APA WF# 21-31 Applied Behavior Analysis (ABA) Revisions

Libby Light-Motley:

Do we need to register in advance to attend the public hearing on 1/18/2022? If so, how do we do so? Thank you!

OHCA Response:

Thank you for your comments/questions. The public hearing will be held at the OHCA's public location and through Zoom. Pre-registration is not required if you plan to attend the meeting in person.

The Zoom registration details will be uploaded to the OHCA's public calendar at a later date.

Jonathan Wedel:

A collective effort to continue improving, refining and clarifying our ABA regulations is welcomed. In the interest of brevity, we will identify only the few sections we believe require additional clarifying in order to avoid confusion, or worse, adverse effects to SoonerCare members and summarize why. We would appreicate the opportunity to collaborate to refine these sections to ensure they (i) are clearly communicated such that the public can use and understand them, (ii) that they accord with EPSDT and Mental Health Parity Standards, and (iii) do, in fact, contribute to ensuring accuracy and completeness in clinical documentation as well as better individualized treatment plans--and treatment outcomes--for SoonerCare members. First, we propose that Sections 317:30-5-312(b), as drafted, unintentionally limits permitted ABA services to those targeting only maladaptive behaviors, excluding treatment aimed at underlying skill deficits in communication, adaptive behavior or social skills, which would result in a negative effect on SoonerCare member outcomes, and moreover a negative effect on public health, safety, and environment, with no perceivable benefit. Second, we request further clarification, using defined langue, of Section 317:30-5-312(c). The term "member record" raises confusion as to whether this information must be (i) recorded and maintained by the ABA provider and available for inspection, or instead (ii) must be submitted to SoonerCare routinely for SoonerCare to record, manage and maintain. Third, we propose that Section 317:30-5-313(2)(a), as drafted, is, on the one hand, unclear because we are unsure what appropriately constitutes a "thorough clinical assessment" as that term has been added here next to the previously exclusive option of a "comprehensive diagnostic evaluation"; and, on the other hand, as written, may lead to disruption of care for SoonerCare members who are unable to timely receive an evaluation and therefore experience a significant (6 months or more) disruption of care, which will surely cause a significant reversion of behaviors and loss of treatment progress. Fourth, we propose that Section 317:30-5-316(4), as drafted, causes confusion. It is unclear whether this language intends to propose any changes to current concurrent billing practices. To the extent the new language intends to restrict concurrent billing of BCBA and RBT providers for different services provided at the same time, this proposed language will have a significantly detrimental affect on SoonerCare members, ABA providers (clinically and economically), the related small businesses, public health, safety and environment, etc. Thank you for your consideration, and I look forward to working on this together!

OHCA Response:

Thank you for your comments/questions. The OHCA takes every comment under advisement. OHCA has updated its proposed rule language to ensure the assessment and treatment protocol includes but is not limited to antecedent and consequence interventions as well as teaching replacement skills specific to the function of the identified maladaptive behavior. Furthermore, rule language has been updated to clarify that the member record should be documented, maintained, and released for inspection upon request by the OHCA. The proposed changes now clarify that when a clinical assessment is completed by one of the eligible providers, the assessment should outline the appropriate autism diagnosis, along with the supporting clinical rationale. This will be accepted in place of the comprehensive assessment provided by a licensed psychologist. New changes to proposed policy requires that the appropriate BCBA and RBT, who is providing the treatment, is listed when billing CPT codes concurrently.

Mary Ann Shepherd:

317:30-5-312(b)(5) as drafted could unintentionally exclude previously covered, medically necessary preventative self-care skills training. Many behavioral challenges result from an underlying skill deficit in communication, adaptive behavior or social skills.

Specifically, many challenging behaviors such as aggression, self-injurious behavior or elopement exist due to an underlying skill deficit. Additionally, untreated skill deficits could result in an escalation or future manifestation of behavioral challenges. Therefore, it is important to address skill deficits as part of a comprehensive treatment plan as well as to prevent a future escalation or manifestation of challenging behaviors.

