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Emily:

Article 317:30-5-314(b).3.G specifies that ABA services provided by a clinic or agency owned or partially owned by the child/youth’s responsible adult would be an 'excluded' service.  This is unethical and feels very targeted.  I personally own a clinic that offers ABA therapy.  My son has needed ABA therapy for many years.  He has gone to multiple other clinics and has gotten sub-par care.  Therefore, we have established an ethical way for him to receive services in the clinic we own.  My husband and I have absolutely no connection to his care whatsoever, other than as parents, as we contract a third party BCBA to supervise the RBT that provides his treatment.  Excluding services due to a patient's parents' level of ownership in a clinic is unethical and should have no bearing on whether the services would be covered or not.  Many individuals' own clinics where they don't even work and have nothing to do with daily operations.... a client should not be penalized for this.  I adamantly oppose this specific exclusion and deem it unethical.  No other insurance has such an exclusion, and Medicaid should not be allowed to exclude this.  Furthermore, if this is deemed to be acceptable, patients and clinics should be given at minimum a year or two years to transition to another clinic as that is the average wait list for therapy and it is unethical to stop medically necessary services so abruptly.  Thank you for your consideration.

Kent:

As a parent and small business owner, I am deeply disheartened by the emergency action order that has abruptly stripped my child of critical access to behavioral therapy. This decision not only impacts my family but unfairly penalizes families like mine, who dedicate their lives to providing high-quality care and resources for children in need.

My child, like so many others, relies on therapy to develop essential life skills, manage daily challenges, and thrive in ways that were once thought impossible. To deny access to these services simply because the clinic providing care is owned or operated by a parent or guardian is not only unethical but deeply discriminatory. It creates an unfounded stigma against parents who are professionals in this field, as though their dual roles as caregivers and clinicians somehow compromise the integrity of their child's care.

This policy assumes a conflict of interest where none exists. Behavioral therapy is evidence-based and data-driven, with measurable outcomes that ensure accountability regardless of ownership. The professionals providing services are licensed and operate under strict ethical and regulatory guidelines that safeguard the quality and impartiality of care. Why, then, should my ownership of a clinic disqualify my child from receiving the same state-covered services available to others?

The sudden nature of this order has placed my family in an untenable position. Beyond the financial strain, it disrupts the continuity of care, jeopardizing the progress my child has worked so hard to achieve. Behavioral therapy is not a luxury; it is a necessity for children with developmental and behavioral needs. This action effectively denies children their right to equitable healthcare, punishing them for circumstances beyond their control.

I urge you to reconsider this harmful policy, specifically Article 317:30-5-314(b).3.G. Rather than targeting families, let us focus on strengthening accountability and transparency measures across all providers. Denying children access to care sets a dangerous precedent and erodes trust in our healthcare system. I am not just advocating for my child but for all families who have been unjustly affected by this sweeping and ill-conceived decision.

Our children deserve better. They deserve equal access to the resources that allow them to reach their fullest potential, regardless of who owns the clinic providing those resources. I implore you to rescind this order and work with parents and professionals to find solutions that prioritize the well-being of our most vulnerable citizens.

Rachael:

In response to APA WF 24-23 Circulation Document:

C. A description of the classes of persons who will benefit from the proposed rule:

 The proposed rule changes will benefit all SoonerCare members who receive ABA services by ensuring a sufficient standard of care.

This statement is false concerning ABA therapy in the school environment.  By eliminating this service when it is clinically necessary, the standard of care for that client is lessened possibly to the detriment of the client's total school success. 

D. A description of the probable economic impact of the proposed rule upon the affected classes of persons or political subdivisions, including a listing of all fee changes and, whenever possible, a separate justification for each fee change:

There is no probable economic impact and there are no fee changes associated with the rule change for the above classes of persons or any political subdivisions.

This statement is also untrue, while the fees associated with the services are not changing, eliminating the services in certain environments potentially causes families in low SES statuses to suffer financially due to frequent suspension from school when children engaging in maladaptive behaviors are not given needed supports in the school environment.  This lack of work by the families can lead to job loss, and potentially dire family circumstances only exasperated by the needs of a child with autism. 

If the OHCA thinks that there are issues with providing ABA services in the daycare/school settings. In that case, a revision of services/requirements should be instituted, not a total and complete omission of the services.  Schools and families have written these services into IEPs which are binding documents.  This should be considered when moving forward to permanency. There are many stakeholders involved in this decision.  All should be considered equally. 

Esther:

While many of the new criteria read similar to some private insurance requirements, the proposed restrictions on location, intensity and modality of services will not lead to improved measurable outcomes. For example, parent training can be effective when delivered via telehealth. Practicing interventions plays a role in generalization. I can see the argument that it is best to do that in the physical presence of a BCBA. That does not equate to it cannot be done via telehealth. Sometimes the obstacle is in understanding how the intervention addresses the function. That is a discussion. A discussion that is equally effective physically or via telehealth. Follow up and reporting of data on how parent implemented intervention is going can be done with physical paper data sheet exchange just as easily with an electronic copy of the same data sheet, via telehealth.

