution that we can come back with, yes.

[Rep. Alyssa Black (Chair)]: Go ahead, Daisy. I don't think we

[Rep. Daisy Berbeco (Ranking Member)]: have until July. I think you're going to have a lot of fewer providers in July to revive. But no matter how much money you have, doors are closing right now. And I'm sure you're hearing about that. I certainly am from my constituents.

[Commissioner Gross (DVHA/AHS)]: We've heard from three providers who are no longer accepting new, but we have not seen it actually across the board. And there have been some providers who have said that they have access to take on new members.

[Rep. Daisy Berbeco (Ranking Member)]: And the telehealth votes?

[Commissioner Gross (DVHA/AHS)]: Can't talk. I don't have that information right now.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah. I mean, I think the committee should consider having some reporting done much sooner than July. I don't think that our autistic family members and constituents can wait that long. These are essential benefits, essential things like toileting. This is not where we save money.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: I think the bottom line is sort of that there's federal interest in this issue. We had to do these things to align with credit coding. The solution would be for to look at the rates, and we are doing that. No, I'm not a provider.

[Rep. Daisy Berbeco (Ranking Member)]: However, I have been doing research on this, and we both know since December, and I've been working with providers. I've also been given a lot of information about the AMA CPT codes. And I think it's very debatable, your interpretation of that coding manual, because you read to me the descriptions of ninety seven thousand one fifty five and ninety seven thousand one fifty three. And the manual text that I have seen says that adaptive behavior treatment by protocol can be administered with the technician in the room when there is a QHP directing the technician who is implementing the protocol with a patient. So for example, if I'm a patient and I'm working with my provider, the provider's supervisor needs to supervise if ever my service needs modified. So if my supervisor, if Alyssa never sees how I'm working with my patient as a new clinician, how is she ever going to assess and help me revise my protocol with my patient? There's no way if there's not concurrent billing. That's why it is legal to have concurrent billing. It's not illegal. And I appreciate that you are protecting Vermont by being incredibly careful with what's allowable so that there is less fraud and abuse. But I really wish that we would instead see an increase in the way that our special investigations unit operates.

[Commissioner Gross (DVHA/AHS)]: The thing is that the stance is that we've been very proactive around this concurrent billing to reduce the risk that's on Vermont. So the policy, it's not gonna change, but the plan and we have a plan to monitor. And as soon as we see something, we can go through it and make those changes. So if that's a request of, hey, we're turning back these codes and it's costing us x number of money in our BAA, you will see that.

[Rep. Daisy Berbeco (Ranking Member)]: I want to know when a door closes.

[Rep. Alyssa Black (Chair)]: I would just say, I know it's not bad coding, but coding is up to interpretation and that it's interpreted many different ways, and I readily accept that if there is someone who is interpreting it a certain way and that person or entity has the oversight of our Medicaid program, I'm willing to accept that. I am more concerned that we know that this will have an impact and we are not making an immediate and what could be a very easy rate increase on proper, what we're calling now proper coding to mitigate the loss of what has been usual practice. That's more of my concern. I'm just tougher. Then we'll move on to the barriers.

[Rep. Brian Cina (Member)]: My concern, I have a concern because I haven't What heard the word used at role does the guardian play in the decision making that you've just described? The guardian of the person who's getting the service.

[Commissioner Gross (DVHA/AHS)]: Not sure. The Guardian has a say in the treatment plan for the AVA benefit. So they play a role there.

[Rep. Alyssa Black (Chair)]: What?

[Commissioner Gross (DVHA/AHS)]: No. I'm just trying to understand your question.

[Rep. Brian Cina (Member)]: And you people sit in your offices and you develop these plans, and you told us who you work with to develop of the plans, the provider, that you didn't say guardian.

[Rep. Alyssa Black (Chair)]: In other words,

[Jill Wilson, Medicaid Health Assistant Director]: were families involved?

[Rep. Brian Cina (Member)]: The family that's getting the service, who knows that person better than the Ghanaian? And my question is just how involved are they in this decision that's been made? I know they have to sign with that.

[Jill Wilson, Medicaid Health Assistant Director]: Madam Chair, it sounds to me like, I think the question really comes down to whether or not we should adjust that reimbursement for the code that we are continuing to reimburse, which I think is a conversation. We did assume that the budget would be reduced by the dollars that we're talking about here. And so I think that it's a tension between us in terms of our position on what to do and yours. That's what the budget process is about. So I think that's, I assume that we will continue to talk about this in the context of those dollars.