Revisions to allow for clinicians to proactively treat skill deficits prior to an escalation of behavior reduces future costs to the system which may require more intensive or longer duration of treatment to remediate learned maladaptive behaviors in order to teach a more appropriate and skill based approach to meeting the clients individual needs.

The current research supports a number of assessments and protocols to treat skills that do not necessarily rely on functional analysis are documented throughout the literature as part of evidence based practice. The way the current wording is written it limits professionals from addressing skill deficits for each individual at the onset of diagnosis and as part of early intervention.

Section 317:30-5-312(c) as drafted causes confusion by using the term "member's record," which is not defined within the document.

This section does not clearly indicate what records are to be maintained at the site and what records are to be submitted as part of initial and re-assessment for treatment authorization. This information is routinely kept by providers for a minimum of 7 years per HIPAA requirements. However to supply this information to the OHCA on an ongoing basis would be cumbersome to both the provider as well as OHCA authority to maintain these records. This could easily be clarified by indicating these records must be maintained by the BCBA/Provider and could be requested upon audit or on an as needed basis but not required as part of ongoing authorizations.

317:30-5-313(2)(a) changes the previous requirement of a "comprehensive diagnostic evaluation completed . . . with the last two years." There are two changes to note:

This section requires a comprehensive diagnostic evaluation or clinical assessment every 6 months. Industry standards typically consider a diagnostic evaluation to be current for a period of 2-3 years. Many of the diagnostic assessment batteries are only designed to be administered once in a 12 month period and more frequent administration would invalidate the results of assessments due to practice effects. Additionally, nationally waitlists for assessments can be 1-2 years. By requiring more frequent assessments it could result in invalid results, is an unnecessary use of resources, a strain on the system which could prevent other children who have not yet received a diagnostic assessment from accessing necessary appointments because of frequent re-assessments, and a delay or interruption in services due to wait lists. Furthermore, assessments are only authorized once every 12 months so the clients/clinician’s would be unable to access necessary authorization for the services.

317:30-5-316(4) ABA was designed as a tiered model of service delivery to reduce the financial burden and allow access to services by allocating resources across providers. By limiting concurrent billing, this would result in BCBA not being able to provide the necessary supervision of lesser trained professionals and could compromise quality of care, could result in unsafe practices, and an increase in maladaptive behaviors. This would subsequently increase the need for services and become financially burdensome on the system. Allowing for concurrent billing allows for a more efficient use of the BCBA’s time and resources to supervise service delivery across lesser trained professionals which are reimbursed at a lower rate. This also allows BCBA’s to provide training to parents to effectively address challenging behavior in the home setting which also serves to decrease the duration of services and increase generalization of treatment and skill acquisition across treatment settings. The way the current revisions are written, it is unclear what OHCA is requiring of the BCBA to continue to deliver ethical and evidence based services within a tiered model of service delivery which has been demonstrated to be the most cost effective method of treatment and resources. It is unclear if these services must be requested in advance, how they should be requested, and if prior authorization is required for these services. Currently, OHCA allows for this service, as do most insurance carriers, and is a generally accepted standard of care. A lack of concurrent billing would result in a disparity of services, a lack of medically necessary treatment, and a lack of adequate training and supervision as required by licensing boards, and ultimately lower quality care which would cause a future strain on adult services and long term care for individuals with disabilities. Revisions should clearly indicate that concurrent billing is a billable service and if additional authorization or documentation is required to continue concurrent billing, what is required of the BCBA to document the services provided concurrently, what is expected in documentation, and if prior authorization is required, how to ask for that authorization since it is not currently located on the existing authorization documents.