Discontinuing coverage for services that improve daily living, social functioning and relationship skills and services rendered in the community are also not in the best interest of the client. Simply eliminating or reducing problem behavior does not translate to an improvement in the life of the client or those in their surroundings. Where is the line between teaching a child to make requests politely and teaching them to share politely. Teaching them not to destroy the roll of toilet paper does not mean much if they never learn to use the toilet independently.  There are instances where the persons in the natural environment are part of the learning history keeping maladaptive behavior going. A neutral third party (ABA practitioner) can disrupt that learning history and create a new history of appropriate behavior that can then be transferred back to those in the natural environment. This is true in settings other than the home. Clients need to learn function in all the natural environments they are a part of. ABA practitioners are well versed in generalization across settings. Limiting their ability to do this will not improve measurable outcomes. Similarly placing time limits for achieving generalization or target levels of proficiency goes against the BACB code of ethics. Treatment duration is data driven not deadline driven. That would equate to setting up one-size-fits -all-trials-to -criteria-requirements for clients in settings outside the home. That also goes against the code of ethics which states that treatment is to be individualized to each client.  Just as the BACB requirements must be met by practitioners, the code of ethics that guide those practitioners should not be overlooked.

K.S:

In response to APA WF 24-23 document; 317:30-5-314. Prior authorization, service limitations, and exclusions to treatment b: Service limitations 1. settings. (A) ABA services are not allowed in a daycare setting or school setting, without OHCA approval. If approved, it will be time-limited to three (3) months or less. The BCBA shall create and submit a treatment plan that identifies the goals outlined to assist school staff with the members without ABA staff being present throughout the school year.

ABA is highly effective in the natural environment including the school setting. I have worked in the school setting in ABA for many years and seen great benefit in the support for the learner and the school staff. ABA therapists play a vital role in supporting both teachers and students within the classroom. By providing targeted behavioral support, offering strategies to enhance communication and social skills, assisting the learner with tasks, training teachers in ABA principles, and promoting emotional regulation, the ABA therapist helps create a positive, inclusive, and effective learning environment. This collaborative effort ensures that students with autism have equal opportunities to succeed and thrive academically, socially, and behaviorally in the school setting. Without the support of ABA in the classroom/daycare setting, many students often get sent home daily as schools do not have the capacity to provide the necessary 1:1 support. This causes undue strain and burden on the student and the families. Often times, schools are seeking the help of ABA companies to support children who are struggling in the school setting. By eliminating these locations fully, it only creates a greater burden to families, teachers and the student. ABA is a medically necessary prescription and should be treated as so. If a licensed professional finds justification through assessments that school based services are recommended, this should be taken into consideration and not eliminated fully. For the daycare setting, these are private businesses not funded by medicaid so the location should have no factor into if ABA is allowed. Providing ABA in the natural setting is effective and is evidence based. This should not be a permanent change and should be individualized.

Mariel:

CASP is a non-profit trade association of autism service provider organizations, with a demonstrated commitment to promoting and delivering evidence-based practices for individuals with autism. CASP represents the autism provider community to the nation at large, including government, payers, and the general public. CASP provides information, education, and promotes the generally accepted standards of care for applied behavior analysis (ABA). CASP is committed to addressing barriers that impact access to quality services delivered by qualified providers.

On behalf of CASP member organizations providing services to Oklahoma Health Care Authority (OHCA) beneficiaries, thank you for the opportunity to provide comment on APA WF# 24-23 Applied Behavior Analysis (ABA) changes.

CASP applauds OHCA for seeking approval of emergency rule revisions to update outdated ABA policies and ensuring that services meet a standard level of quality for all applicable OHCA beneficiaries. CASP and our member organizations appreciate OHCA’s continuous commitment to quality improvement, and aligning the rule with best practices, Federal Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) requirements and generally accepted standards of care (GASC). We also recognize OHCA for the steps it is taking to ensure consistent application of the ABA policy across Sooner Select Managed Care Organizations (MCOs).

 Now that Oklahoma Medicaid beneficiaries utilize Sooner Select MCOs the Federal Mental Health Parity and Addictions Equity Act (MHPAEA) applies to the ABA benefit, and any other mental health and substance use disorder benefits managed by the MCOs.

The following proposed revisions are significant steps forward for OHCA beneficiaries:

Aligning RBT supervision requirements with the BACB minimum expectation of 5%.

Requiring treatment plan goals to relate back to the core deficits associated with autism spectrum disorder (ASD) as outlined in the Diagnostic and Statistical Manual of Mental DIsorders (DSM) and acknowledging functional limitations that interfere with participation in daily life and activities; rather than the previous reliance on maladaptive behavior, alone.

Inclusion of an interdisciplinary team (IDT) to complete comprehensive diagnostic evaluations (CDE) On September 9, 2024, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules implementing MHPAEA. The final rules amend certain provisions of the existing MHPAEA regulations and add new regulations.  In 2023, the Departments reported one of the most common NQTLs  involved family guidance requirements to maintain access to medically necessary ABA services..

“Example 9—More restrictive requirement for primary caregiver participation applied to ABA therapy. The medical necessity criteria for coverage of ABA therapy requires evidence that the participant's or beneficiary's primary caregivers actively participate in ABA therapy, as documented by consistent attendance in parent, caregiver, or guardian training sessions. In adding this requirement, the plan deviates from independent professional medical or clinical standards, and there are no similar medical necessity criteria requiring evidence of primary caregiver participation to receive coverage for any medical/surgical benefits.”