[Rep. Alyssa Black (Chair)]: So, as we have discussion around the budget this year, if we choose to not recommend, the governors recommend with the stipulation that that money will go to rate increase or the billing that is still being allowed, that being discussed, I think we'll have. I think that's a good idea.

[Rep. Leslie Goldman (Member)]: So is that a million dollars, is that what you're talking about? What is that about?

[Rep. Alyssa Black (Chair)]: What is the general fund on that? I think the general fund is one. What was the is it general fund 1.4?

[Commissioner Gross (DVHA/AHS)]: The total I don't know, I'm not sure, I'll get back to you if the 1.4 is general fund or if it's combined.

[Rep. Alyssa Black (Chair)]: The 1.4 is general fund, then this a huge hit. It's a big difference.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: Thank you.

[Rep. Alyssa Black (Chair)]: I think it's in our budget slides from this morning. I was gonna say from last week, but that was just this morning. Alright, well thank you for coming

[Rep. Daisy Berbeco (Ranking Member)]: in and thanks for bearing the breadth of the concerns.

[Rep. Alyssa Black (Chair)]: And I'm really impressed Courtney because you actually didn't need any of your notes. Grace. I'm sorry. Courtney's next. Sorry. Need to leave up my schedule.

[Commissioner Gross (DVHA/AHS)]: So

[Rep. Leslie Goldman (Member)]: we do

[Rep. Alyssa Black (Chair)]: have What about the nudity ladies? Hi, Courtney. Thanks for joining us. Hello. Hi. Introduce yourself and tell us a little bit about yourself and what you do and your input on this issue.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Sure. And I've I have notes I'm gonna be referencing, so I apologize if I'm reading a bit from them.

[Rep. Alyssa Black (Chair)]: No. That's alright.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: So I'm Courtney Keen, and really appreciate the opportunity to have this be part of this conversation quite a bit. I am here wearing two distinct hats, one as a clinician, co owner and operator of an ABA organization in White River Junction, Vermont. And I am also, as of last Monday, the chair of the Vermont Association of Applied Behavior Analysis. I'm also a BCBA, a board certified behavior analyst, and a Vermont licensed behavior analyst. Okay for me to dive in?

[Rep. Alyssa Black (Chair)]: Yes, please.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Excellent. Okay. So something that I wanted to share for some context as well. My husband, Chris, and I, he's also a BCBA. We own Keen Perspectives in White River Junction, and we are a dual accredited organization by the Autism Commission on Quality and as a Behavioral Health Center of Excellence. Chris and I were also the Vermont Small Business Persons of the Year in 2023. And I don't say that to gloat, I say that to show our commitment to our workforce, our community, and the services we provide. So additionally, you're going to hear from two of my colleagues who are also BCBAs and practice owners in Vermont serving Vermont Medicaid beneficiaries. So they're hovering in the background, and I'm going to make sure to leave time for them. Combined, our three organizations estimate that we served around 40% of those three twenty unique Medicaid members that were referenced, by Diva in 2025. At our organization, Keen Perspectives, we support a large number of children with level three or profound autism who require very comprehensive, care and level of service. Just to give you a very brief, overview of what ABA is, applied behavior analysis, think of it as a treatment and a teaching methodology, often prescribed for children with autism. Today in this context, we're speaking about a model based on medical necessity, often considered outpatient specialist services in the healthcare field. As a treatment, ABA is individualized, and it's based on each patient's presentation of their symptoms of autism. And it's based around their strengths, and specific barriers to learning. It's also provided across settings. So it might be in a clinic, it might be in homes, it might be in the community. The science of ABA can be supported anywhere objectively, and often in like a single or a tiered delivery model. My testimony is going to focus on two main issues, concurrent billing and telehealth. The changes that went into effect on January 1 are already having sweeping impacts across Vermont. As you mentioned, you're hearing from providers and families already. It's already being felt. Providers are already starting to make changes to reduce or eliminate services for their Medicaid members in 2026, ourselves included at Came Perspectives. Before I dive into some stuff that I've prepared, I wanted to comment on the OIG audit of Wisconsin just very briefly. So my understanding of the OIG audit in Wisconsin is that the Wisconsin policy excluded concurrent billing. And since the state policy excluded it, it should not have been billed for. So that was a state specific issue, and it was not coding guidance. So the issue was that it wasn't in their policy, so they shouldn't have been billing, not that it was a coding issue from the get go. That's my understanding of that OIG audit. But back to the things that I specifically wanted to share. The reasoning for the changes that we've heard that providers are operating on outdated information, specifically based on this knowledge based article from the AMA. So we, as providers, but I'll speak for myself, as Courtney from Keen Perspectives, that we think this is not accurate and that Diva is actually operating off of unofficial information that's not considered official coding advice. It is not widely available. It's only accessible with a subscription, and it does not constitute official direction from the AMA. There have been no coding changes to ABA coding guidance since our codes became permanent in 2019. So the best resources for that are the 2026 American Medical Association CPT coding book in addition to a 2019 CPT Assist article. What's really nice about these resources is that all of the codes and code descriptors are clearly defined in those documents. And anything that can't be billed concurrently is clearly outlined in the parentheticals in that document. And ninety seven thousand one fifty three and ninety seven thousand one hundred fifty five are not outlined as in those parentheticals. So nothing else would be considered official except for those two documents. The AMA itself would not approve or publish multiple codes unless they were considered separate and distinct services and are codes for a technician delivering treatment by protocol, is 9700153, and protocol modification delivered by a qualified health professional, which is 9700155, they are very separate and distinct. Additionally, there's a pending code change application. There will be new ABA codes and new guidance going into effect 01/01/2027. Until that information is made publicly available sometime later in 2026, there have been no updates to this code set since it was introduced in 2019. Was prepared to talk about the definitions of the two codes. Is that something you'd like me to touch on? Does the committee feel comfortable with those?