OHCA Response:

Thank you for your comments/questions. The OHCA takes every comment under advisement. OHCA has updated its proposed rule language to ensure the assessment and treatment protocol includes but is not limited to antecedent and consequence interventions as well as teaching replacement skills specific to the function of the identified maladaptive behavior. Furthermore, rule language has been updated to clarify that the member record should be documented, maintained, and released for inspection upon request by the OHCA. The revised proposed changes better clarify that when a clinical assessment is completed by one of the eligible providers, the assessment should outline the appropriate autism diagnosis, along with the supporting clinical rationale. This will be accepted in place of the comprehensive assessment provided by a licensed psychologist. New changes to proposed rules require that the appropriate BCBA and RBT, who is providing the treatment, is listed when billing CPT codes concurrently.

Christa Stevens:

Autism Speaks is dedicated to promoting solutions, across the spectrum and throughout the life span, for the needs of individuals with autism and their families through advocacy and support; increasing understanding and acceptance of people with autism spectrum disorder; and advancing research into causes and better interventions for autism spectrum disorder and related conditions. We write to you today in response to Proposed Rule APA WF # 21-31. We appreciate the opportunity to provide public comment on the proposed rule.

We are grateful to the Oklahoma Healthcare Authority (OHCA) for working to ensure that Medicaid-enrolled children in Oklahoma who are diagnosed with an autism spectrum disorder (ASD) have access to medically necessary care, including ABA. Since the Centers for Medicare & Medicaid Services (CMS) first issued the CMS Informational Bulletin on Clarification of Medicaid Coverage of Services to Children with Autism (CMS Informational Bulletin) in 2014, we have advocated tirelessly to ensure that all states provide the medically necessary care to which children with autism are entitled.

We share the following numbered concerns:

1. We request that the treatment plan description as found in 317:30-5-312(b) be updated to reflect the generally accepted standards of care.

We ask for this change so that the rule is congruent with generally accepted standards of care. One reference source for such standards is Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, Second Edition. In this resource, treatment plan development is described as follows:

A developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. The information from this process is the basis for developing the individualized ABA treatment plan. An ABA assessment typically utilizes information obtained from multiple methods and multiple informants, including the following:

File Review: Information about medical status, prior assessment results, response to prior treatment and other relevant information may be obtained via file review and incorporated into the development of treatment goals and intervention. Examples of assessments that should be reviewed include intellectual and achievement tests, developmental assessments, assessments of comorbid mental health conditions, and evaluations of family functioning and needs. In some cases, if assessment information is incomplete, the Behavior Analyst should refer the client to other professionals for needed assessments.

Interviews and Rating Scales: Clients, caregivers, and other stakeholders, as appropriate, are included when selecting treatment goals, developing protocols, and evaluating progress. Behavior Analysts use interviews, rating scales, and social validity measures to assess perceptions of the client’s skill deficits and behavioral excesses, and the extent to which these deficits and excesses impede the life of the individual and the family. Examples of rating scales include adaptive-behavior assessments, functional assessments, among others.

Direct Assessment and Observation: Direct observation and data collection and analysis are defining characteristics of ABA. The analysis of such data serves as the primary basis for identifying pretreatment levels of functioning, developing, and adapting treatment protocols on an ongoing basis, and evaluating response to treatment and progress toward goals. Behavior should be directly observed in a variety of relevant naturally occurring settings and structured interactions. Examples of structured direct assessments include curricular assessment, structured observations of social interactions, among others.

Assessment from Other Professionals: Periodic assessments from other professionals may be helpful in guiding treatment or assessing progress. Examples might include assessment of general intellectual functioning, medical status, academic performance, among others.

Furthermore: goals are prioritized based on their implications for the client’s health and well-being, the impact on client, family, and community safety, and contribution to functional independence. ABA treatment goals are identified based on the previously described assessment process. Each goal should be defined in a specific, measurable way to allow frequent evaluation of progress toward a specific mastery criterion. The number and complexity of goals should be consistent with the intensity and setting of service provision. The appropriateness of existing and new goals should be considered on a periodic basis.