CASP respectfully requests that OHCA reconsider the following sections to align parent participation requirements with the generally accepted standards of care and MHPAEA requirements. 

317:30-4-315 (2) (3) (4) Increased parent participation requirements to request an increased level of overall care in subsequent authorization periods

Generally accepted standards of care indicate:“While caregiver participation can be additive to effective treatment, it is not a substitute for treatment and is not a condition for providing services. Numerous modalities and methods exist to include caregivers in a treatment program, even when direct participation is not possible or advisable.”

“... it is not a replacement for professionally directed and implemented treatment, nor should it be a requirement for access to treatment. The dynamics of a family, their well-being, and how ASD impacts them should be reflected in how the treatment is implemented in individual cases. The ability of family members to support treatment goals outside treatment hours will be partially determined by how well-matched the treatment protocols are to the family’s culture, values, needs, priorities, abilities, and resources.”

Treatment limitations include limits on benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting periods, or other similar limits on the scope or duration of treatment. Unless similar medical/surgical benefit (Med/Surg) limitations exist and are applied to predominantly all Med/Surg benefits, then the following aspects of the policy are clear quantitative and non quantitative treatment limitations under MHPAEA:

317:30-5-313 (b) Frequency and Duration

As written the entire Frequency and Duration section do not meet MHPAEA requirements. The language is prescriptive in nature and does not allow for individualization based on unique OHCA beneficiary needs. CASP recommends significant revisions to reflect the opportunity for additional considerations within each proposed intensity category, or the removal of these categories all together. Language indicating “at least two of the following” while including  only two options is misleading. As written, individuals must have  ASD level 2 or level 3 and engage in challenging behavior to access comprehensive services. This directly  contradicts best clinical practice and generally accepted standards of care, which recognize the importance of early intensive behavioral intervention.

“Intervention must be implemented as early as possible to improve the developmental trajectory of children diagnosed with autism. Effective early intervention focuses on establishing foundational skills, such as environmental awareness, imitation, functional communication, self-management, daily living skills, and the building blocks for social interaction. These foundational skills reduce the pervasive impact of ASD and minimize the likelihood of additional disability in the form of intellectual impairment. In addition to building skills, early development is the optimal period to reduce and mitigate challenging behaviors.”

Furthermore, EPSDT requires;

 “...that children receive early detection and preventive care, in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible…Ultimately, the goal of EPSDT is to assure that children get the health care they need, when they need it – the right care to the right child at the right time in the right setting.”

The right time and right setting, include timely access to comprehensive care, when medically appropriate, based on the qualified licensed behavior analyst’s (LBA) clinical judgment.

317:30-5-314. Prior Authorization, Service limitation, and exclusions to treatment.

(  a) Prior authorization (1) lists several assessments that may be utilized, however, the list is not exhaustive, and does not allow for clinical judgment and evaluation of an individual beneficiary's strengths, weaknesses, and areas of concern. Rather than provide a list, CASP recommends language that is consistent with the generally accepted standards of care and best clinical practice. Specifically:

“Individualizing ABA care is critical to achieving optimal patient outcomes. Behavior-analytic services are designed to support the development of skills to enhance patient well-being, autonomy, and independence and to expand opportunities throughout the lifespan. The course of treatment is guided by assessment and a treatment plan tailored to support the needs of the patient.”

(2) (J) The requirement to document a beneficiaries schedule, hour by hour, including all possible members of the treatment team, with name and credential, is onerous and a NQTL under MHPAEA, unless this requirement exists for substantially all Medical/Surgical benefits by the Sooner Select Managed Care Organizations (MCOs).  Alternatively, CASP recommends a daily schedule that includes general information about the specific goals, objectives, and activities that may be addressed during ABA. This allows the necessary flexibility to ensure overall compliance with OHCA’s expectations, while not limiting the LBA and their team from making appropriate adjustments to an individual’s treatment team, schedule, or appropriate modifications based on program evaluation, data analysis, and clinical decision making. 317:30-5-314 (b)(1) Service limitations.

EPSDT requires the right care, to the right child, at the right time, in the right setting. Part 1 (A) (B) and ( C) limit access to care in specific settings that directly contradict EPSDT and MHPAEA requirements. CASP agrees that services rendered by the LBA, or the individuals they supervise,  should not be educational or custodial in nature. Providing stringent limitations on access in these settings may compromise appropriate transition and discharge planning, and adequate assessment and treatment of challenging behavior(s) in the environment where they occur. Rather than the current language regarding service limitations in the school or daycare setting, CASP recommends removing references to these services being time limited to three (3) months or less.

317:30-5-314 (b)(3)

(B) ABA addressing goals only related to performative social norms that do not significantly impact health, safety, or independence.

(L) ABA authorized for toilet learning/ toilet training.

EPSDT allows for authorization of treatment that can maintain a health condition, including preventing a condition from worsening. The core diagnostic criterion associated with ASD include deficits in social communication and insistence on sameness through rigid/ routine oriented responding.  These deficits impact an individual’s ability to interact safely and independently within their environment. Deficits are often addressed through social communication goals that may not directly address health, safety, or wellbeing but are a required prerequisite behavior that leads to a long-term impact in these areas. Toilet learning/ toilet training often addresses both deficits in social communication and rigid/routine oriented responding. When toileting is directly related to these deficits, and not for the convenience of the parent or caregiver, these programs meet the EPSDT requirement of ameliorating, or preventing the worsening of,  the health condition.