[Rep. Alyssa Black (Chair)]: Yeah, I think that's fine.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Okay. So the two codes in question being billed concurrently, 9700153, adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or QHP. 97,155 is adaptive behavior treatment with protocol modification administered by a physician, which may include simultaneous direction of a technician. And that's the key part of this. Anytime that 97153 is being delivered by a technician by a frontline service provider, our generally accepted standards of care in ABA, they require occurs for a specific percentage of time while a technician is delivering ninety seven thousand one fifty three. Both of those services are separate and distinct, and they're both client centric. Yeah, those are the pieces I want to touch on there.

[Rep. Leslie Goldman (Member)]: Can I

[Rep. Alyssa Black (Chair)]: because I don't have CPT right in front of me? Your description so there's the technician, the technician under the supervision, although you didn't use the word supervision, the direction. Mhmm. I think you said the direction of the licensed provider. But then the license the code for the licensed provider is for modification. Mhmm. Now so they're both time codes. So would you let's say you were provide the technician was providing an hour of of services, and the supervisor just did in that full hour, you know, maybe I'm assuming they're time based codes where you gotta meet half 50% plus. So fifteen minutes where they were actually doing modification. Yep. Would you bill four units of the technician and one unit of the supervisor doing the modification? Or would you bill full four units because the supervising physician was there at the time even though they weren't modifying anything for most of it? I really got into the weeds with your accident.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: That's such a great question. I'd never thought about that perspective off the codes. Your first example is accurate. So if there's an hour of service that's being provided by a technician by protocol, a qualified healthcare professional is there providing protocol modification with direction of that technician, they're billing for that fifteen minute unit only. So one unit, and then the technician is billed for four units because they're fifteen minute units.