Treatment plans should not be focused on maladaptive behaviors and the amelioration of such behaviors. Instead, per the CMS bulletin, the plan should provide for medically necessary care to “develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.”

2. We request that 317:30-5-313 (6) & (7) be replaced with language consistent with the CMS Informational Bulletin.

The CMS Informational Bulletin requires Oklahoma to provide treatment “that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions” . . . “all deficits and conditions arising from a child’s ASD are subject to treatment.” Therefore, the treatment may serve to “strengthen the individual's/parent's/legal guardian's capacity for self-care and self-sufficiency to decrease interventions in the home by those other than the parent(s)/legal guardian(s)” but should intend to correct or ameliorate all deficits and conditions arising from autism.

Additionally, EPSDT does not in any capacity allow for a “fail-first” approach to treatment which seems to be implied in the proposed rule. Under EPSDT, the application of other treatment modalities is neither necessary nor required.

3. Rather than limit treatment to maladaptive behaviors, we request that 317:30-5-31(1) connect treatment to symptom amelioration as required by EPSDT. The symptoms of autism extend beyond those that could be categorized as “maladaptive behaviors” and are detailed in the DSM-5.

Further, the identification of a child’s strengths and weaknesses across domains is part of a developmentally appropriate assessment process. Additionally, potential barriers to progress—beyond an FBA—should be identified through the process.

4. Regarding (2)(D) we recommend that this language be eliminated and that the core deficits of ASD (as described in the DSM-5) be the central focus of the treatment plan.

Medically necessary care for autism is broader in scope than maladaptive behaviors and should correct or ameliorate all the deficits and conditions of autism. If ABA is prescribed, services under EPSDT should be available to all individuals across the spectrum.

5. We request that (2)(I) be eliminated.

See the explanation to #4 above.

6. We request that (2)(L) be removed.

EPSDT requires coverage of medically necessary care for those under 21 with ASD. In contrast, educational services are regulated under IDEA and are intended to enable a student with a qualifying disability to access the curriculum in the least restrictive environment appropriate to that individual student. IDEA educational services are not medical in nature. Information regarding these two services should not be intermingled.

7. We request that 317:30-5-315 be replaced with the generally accepted standards of care in the publication listed in #1 above.

In that resource, progress tracking is described as follows:

The measurement system for tracking progress toward goals should be individualized to the client, the treatment context, the critical features of the behavior, and the available resources of the treatment environment. Specific, observable, and quantifiable measures should be collected for each goal and should be sensitive enough to capture meaningful behavior change relative to ultimate treatment goals.

The results of standardized assessments may be used to monitor progress toward long-term treatment goals. However, IQ scores and other global assessments are not appropriate as sole determiners of an individual’s response or nonresponse to ABA treatment. Many individuals may show substantial progress in important characteristics of the disorder (for example, language functioning, social functioning, repetitive behavior, adaptive behavior, safety and wellness, and co-morbid mental health conditions) without a substantial change in measures of intellectual functioning. Thus, scores on such assessments should not be used to deny or discontinue ABA treatment.

8. We request that 317:30-5-315 (4) be replaced with the direct supervision activities described below which are generally accepted standards of care as described in the publication listed in #1 above.

Case supervision activities can be described as those that involve contact with the client or caregivers (direct supervision, also known as clinical direction) and those that do not (indirect supervision). Both direct and indirect case supervision activities are critical to producing good treatment outcomes and should be included in service authorizations. It should be noted that direct case supervision occurs concurrently with the delivery of direct treatment to the client. On average, direct supervision time accounts for 50% or more of case supervision.

The list below, while not exhaustive, identifies some of the most common case supervision activities:

Direct Supervision Activities; Directly observe treatment implementation for potential program revision; Monitor treatment integrity to ensure satisfactory implementation of treatment protocols; Direct staff and/or caregivers in the implementation of new or revised treatment protocols (client present).