CASP recommends further clarification for (B) such as:

“when the treatment plan does not clearly indicate how the proposed goal relates back to a core deficit associated with autism, or a prerequisite skill necessary to address a core deficit, and is related to performative social norms that do not significantly impact, health, safety or independence.”

CASP recommends the removal of toilet learning and toilet training from (L)

CASP is thankful and appreciative for the steps to improve the ABA policy, ensure consistent implementation, and establish increased oversight and protections for some of Oklahoma’s most vulnerable citizens, children with autism. On behalf of CASP and our Oklahoma member organizations, I  am happy to answer questions and look forward to serving as a resource for this policy and any future policies impacting behavior analysts and the autism community.  

Mallory:

To Whom it may Concern:

I am writing this comment on behalf of the Oklahoma Association for Behavior Analysts (OKABA). OKABA is a state-wide non-profit organization of Behavior Analysis providers, dedicated to promoting education and solutions for Behavior Analysts providing services in Oklahoma. We greatly appreciate the opportunity to provide input on the Applied Behavior Analysis (ABA) services proposed changes found in APA WF # 24-23 and hope our collaborative efforts can support the state agency providing equitable care to Oklahomans receiving the ABA benefit through Medicaid. We applaud OHCA’s efforts to update the Applied Behavior Analysis policy to ensure timely, equitable, and quality care for members in Oklahoma. We specifically appreciate the updates to the policy in the following sections:

317:30-5-312 (a)(5) Treatment plan components and documentation requirements being clearly related to the core deficits of ASD as defined by the DSM. This section of the policy allows for a more equitable coverage policy that encompasses the many ways ASD can manifest in an individual.

317:30-5-312 (a)(5)-(9) aligns with best practice for clinical documentation by requiring objective measurable and obtainable goals, operationally defined behavior definitions, and a specific titration plan to face services over time.

317:30-5-313(a)(2)(C) the language specifying that an updated diagnostic evaluation is not necessary to be re-completed bi-annually aligns with best practice as defined by the Council of Autism Service Providers and supports continuity of care for members

317:30-5-313(a)(5) states “the member exhibits functional limitations that interfere with participation in daily life and activities that are specific to the core deficits of ASD as outlined in the DSM” which creates a more equitable, inclusive description of the broad symptoms of ASD that can manifest in an individual.

With the proposed changes, we share the following lettered rationales that will apply to the concerns numbered below:

A. In 2014 the Center for Medicare and Medicaid Services (CMS) published a bulletin titled “Clarification of Medicaid coverage of services to children with Autism”1. State Medicaid agencies must cover services under 1904(a)(4)(B) for Early Periodic Screening, Diagnostic and Treatment services (EPSDT). The CMS information bulletin requires Oklahoma to provide treatment “that is determined to be medically necessary to correct or ameliorate any physician or behavioral conditions” ... “all deficits and conditions arising from a child’s ASD are subject to treatment”. Therefore, treatment determinations for a member should be derived from symptom presentation, assessment results, deficits associated with the diagnosis of ASD, and treatment needs of the member to comply with EPSDT.

B. Medicaid Managed Care Organizations are required to comply with 42 CFR 438.910. In 2017 CMS published a toolkit titled “Parity Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children's Health Insurance Programs” which outlines a state’s managed care organizations, alternative benefit plans, and CHIP services must be provided in compliance with parity standards2. MHPAEA requires that “treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the “predominant” treatment limitations applied to “substantially all” medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits”. A group health plan (or health insurance coverage) may not impose a quantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the plan (or health insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the quantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical/surgical benefits in the classification.

With the proposed changes, we share the below numbered concerns:

1. 317:30-5-311(b)(5)-(6) we request additional language to clarify the allowance of telehealth providers in accordance with 317:30-3-27.

Out-of-state telehealth providers are frequently necessary to ensure members have an adequate network of ABA providers, especially in rural communities. Discontinuing care for members receiving supervision services from an out-of-state telehealth provider may cause disruption to member services, and for some it would require discontinuation of services if a provider cannot be located. We request this language be eliminated in consideration of unproven network adequacy standards required of the state found in 42 CFR 438.68. Out-of-state telehealth supervision and caregiver training services (CPT 97155 and 97156) can be commonly delivered by an out-of-state provider supervising the in-state face-to-face clinician rendering direct services physically with the individual (CPT 97153). Disallowing supervision and caregiver training from an out-of-state provider would eliminate the ability for many children to receive in-state direct therapy services, and result in the inability for individuals with ASD to access treatment.

On September 26th, CMS published a response to the State Health Official titled “Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements” 5 . CMS states “For children whose medical needs cannot be met by in-state provider to deliver medically necessary services, states should screen and enroll out-of-state providers within an abbreviated timeframe to ensure children can access care in a timely fashion”. We request that OHCA abide by the CMS guidance and allow for out-of-state providers when a beneficiary will otherwise lose access to care. We further request that OHCA carry that burden by ensuring any authorization denials due to a provider being located out-of-state result in a follow up from the state or the MCO that results in the beneficiary successfully transitioning to an in-state provider with an approved authorization, or by contracting with the out of state provider. We request that OHCA consider the disruption that changing providers may have on a child with autism mid-treatment, and continue to approve current members receive services from an out-of-state provider to support the child’s needs.