[Rep. Alyssa Black (Chair)]: Right. So I just want to be clear that they're only billing for the time where modification is actually happening. They're not billing for time for supervision, just in general. Correct. If they're standing there watching. Oh, Correct. Okay. Keep going. Sorry.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Please don't apologize. Thank you for asking that. Okay, next I wanted to touch briefly on telehealth. And then Brian, one of my colleagues, he's going to talk a little bit more about telehealth as a Vermont telehealth provider. So regarding the telehealth pieces, I wanted to share that the 2026 Medicare physician fee schedule that went into effect 01/01/2026. It includes all of the ABA treatment codes approved on a permanent basis. And in both the proposed and then the final rule that went through, CMS said they were making this change because they wanted to respect each clinician's professional judgment in evaluating the most appropriate methodology to receive care that includes, telehealth. So they said that ABA codes can be delivered via telehealth and really wanted to encourage clinician individual decision making and family choice and looking at what families need, what their children need. In speaking as myself, keen perspectives, think it would be reasonable and appropriate for Diva to ask for clinical rationale from providers and make that an expectation and a standard. Because we aren't saying that everyone should get access to all telehealth all the time. But we do feel strongly that there can't be a blanket rule, then no one can receive the services that Diva removed from that approved list of codes. For keen perspectives, just thinking about impact, our January impact was a 14.4% in decreased compensation for services rendered compared to what it would have been had concurrent billing not been removed. And we consider this a baseline impact because there were holidays, snow day, delay closures, and a very large number of client cancellations due to the flu. We service 10 Medicaid members actively in our center, and we have 10 on our wait list. I didn't know it was that many till today. We also have diagnosing physicians calling us to find out if we're still taking Medicaid because other providers in Vermont are no longer, and they're trying to figure out where to send referrals. With regards to the ABA case rate model, where providers are reimbursed for total hours provided and it's not fee for service, as was, discussed by Diva. That ABA case rate model really should not exclude the hours when determining tiers for payment. They are treatment hours being delivered, and there's no question about the value of the services being delivered. And quite frankly, providers need to be paid for the services that are being rendered, those hours still should be accounted for in how services are billed. There's nothing cited in that knowledge base question and answer that Diva is referencing, which is how they made their decision, to contradict that. So the basis for excluding those concurrent billing codes from the tier payments, we feel is not valid in terms of payments. So the concurrent nature of billing, these are both direct services being provided while other services are being provided and both, well, any service being provided should be compensated just as a practical matter. They should be compensated under the formula that Diva is currently operating under. Otherwise, asking us to provide medically necessary services in line with generally accepted standards of care is effectively forcing providers to provide services for free or not provide services in line with those generally accepted standards of care. Both are scary. There continues to be an overall network inadequacy, especially in rural parts of the state. Rates are one of the main things that attract providers to networks. I was happy to hear there'll be a reevaluation of the overall fee schedule. It has not been updated since 2019. In addition to reevaluating the fee schedule, fixing clinical and administrative barriers that have now been implemented would really help ensure more access to care for a lot more Vermont children and families that are currently unable to access services. Then my parting words before I hand off the microphone, I was noting our governor's three main priorities for this year, and all are relevant to this argument. Growing the economy, we need more ABA providers across Vermont, not less. The 2025 CDC reports autism diagnosis are one in thirty one. That is increasing every two years that they share that report. Making Vermont more affordable, ABA organizations are large employers. We have really large workforces because a lot of our services are one to one. And just by the nature of how we provide services to 20 total children right now, and we have 33 employees. So it's a large number of people contributing to the workforce. And protecting our most vulnerable. These changes will immediately, they are immediately, doing the opposite of protecting the vulnerable and will also have ramifications in the Vermont economy in other ways. Parents will have to stay home if their kids can't access school services and they don't have access to ABA. There'll be a lot more people unemployed if they don't have jobs because kids aren't accessing services. So we're all here for the same thing for all of these children and families, in Vermont. And I'd like to also give, Melinda and Brian a little bit of time if there's still some available to share because they're also providers.

[Rep. Alyssa Black (Chair)]: Yes, there absolutely is available time. Before you go or before you step back, should say, when you were referring to the telehealth, so it's my understanding that Diva is going to continue 97155, +1 56, and +1 57. What codes are they not going to cover that you could be covered?

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: I'm wondering if Brian is one of the largest telehealth providers

[Rep. Daisy Berbeco (Ranking Member)]: in Vermont.

[Rep. Alyssa Black (Chair)]: Well, let's thank Brian that.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: I think he would a great person to talk, not to put you on the spot,

[Rep. Alyssa Black (Chair)]: Yes. No, that's all right. Let's talk to Brian. So we also have Brian and Melinda with us. Hi, Brian.

[Rep. Brian Cina (Member)]: Hey, everyone. Thanks

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: for allowing us to talk. We appreciate it quite a bit. Do you want me to just to jump on in with my my talk or you want me to answer that question?

[Rep. Alyssa Black (Chair)]: If you can answer that question really quickly and then go into your talk.