Indirect Supervision Activities: Develop treatment goals, protocols, and data collection systems; Summarize and analyze data; Evaluate client progress towards treatment goals; Adjust treatment protocols based on data; Coordinate care with other professionals; Crisis intervention; Report progress towards treatment goals; Develop and oversee transition/discharge plan; Review client progress with staff without the client present to refine treatment protocols; Direct staff and/or caregivers in the implementation of new or revised treatment protocols (client absent)

Thank you for the opportunity to submit these comments in response to the proposed rule.

OHCA Response:

Thank you for your comments/questions. The OHCA takes every comment under advisement. OHCA has updated its proposed rule language to ensure the assessment and treatment protocol includes but is not limited to antecedent and consequence interventions as well as teaching replacement skills specific to the function of the identified maladaptive behavior.

There is no new language in sections OAC 317:30-5-313 (6) & (7), 317:30-5-314 (1), (2)(D), (2)(I), (2)(L), 317:30-5-315 other than minor modifications to correct grammatical errors and to update a policy reference(s). The language is underlined because the policy was reorganized into its own Part. This policy language was previously approved by the OHCA Board on March 17, 2021, and through the Legislative House Joint Resolution (HJR) on May 26th, 2021, which was official signed by the Governor on June 11th, 2021.

Andrea Buffington:

We appreciate the opportunity to provide public comment on the proposed rule, which will: “establish new documentation and signature requirements to ensure accuracy and completeness in clinical documentation as well as better individualized treatment plans for members. Additionally, the proposed changes will clarify the conditions under which concurrent billing codes The proposed revisions will establish new documentation and signature requirements to ensure accuracy and completeness in clinical documentation as well as better individualized treatment plans for members. Additionally, the proposed changes will clarify the conditions under which concurrent billing codes can be used for the treatment of members,”

Respectfully, we ask you to consider the following:

317:30-5-312

b) Treatment plan. The treatment plan is developed by a BCBA or a licensed psychologist from the FBA. The treatment plan shall:

Treatment plans are not intended to be exclusively focused on maladaptive behaviors and their amelioration, rather a treatment plan should provide for medically necessary care to “develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual,” as stated in the CMS bulletin.

We request that the treatment plan description as found in 317:30-5-312(b) be updated to reflect the generally accepted standards of care from the Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers 2nd.

(c)(10) Treatment plans are not valid until all signatures are present [signatures are required from the member, if fourteen (14) or over (unless the member who by reason of a physical or mental incapacity cannot give consent as defined by state law)], the parent/guardian [if younger than eighteen (18) or otherwise applicable] and the supervising BCBA or licensed psychologist. The signatures may be included in a signature page applicable to both the assessment and treatment plan if the signature page clearly indicates that the signatories consent and approve of both.

Pursuant to Oklahoma law, individuals under the age of 18 do not have the legal capacity to enter into or be held to signatory contracts of any kind. (O.S. 15 sections 11 & 13) We request that the provision requiring members fourteen or over to sign the treatment plan be removed.

317:30-5-313

(6) The focus of treatment is not custodial in nature (which is defined as care provided when the member "has reached maximum level of physical or mental function and such person is not likely to make further significant improvement" or "any type of care where the primary purpose of the type of care provided is to attend to the member's daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel.") Interventions are intended to strengthen the individual's/parent's/legal guardian's capacity for self care and self sufficiency to decrease interventions in the home by those other than the parent(s)/legal guardian(s).

(7) It has been determined that there is no less intensive or more appropriate level of service which can be safely and effectively provided.

As previously mentioned, the CMS Informational Bulletin requires states to cover treatment “that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions.” It goes on to state that “all deficits and conditions arising from a child’s ASD are subject to treatment.” It also is not only to “strengthen the individual's/parent's/legal guardian's capacity for self-care and self-sufficiency to decrease interventions in the home by those other than the parent(s)/legal guardian(s).” Rather, treatments are intended to correct or ameliorate all deficits and conditions arising from a child’s ASD. Medically necessary care as defined under EPSDT does not in any capacity allow for a fail-first approach to treatment. Application of other treatment modalities is neither necessary nor required.