2. 317:30-5-313(a)(2)(C) is updated to reflect that a CDE should “not be older than two (2) years” and “OHCA may request an additional assessment/evaluation if diagnosis and recommendations are not clearly defined”. This quantitative restriction for members to obtain access care raises concern to compliance with MHPAEA.

Please see rationale for B above.

Rather, we request the language be revised to support collaboration based on the individual circumstances of the member to address ongoing behavioral excesses and deficits that may clinically warrant further diagnostic evaluations.

3. 317:30-5-313 (a)(2)(E) OHCA can request CDE of clinical assessment during PA process if medical, behavioral health changes or concerns regarding treatment identified through PA process. The Counsel of Autism Service Providers (CASP) published a document titled “Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder: Third Edition”, which is a source of the generally accepted standards of care (GASC) in ABA3. The GASC states “ABA should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions”.

We request the language be revised to be consistent with the GASC and ensure this provision is utilized to support members in access, rather than restrict or delay a member's access to care.

Furthermore: The 2014 CMS bulletin states “When a screening examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnosis and treatment without delay”.

We request the language be revised to state that the request of any CDE or clinical assessment will be deferred to clinical determination by the provider and will not result in a delay to an EPSDT benefit. Please refer to rationale A.

4. We request that 317:30-5-313(a) (6) be revised to remove contradiction and be congruent with 317:30-5-312(a)(5) which states that the treatment shall “clearly relate to the identified maladaptive behavior and/or should include functional goals and those related to core deficits of ASD as defined by the DSM”.

Rather than limiting treatment to only members who display the atypical or disruptive behaviors identified by OHCA, we request the language be revised to encompass the continuum of symptoms that can present for an individual with ASD as defined by the DSM-V. The state Medicaid agency is required to cover symptoms beyond what could manifest as “maladaptive behaviors”. Rather, the CMS bulletin provides that “States are required to arrange for and cover for individuals eligible for the EPSDT benefit any Medicaid coverable service listed in section 1905(a) of the Act that is determined to be medically necessary to correct and ameliorate any physical or behavioral conditions”. An individual with ASD may manifest symptoms of their condition as behavioral limitations, rather than excesses, that limit their ability to participate in daily life and typical activities. The policy requiring behavioral excesses only, without consideration of behavioral limitations, eliminates coverage for many diagnosed with ASD that should have coverage for their symptoms under the EPSDT benefit. Please refer to rationale 1a in addition.

Furthermore, 317:30-5-313(a)(6)(A)-(G) require the member to manifest symptoms of their diagnosis through symptoms that present safety risks to themselves and others before accessing treatment. A “fail-first” approach to treatment is implied in the proposed rule, which is inconsistent with the requirements of EPSDT and MHPAEA. Please refer to rationale B.

5. We 317:30-5-313(b)(1)(a)-(f) be eliminated due to contradictions with 317:30-3-1(f)(1) which states “Services must be medical in nature and must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability”.

5a. The Council of Autism Service Providers (CASP) published a guideline titled “Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder:

Third Edition” which serves as the GASC for ABA.

The language implies that dosage of treatment be based solely on the severity level of the diagnosis while the member must display specific behavioral excesses defined by OHCA.

We request the language be eliminated, and language included that the treatment frequency and duration be made consistent with the generally accept standards of care as defined by the Counsel of Autism Service Providers as required by 317:30-3-1(f)(1).

CASP defines treatment intensity as “individualized and based on the patient’s response to treatment (data supporting the need to increase or decrease) ... treatment intensity should reflect the complexity, breadth, and depth of treatment targets, as well as the environment, treatment protocols, and significance of patient's needs...regardless of whether the treatment is focused or comprehensive, the specific number of hours of services should be individually determined based on data collected duration evaluations, assessments, and clinical impressions. Providers assess treatment needs and require dosage based on a multidimensional assessment that considers a wide variety of information about the patient”.

Furthermore: The application of a quantitative treatment limit conflicts with MHPAEA requirements outlined in 42 CFR 438.910. Please see rationale B.

6. 317:30-5-313(b)(2) we request be eliminated. Requiring an individual’s parent’s/legal guardian to be the intended individual to acquire treatment responsibility of the member is inconsistent with an individual's rights to treatment under EPSDT. Please see rationale A.

7. 317:30-5-313(B)(4) we request be amended to include language that requires compliance with 42 CFR 438.910. We request that clarification be added that an individual is not required to “fail” a course of treatment (or dosage of treatment) prior to obtaining what is clinically recommended consistently with the generally accepted standards of care, to avoid a “fail-first” policy interpretation as well as to remain compliant with 317:30-3-1(f)(1). Rather, we request that treatment dosages be consistent with the generally accepted standards of care from the initiation of services and determined based on individuality and other provisions of the policy hereinafter. Please see rationale B and 5a.

8. 317:30-5-314(a) (2)(J) we request be eliminated.

This requirement would not be possible to accurately predict future staffing changes and/or unexpected patient needs throughout a 6-month authorization during a high dosage treatment. This requirement poses concerns with Mental Health Parity. Please see rationale B.