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: I think my personal opinion being a long history of utilizing telehealth that we should have a more clinical foundation of assessing what codes would be appropriate for what family and not make brushing statements of yes or no. I think there needs to be more rigor upfront to determine what is effective for a child as well as a family's home. And that's how we operate day in and day out as an organization.

[Rep. Alyssa Black (Chair)]: Okay. Thank you. Want to go into Absolutely. Your

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: Okay, so I want to first say so my name is Brian Merrier, born and raised Vermonter and very proud of being from this state. I'm a board certified behavior analyst. I have my master's in education. I'm a national consultant on applied behavior analysis, as well as helping other agencies succeed. I am a national presenter going to conferences nationally speaking on quality of services, what it means to be a ethical and responsible business owner in a very difficult, difficult industry. I started autism advocacy intervention with my wife in 2015. We've been providing applied behavior analytic services for over a decade across the country. We provide services in our clinics, in home, telehealth, and utilize telehealth as well as in person in numerous school districts around the state of Vermont, as well as across the country. We have serviced thousands of families nationally and have proudly delivered Medicaid funded services to Vermont for more than six years. And today, AAI services roughly 80 Vermont Medicaid funded families. While experience and scale matter, what matters more is fit. ABA is not a one size fits all service. Effective care requires meeting a child and a family where they're at developmentally, behaviorally, and environmentally. Telehealth is one modality among several. It is not appropriate for every child and should never be casual or by default. But when it is clinically appropriate, it can be highly effective. I'm here today because DIVA's policy change as of January 1 removes telehealth from core ABA treatment codes and restricts the ability to bill for clinical oversight program modification when direct treatment is occurring. These changes will reduce access and compromise quality of care for autistic Vermonters. This policy does not raise standards. It removes tools that are currently working. At AAI, telehealth is not a convenient model. It is a structured clinical service with clear guardrails. We use formal readiness tools to determine whether telehealth is appropriate for a child and the family. We assess the assessment considered utilizes baseline skills, behavior profile, caregiver capacity, safety considerations, and access to reliable technology. If a family or child is not ready, telehealth is not used. If telehealth is initiated, and later proves to be a poor fit, services are transitioned either to our clinic, in home, or to another provider available within the region. This distinction matters because telehealth should never be forced, but neither should it be taken away when it fits. In Vermont, eliminating telehealth does not mean families seamlessly transition to in person care. For many families, it means fewer hours or no services at all. Vermont has limited workforce, particularly in rural regions. Many families face transportation barriers, lack of reliable vehicles, or live in housing situations where in home services are overwhelming and not feasible. We have also learned directly from autistic individuals that some engagement, that telehealth engagement is more effective, more predictable, and less intrusive on their environment. For these individuals, telehealth is not second best. It is a modality that allows them to participate meaningfully. And we as providers understand how important generalization of those learned skills are as well. Learning how to apply those in a secure, safe environment, move them into the community, move them into clinics is always our goal. Families are not here today to testify. So I want to responsibly bring some of their voices into this room. In a blind family survey conducted with the families participating in our telehealth services, parents wrote very high satisfaction and a strong recommendation to recommend our service. One parent writing simply, my family, my child continues to grow and our quality of life has improved going through your therapy. We do not rely on opinion, we rely on outcomes. We track skill acquisition rate over time. When we compare children with similar starting profiles and needs, telehealth services, when appropriately matched, show learning rates that are comparable to, and in some cases stronger than in person care. What is difficult to understand is that AAI undergoes regular audits, including what used to be annual, but now biannual audits with Vermont Medicaid. Our telehealth and in person and clinic based services has consistently met quality and compliance standards. Every year we have received an A rating. Diva has been aware of this, has monitored, knows about our telehealth utilization for years, and has celebrated our services. To now criticize this modality as ineffective does not align with that documented history. I also want to acknowledge DIVA's responsibility to ensure program integrity and prevent inappropriate billing. That responsibility matters and providers share it. What I'm having a hard time understanding is how discussion around fraud or billing compliance is translating into restriction of telehealth or limiting real time clinical oversight. These are two very separate issues. Fraud prevention is addressed through documentation, standards, audits and enforcement, not eliminating clinically effective models of care. Telehealth does not create fraud. Poor oversight does. And oversight can be improved upon. This brings me to the concurrent billing. DIVA is not saying that providers cannot deliver or bill for clinical oversight under fivefive. The policy is prohibiting 97,153 that happens at the same time. The challenge is that these two codes are clinically different, as Courtney shared. In a high quality ABA care with program modification doesn't just happen in the beginning, it happens throughout the treatment. It happens during the treatment when the clinician sees what is working, makes immediate adjustments and ensures the child is receiving effective and safe care By prohibiting billing when these services occur, the policy discourages the very oversight they claim to value. DIVA requires providers to deliver ongoing clinical oversight as part of the medically necessary ABA care, yet the policy structurally now prevents reimbursement. Providers are still expected to deliver the service, but are now being prevented from being paid for it. I also wanna raise a concern about process. Historically, Diva has engaged with providers, including myself, very closely and other professional organizations when considering policy change that affect care and delivery. In this case, there was zero collaboration with providers or any of the families that I serviced throughout the entire state. Many of us worked with many national organizations that insurance companies, providers and states listened to. They were a part of this process when it was brought to the table and for some reason, DIVA is not listening, and we're a little confused and not sure why. Further, DIVA is leveraging information inside documents, cherry picking very slim aspects where those very documents, for example, with telehealth define objectively why telehealth is effective. What is also