We ask that 317:30-5-313 (6) and (7) be eliminated from the proposed regulation and replaced with language consistent with that which is included in the CMS Informational Bulletin. For example, “ABA services are designed to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.”

317:30-5-314

(1) The criteria include a comprehensive behavioral and FBA outlining the maladaptive behaviors consistent with the diagnosis of ASD and its associated comorbidities Medically necessary care specific to autism spectrum disorder is not limited to maladaptive behaviors but is intended to correct or ameliorate all deficits and conditions arising from a child’s ASD. Additionally, as previously mentioned, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress rather than be limited to an FBA.

Rather than restrict treatment to maladaptive behaviors, it is our recommendation that the language in (1) reference the most recent version of the DSM to identify the various symptoms that should be ameliorated under the medically necessary care required by EPSDT.

(2)(D) Clearly define in measurable and objective terms the intervention plan so it can address specific target behaviors. The intervention plan should be clearly linked to the function of the maladaptive behavior and include antecedent interventions, replacement skills to be taught, and modification of consequences. Additional goals may be identified that are related to the core deficits of ASD and are prioritized based on current research and social significance for the individual.

Again, medically necessary care specific to autism spectrum disorder is not limited to maladaptive behaviors but is intended to correct or ameliorate all deficits and conditions arising from a child’s ASD. Additionally, as previously mentioned, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress rather than be limited to an FBA.

Please note that there is no mention of maladaptive behavior in the DSM-5 diagnostic criteria for ASD. Limiting coverage to individuals that require treatment for maladaptive behavior is inconsistent with CMS and EPSDT requirements. If deemed medically necessary by the individual’s care team, including a referring physician and BCBA, services should be available to all individuals across the autism spectrum.

We ask that this language be removed with treatment plan focus remaining on core deficits of ASD (social communication/interaction and restricted repetitive behavior) as defined in the most recent version of the DSM.

(2)(I) …Treatment (behavioral training) will be individualized and documentation will support the identified atypical or disruptive behavior.

Medically necessary care specific to autism spectrum disorder is not limited to maladaptive behaviors, but under the requirements of EPSDT as explained in the July 2014 CMS bulletin is intended to correct or ameliorate all deficits and conditions arising from a child’s ASD. It goes on to state that “all deficits and conditions arising from a child’s ASD are subject to treatment.”

We ask that the language in (2)(I) be eliminated.

(2)(L) Documentation may be requested by the OHCA to support coordination of services with other providers and to prevent overlap and duplication of services including those in school settings.

EPSDT requires coverage of medically necessary care for children under the age of 21 with autism spectrum disorder. In contrast, educational services are regulated under the Individuals with Disabilities Education Act and are intended to enable a student with a qualifying disability to access the curriculum in the least restrictive environment appropriate to that individual student and not medical in nature. These are two separate entitlements and information regarding them should not be intermingled in educational or medical records.

We respectfully ask that this language be removed.

317:30-5-315

(3)A functional analysis shall be completed by the provider when no measurable progress has occurred, or it may be requested by the OHCA. The functional analysis should record the member's serious maladaptive target behavioral symptom(s) and precipitants, and document the modifications of the current treatment plan to address progress, as well as make a determination of the function a particular maladaptive behavior serves for the member in the environmental contex

According to Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers 2nd,,

The measurement system for tracking progress toward goals should be individualized to the client, the treatment context, the critical features of the behavior, and the available resources of the treatment environment. Specific, observable, and quantifiable measures should be collected for each goal and should be sensitive enough to capture meaningful behavior change relative to ultimate treatment goals.