9. 317:30-5-314(a)(2)(L) we request be eliminated.

This requirement raises concern of a quantitative treatment limit under Mental Health Parity. Please see rationale B.

 Also, this requirement could conflict with EPSDT requirements for the state if a guardian/caregiver is solely responsible for a child and cannot attend treatment at this quantified rate determined by OHCA. This could in turn disrupt a child from receiving an EPSDT entitled benefit, to correct and ameliorate the symptoms of their condition. Please see A.

10. 317:30-5-314 (B) (a)(A)-(C) we request be eliminated. Please see rationale A and B.

Additionally, we request that this language be eliminated to be consistent with 317:30-3- 1(f)(1). The CASP guidelines state “ABA treatment must be deliverable in any setting that is relevant for the patient to achieve treatment goals, whether in the home, at school, in a clinic or center, or in the community...ABA treatment must not be restricted to a priori to specific settings but instead should be delivered in the settings that maximize treatment outcomes for the individual patient.. It may be necessary for a patient to receive services in a particular location for a variety of reasons, including but not limited to generalization needs, the impact of interactions in this environment on skill building or behavioral targets in the treatment program or to access the required intensity of services for the patient”.

The implications of this section inadvertently imply that the sole purpose of treatment in school would be to transition services to the school professionals through the IEP process. We request this be removed, to not conflict the member’s educational rights with the requirements for medical services under the EPSDT benefit. These programs should not intermingle or reduce a member's ability to access their EPSDT benefits.

Furthermore: The quantitative limitation on duration of school services is effectively a quantitative treatment limit raising concerns with compliance to MHPAEA. Please see rationale B.

CMS published guidance on “Best Practice for Adhering to Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements” 5. The CMS guidance states “Consistent with the federal disability rights laws and the Supreme Court’s decision in Olmstead v. L.V., 527 U.S. 581 (1999), states must ensure that services covered under EPSDT are provided in the most integrated setting appropriate for the child, which includes clinics, or in schools, and at home, and must avoid unnecessary placements in segregates treatment setting… Lastly, states must ensure compliance with MHPAEA”.

The Olmstead decision relies on 28 C.F.R 35.130(d) which states that depriving children of this care also exposing them to the risk of unnecessary segregation and institutionalization in further violation of the ADA. CMS further states that “States are obligated to meet the requirements of the Americans with Disabilities Act”5. OHCA’s recent guidance and suggestions that ABA can be provided by the school through the IDEA process, is not an appropriate solution, as this dismisses the state’s responsibility to provide services compliant with EPSDT and the Olmstead decision. The guidance is clear that EPSDT requires “Children should be cared for in the most integrated setting appropriate for their needs” as a responsibility of the Medicaid agency, not the school.

11. 317:30-5-314 (B)(2)(A) (i)(I)-(VII) we request be revised

The coverage and service limitations outlined for concurrent billing of RBT and supervision hours provides inconsistencies with the Adaptive Behavior Treatment CPT category 1 code descriptors published by the ABA Coding Coalition, the group of representatives that drafted and published the CPT code descriptors to the American Medical Association Editorial Panel that resulted in the code set for adaptive behavior services, effective January 1, 20194. We request the language be revised to be consistent with the American Medical Association CPT code definition of allowable activities.

12. 317:30-5-314(b)(2)(C) we request be eliminated.

Please see rationale B.

13. 317:30-5-314(b)(3) (B)(F) and (L) we request be eliminated. The restrictions on these provisions of services eliminate components of treatment required to be covered under the EPSDT benefit. For example, if a child demonstrates behavioral excesses or limitations as a result of their diagnosis, that manifests in inability to complete toilet training, this is a requirement to be covered under EPSDT to “correct and ameliorate” the symptoms of the condition across contexts for the member. Please see rationale A.

14. 317:30-5-315(2) (3) and (6) we request be eliminated. We express significant concerns with restricting access to an EPSDT benefit entitled to a member, due to parents' inability to attend. Additionally, we express concern with compliance with MPHAEA. Please see rationale A and B.

15. 317:30-5-315(12) we request be eliminated Providers only being allowed to request prior authorization within the final 7 days of a course of treatment for an extension request, while simultaneously allowing MCOs to comply with 42 CFR 438.210(d)(1)(i)(A), which allows 14 days for a PA decision, results in non-covered services that many providers cannot support financially. 42 CFR 438.208(b) requires that each MCO must “deliver care to and coordinate services for all MCO, PIHP and PAHP enrollees...and ensure that each enrollee has ongoing source of care appropriate to his or her needs”. Allowing a discontinuation of care between each extension request creates a breach of fiduciary responsibility from the state.

16. 317:30-5-315(2)-(4) and (6) we request be amended for compliance with EPSDT and Mental Health Parity requirements. Please see rationale A and B.

OKABA is thankful for the steps taken to improve the ABA policy and benefit members. Citizens accessing this benefit, children diagnosed with autism, are some of Oklahoman’s most vulnerable citizens and we applaud efforts to support quality oversight of the program. We look forward to being a resource for this policy and future policies that impact behavior analysts and the autism community.

Thank you for your consideration to these comments on behalf of the Oklahoma Association for Behavior Analysts (OKABA). 