[Rep. Daisy Berbeco (Ranking Member)]: think Daisy

[Rep. Alyssa Black (Chair)]: actually has a question.

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: No, please Daisy.

[Rep. Alyssa Black (Chair)]: Well, it's

[Rep. Daisy Berbeco (Ranking Member)]: less a question and more just to check-in with you because if your testimony is written, I'd appreciate it if you could submit the written testimony because I know that we

[Rep. Alyssa Black (Chair)]: have one other speaker after you

[Rep. Daisy Berbeco (Ranking Member)]: and we have to be on the floor in ten minutes.

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: Fair enough. Perfectly fine. I'm done with the report, so that's perfectly fine. Happy to let others or I can answer any question anybody would like.

[Rep. Alyssa Black (Chair)]: I really appreciate your testimony.

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: And if you would send it in writing, that's

[Rep. Alyssa Black (Chair)]: great because we often go back and refer back to that.

[Brian Merrier, BCBA; Autism Advocacy Intervention (AAI)]: Absolutely.

[Rep. Alyssa Black (Chair)]: And this is a budgetary item for us to consider this year. So, thank you so much, Brian.

[Rep. Brian Cina (Member)]: Thank you, I appreciate it.

[Rep. Alyssa Black (Chair)]: Melinda? Thank you.

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: Hi, can everyone hear me okay?

[Rep. Leslie Goldman (Member)]: We can.

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: Oh, good. I'm going to turn on my video. I've been having connectivity issues this entire meeting, so I've already given Courtney the go ahead if I glitch out that she can take over in my

[Rep. Alyssa Black (Chair)]: stead. And Grateful you're here in whatever mode you're able to get. There you are.

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: All right. I'll try not to move, but I'm usually not this robotic. Thank you first and foremost for allowing us to come here and speak today. It really makes a difference. My name's Melinda Neff. I'm a BCA in the state of Vermont. I have been for twenty three years now, and I've worked in the field of ABA for twenty six years in this state. I'm the owner, a single owner of Green Mountain Behavior Consulting, which you might hear me call GMBC because it's a mouthful. And yeah, and we've been in business since 2014 and in 2016 we started work with ABA therapy through private health insurance. We currently serve 32 Medicaid clients throughout the state and our locations are as follows: 11 clients in Bennington, five clients in Brattleboro, nine clients in Newport, and seven clients in Montpelier. So I'm a little concerned that I think three out of those four locations were on the list of impacted places. Anyway, though not exclusive, our primary focus is providing early intervention to children under the age of six years old or before they enter into public school with an ASD diagnosis. And just on an aside, I believe in a practitioner and the power of early intervention for these young children and families, but I also believe from the perspective of a parent of a child diagnosed with ASD. As I had the privilege of having our daughter receive early intensive AP intervention from 2006 to 2009. Now this was before the legislation had passed for folks to receive this as a medically necessary treatment and her treatment ultimately allowed her to be able to attend her public school independently and with the needed skills and over time at her three year evaluation resulted in her losing her autism diagnosis or not meeting the criteria anymore. So I stand here before you today as two people, a BCBA for the state and also a parent who has no doubt that her daughter receiving ABA therapy during that critical time of life was key and it's why believe in the work beyond that of a practitioner or even a business owner. So with this, my hope in opening four locations across the state of Vermont was to give back the gift I felt I received all those years ago. It was and still is to give hope and the skills to children and families who need it to provide for our communities and to ultimately pay it forward to schools by helping children and youth gain the skills to access their education as independently as possible. This is why I've always operated with a fiscal goal for our ABA clinics of net zero, meaning that as a single owner of this organization, sorry and I wasn't sure I was glitching out, my goal for the clinics was to provide ABA, not to turn a profit, but to serve. And throughout these ten years of ABA therapy, we've seen many changes occur as it relates to the reimbursement for ABA services, or as I like to say, we've weathered many storms. But these most recent changes no longer seem like a storm that we can weather. Despite our attempts, the recent changes are creating a storm that I am not certain we can weather any longer. We've tried to prepare by cutting jobs, cutting staff incentives, cutting staff benefits, we've increased clinical caseloads, and we've essentially asked folks to do more with less.