The results of standardized assessments may be used to monitor progress toward long-term treatment goals. However, IQ scores and other global assessments are not appropriate as sole determiners of an individual’s response or nonresponse to ABA treatment. Many individuals may show substantial progress in important characteristics of the disorder (for example, language functioning, social functioning, repetitive behavior, adaptive behavior, safety and wellness, and co-morbid mental health conditions) without a substantial change in measures of intellectual functioning. Thus, scores on such assessments should not be used to deny or discontinue ABA treatment.

We request that this recommendation be removed and replaced with the generally accepted standards of care described above as defined in the Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers 2nd..

317:30-5-316

4) Providers may only concurrently bill current Procedural Terminology (CPT) codes when they outline in the prior authorization the following criteria:

(A) The BCBA or licensed psychologist meet with the member and/or parent/guardian and are directing the RBT through one (1) or more of the following:

(i) Selection of treatment targets;

(ii) Collaboration with family members and other stakeholders;

(iii) Training RBTs;

(iv) Creating materials, gathering materials; and/or (v) Reviewing data.

(B) The BCBA or licensed psychologist used behavior training in session. Behavioral skills training consists of instructions, modeling, rehearsal, and feedback between provider and member.

Generally accepted standards of care, as written in Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers 2nd describe case supervision as follows:

Case supervision activities can be described as those that involve contact with the client or caregivers (direct supervision, also known as clinical direction) and those that do not (indirect supervision). Both direct and indirect case supervision activities are critical to producing good treatment outcomes and should be included in service authorizations. It should be noted that direct case supervision occurs concurrently with the delivery of direct treatment to the client. On average, direct supervision time accounts for 50% or more of case supervision.

The list below, while not exhaustive, identifies some of the most common case supervision activities:

Direct Supervision Activities

Directly observe treatment implementation for potential program revision Monitor treatment integrity to ensure satisfactory implementation of treatment protocols Direct staff and/or caregivers in the implementation of new or revised treatment protocols (client present) Indirect Supervision Activities Develop treatment goals, protocols, and data collection systems Summarize and analyze data Evaluate client progress towards treatment goals Adjust treatment protocols based on data Coordinate care with other professionals Crisis intervention Report progress towards treatment goals Develop and oversee transition/discharge plan Review client progress with staff without the client present to refine treatment protocols Direct staff and/or caregivers in the implementation of new or revised treatment protocols (client absent)

We respectfully request that 317:30-5-315 (4) be removed and replaced with the direct supervision activities described above.

OHCA Response:

Thank you for your comments/questions. The OHCA takes every comment under advisement. OHCA has updated its proposed rule language to ensure the assessment and treatment protocol includes but is not limited to antecedent and consequence interventions as well as teaching replacement skills specific to the function of the identified maladaptive behavior. Furthermore, OHCA has revised the proposed policy for clarification and provide further understanding on the needed signature requirements for assessments and treatment plans. New changes require that the appropriate BCBA and RBT, who is providing the treatment, is listed when billing CPT codes concurrently.

There is no new language in sections OAC 317:30-5-313 (6) & (7), 317:30-5-314 (1), (2)(D), (2)(I), (2)(L), 317:30-5-315 other than minor modifications to correct grammatical errors and to update a policy reference. The language is underlined because the policy was reorganized into its own Part. This policy language was previously approved by the OHCA Board on March 17, 2021, and through the Legislative House Joint Resolution (HJR) on May 26th, 2021, which was official signed by the Governor on June 11th, 2021.

Kari Childers:

We appreciate the opportunity to provide public comment on the proposed rule, which will: “establish new documentation and signature requirements to ensure accuracy and completeness in clinical documentation as well as better individualized treatment plans for members. Additionally, the proposed changes will clarify the conditions under which concurrent billing codes The proposed revisions will establish new documentation and signature requirements to ensure accuracy and completeness in clinical documentation as well as better individualized treatment plans for members. Additionally, the proposed changes will clarify the conditions under which concurrent billing codes can be used for the treatment of members,”