Jamie:

Please continue to allow ABA in school therapy.  My sons needs require more professional prompting and guiding than what the school possibly provides. An ABA RBT therapist in school has helped my child in just the short time we have had it.  When it was just the school supposed to provide the service they were not taking my son to GenEd per his IEP.  They told me for a year and half that they didn’t have the staff to accommodate his IEP.  Once I found out they can’t do that I transferred schools here in Norman.  He went an entire year and half without the social and verbalizing skills he can learn while attending GenEd over just being in the Autism classroom.  These are the skills he needs and is very far behind.  He is an only child.  I don’t know any other typical children for him to mimic/interact with except the classroom at school with the other typical children. His RBT knows how to prompt him to socialize and use his verbal skills and calm him down as well if he gets over stimulated to stay in the classroom.  Professionals know how to keep him attending in GenEd.  The paras are not trained like an RBT to know how to keep my child in the typical classroom.  Instead of just taking him back to the Autism environment where he isn’t getting the typical environment skills.  He is level 2 in socializing and verbalizing.

Please I am begging you to    Continue to allow his RBT to be in school for his ABa therapy.  This is the main way I can get him to seeing and understanding typical behavior while he is still young.  

Pinny:

To Whom It May Concern,

We appreciate the opportunity to provide comments regarding the proposed Rule Impact Statement APA WF #24-23

Our initial concern is regarding the following section: 317:30-5-311. (b) (5) All contracted providers must reside in the state of Oklahoma, or within 50 miles of the Oklahoma border as per OAC 317:30-3-89 through 92.

While we understand the intent of this rule to prioritize local provider access, we have significant concerns about its potential impact on the availability of Applied Behavior Analysis (ABA) therapy services in Oklahoma.

1. Limited In-State BCBA Resources The availability of Board Certified Behavior Analysts (BCBAs) who are licensed in Oklahoma and actively providing services in the state is already critically limited. Many licensed BCBAs who reside in Oklahoma do not actively practice within the state, either due to employment in non-clinical roles or relocation to other regions for work. This proposed rule could further exacerbate this scarcity by excluding qualified providers who reside further out of state but who are willing and capable of serving Oklahoma families.

2. Impact on Network Capacity Restricting contracted providers to those residing strictly in Oklahoma or within the limited border zone will significantly reduce network capacity. Many families currently rely on providers from neighboring states to receive timely and high-quality ABA therapy. Limiting access to these out-of-state professionals will create delays in service delivery, longer waitlists, and reduced opportunities for early intervention—all of which are critical for positive outcomes in autism treatment.

3. Rising Autism Rates The prevalence of autism has risen sharply over the past decade, with year-over-year increases in diagnoses across the nation and within Oklahoma. This rise underscores an urgent and growing demand for ABA services that existing in-state providers have not been able to meet. Current in-state resources are insufficient to address this surge, leading to a reliance on out-of-state providers to bridge the gap. Limiting provider eligibility without addressing this mismatch between demand and supply could result in a crisis for families seeking necessary care.

4. Broader Implications In addition to affecting access for families, this proposed rule could discourage highly qualified providers from seeking licensure or practice opportunities in Oklahoma, further compounding the workforce shortage. Collaborative solutions—including expanding, rather than restricting, provider networks—are essential to meeting the needs of Oklahoma’s growing population of individuals with autism.

Recommendations We respectfully recommend the following adjustments to the proposed rule:

1.     Expand the eligible provider radius beyond 50 miles from the Oklahoma border to include all providers located within the United States.

2.     Increase efforts to assess and address the capacity needs of the ABA therapy network to ensure it aligns with the growing demand for services.

In conclusion, while we support efforts to prioritize local providers, we urge consideration of the critical gaps in BCBA availability and the rising need for autism services. A more inclusive approach will better serve Oklahoma’s families and ensure continuity of care for those who need it most.

Our second comment is regarding section 317:30-5-314. (b) Service Limitations.  (1) Settings. The following limitations apply to where ABA services are provided: (A) ABA services are not allowed in a daycare setting or school setting, without OHCA approval. If approved, it will be time-limited to three (3) months or less. The BCBA shall create and submit a treatment plan  that identifies the goals outlined to assist school staff 12 with the members without ABA staff being present throughout the school year. (B) The treatment plan should show a titration of services to school paraprofessionals/staff through the duration of the prior authorization.

While we understand the intent of this rule to ensure collaborative care, it is crucial to clarify the distinct role of ABA services in school settings and their critical importance in supporting children with autism and other developmental disabilities. Below are our comments:

1. ABA Provides Behavioral, Not Educational, Support ABA therapy focuses on addressing behavioral and skill deficits that impede a child’s ability to access education and participate meaningfully in their environment. Unlike educational services provided by schools, ABA targets individualized behavioral goals such as:

·        Reducing challenging behaviors that disrupt learning (e.g., aggression, self-injury, or elopement).

·        Teaching functional communication and social skills to improve peer and teacher interactions.

·        Building independence in daily living skills (e.g., transitioning between activities, following instructions).

These goals are foundational and enable the child to better engage with their educational curriculum. ABA services do not duplicate educational services; rather, they complement them by addressing barriers that fall outside the scope of traditional teaching methods.

2. Collaboration with Schools Is Essential but Requires Flexibility The proposed three-month time limit on ABA services in schools severely restricts the ability of BCBAs to implement meaningful and sustainable changes. Behavioral interventions often require:

·        Comprehensive assessment and data collection to identify specific needs.