[Rep. Alyssa Black (Chair)]: Can interrupt you really quickly, Melinda? Just have you done an analysis of what you think this is going to how this is going to affect you? And I think that question is for both Brian and Courtney as well, if you've done an analysis.

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: Yes. Our in house analysis, just with the non concurrent code billing,

[Rep. Leslie Goldman (Member)]: we

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: showed a 16.6% decrease in revenue, which would have been from '25 to projected '26. So that's higher than what Diva presented as 12%. I don't know if that's because we really strive to, we always strive to meet that supervision best practice hours number. I don't know if you want Brian and Courtney to answer.

[Rep. Alyssa Black (Chair)]: I hear our bells ringing, so I just wanted to get something really quickly. I'm assuming many of the clients that you serve have Medicaid. I'm also assuming that you have clients that have commercial health insurance as well. And I'm wondering how commercial rates and as well as billing policies regarding concurrent billing align or do not align with Vermont Medicaid's new?

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: We currently provide services to mostly Medicaid clients. We, I think, have two part time Blue Cross Blue Shield clients. So maybe, Courtney, you can speak to that a little better because I know that you're kind of fifty

[Jill Wilson, Medicaid Health Assistant Director]: fifty. Mhmm.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Is that something you want me to answer Yeah.

[Rep. Alyssa Black (Chair)]: Right now? If you could. If not, you could send it to us if you know. But we only have a we only have, like, two minutes.

[Courtney Keen, BCBA; Co-owner, Keen Perspectives; Chair, Vermont Association of ABA]: Yeah. I just wanna give I think Melinda just a couple more minutes, I'll put I'll organize some stuff for you.

[Rep. Alyssa Black (Chair)]: Okay. Thank you. Yes. Go ahead, Melinda.

[Melinda Neff, BCBA; Owner, Green Mountain Behavior Consulting]: Thanks. In summary, I suppose this we represent it sounds like 10% at least of Medicaid's total clients across the state and I have to tell you that despite kind of working at a break even place for all the clinics for all these years, I do not believe that we are going to be able to keep our doors open. I've given my teams through the first quarter and so far January was terrible. I'm out of ideas on how to keep it floating and we work in some of the most rural places in Vermont, Newport being one of them. That was a new project for us in 2025 in January. I definitely would not have started that project knowing that these changes were going to occur and impact us so dramatically. So it's been tough and you know I just want you to know that I don't believe I'm going to be the first person that's going to need to close doors, especially before they look at other ways to kind of keep places going and so far me saying this is impactful but I understand the changes Diva has to make and the pressures they're getting and you know just wanted to share, we'll do the best that we can, but it's not looking good.

[Rep. Alyssa Black (Chair)]: Thank you all. Thank you all for joining us. We really do appreciate And your perspective is so important as we move forward in trying to make decisions around the budget this year and the governor's recommend in the budget. Thank you. You. Thank you. Thank you for the work that

[Commissioner Gross (DVHA/AHS)]: you're doing for kids at a pivotal moment Thank you. Thank you.

[Rep. Alyssa Black (Chair)]: We'll be back tomorrow. Floor. Summertime. Oh,

[Grace Johnson, Medicaid Policy Analyst (AHS/DVHA)]: we have a joint hearing

[Rep. Alyssa Black (Chair)]: tomorrow at eleven 10:30, I think

[Rep. Brian Cina (Member)]: it is.