·        Gradual implementation of strategies, allowing time for the child to adapt and learn.

·        Ongoing monitoring and adjustments based on progress.

Additionally, while titration of services to school staff is a valuable goal, effective training requires consistent oversight and reinforcement. School staff often have limited training in behavioral principles, and high turnover rates can further complicate the sustainability of interventions without continued support from ABA professionals.

3. Increasing Demand for Behavioral Support in Schools The prevalence of autism and other developmental disabilities has risen significantly, and schools are increasingly tasked with serving children with complex needs. ABA services provide a critical layer of support to address behaviors that hinder these children’s ability to benefit from their educational environment. Restricting ABA services will likely result in:

·        Increased stress on teachers and paraprofessionals who may lack the training to manage challenging behaviors.

·        Greater disruptions in classrooms, affecting all students.

·        Missed opportunities for children to develop essential skills during formative years.

Recommendations To align this rule with the needs of children and the realities of school settings, we recommend the following:

1.     Extend the allowable duration of ABA services in schools to at least six months, with provisions for renewal based on documented progress and continued need.

2.     Recognize the distinction between behavioral support and educational services, ensuring that ABA interventions are not viewed as duplicative but as complementary to the child’s education.

3.     Enhance collaboration between schools, BCBAs, and OHCA to establish clear guidelines that support sustainable integration of behavioral strategies.

4.     Allow for flexibility in titration plans to accommodate the varying capacities and needs of school staff.

In conclusion, ABA services play a vital role in addressing behavioral challenges that impede access to education, without overlapping with the core responsibilities of school staff. Limiting these services risks leaving children without the support they need to thrive. We urge a reconsideration of the proposed restrictions to better serve Oklahoma’s children and their families.

Thank you for your attention to this matter. We look forward to collaborative efforts to address these pressing concerns.

M Marshall:

As an individual who supports accessible healthcare, I strongly back up the allowance of out-of-state BCBAs to provide telehealth services in Oklahoma. This change is not just a policy update but a lifeline for many families and individuals needing specialized care. Here are a few reasons why this policy update should happen:

•             Increased Access to Specialized Care: Oklahoma has a shortage of BCBAs, especially in rural areas. Allowing out-of-state BCBAs to provide telehealth services can bridge this gap, ensuring that all individuals, regardless of their location, can access high-quality behavioral health services.

•             Continuity of Care: Many families move across state lines but wish to continue receiving care from their trusted healthcare providers. Telehealth enables these families to maintain consistent and effective care from their established BCBAs, which is essential for the progress and well-being of individuals receiving behavioral therapy.

•             Cost-Effective Solution: Telehealth reduces the need for travel, both for providers and patients, leading to significant cost savings. This is particularly beneficial for families who may struggle with the financial burden of frequent in-person visits.

•             Enhanced Flexibility and Convenience: Telehealth offers greater flexibility in scheduling appointments, making it easier for families to fit therapy sessions into their busy lives. This convenience can lead to higher engagement and better outcomes for individuals receiving services.

•             Adherence to High Standards of Care: Out-of-state BCBAs are required to adhere to the same standards and ethical guidelines as in-state providers. Telehealth platforms ensure secure and confidential communication, maintaining the integrity and quality of care.

•             Support for State Healthcare Goals: Allowing out-of-state BCBAs to provide telehealth services aligns with Oklahoma's goal of improving residents' healthcare access and outcomes. It also supports the state's commitment to leveraging technology to enhance healthcare delivery.

In conclusion, allowing out-of-state BCBAs to offer telehealth services in Oklahoma is a forward-thinking policy that will greatly benefit individuals needing behavioral health services. It is a practical, cost-effective, and compassionate solution that addresses the current gaps in care and supports the overall health and well-being of our community.

Nora:

it is unethical for medicaid to not cover ABA/RBT therapy and instructional assistance to children with autism. This program is essential for providing tools to help these children succeed in their lives. My grandson has greatly benefited from this program and he has learned coping skills to interact with his peers and teachers in a very positive way. Taking this benefit away from him  would be a huge detriment to him. He needs this opportunity to continue to grow in both verbal communication and social skills. He needs that extra prompting a trained ABA/RBT can provide to him. Thank you for your consideration.

Dakota

i adamantly oppose this specific exclusion & feel like it is unethical. my nephew, michael, has greatly benefitted from ABA/RBT assistance in the school to improve his verbal communication & social skills. he requires strong prompting to succeed in the classroom. please reconsider this exclusion, thank you for your consideration. 

Serena

My son has been receiving ABA therapy for the last 3 years, in both our home and at his school. Two days ago, all of his ABA therapy services were denied by SoonerCare as not being medically necessary because they take place partially in a school setting. So my son has gone from having 30 plus hours of support to having nothing in the space of one day. This therapy was our families only help with our son, who has severe autism and relies on the support of our ABA services. He has made so much progress in the last 3 years and to know that this won't continue is heartbreaking. And the worst part is he does not understand. He just knows that he went form having support and care to having no one but our family. Unacceptable. Why do we think this is okay to do to vulnerable families who are already struggling?

School support is so important, as it helps him learn to interact with his peers and to work on problem behaviors in the actual setting they are occurring in. I can't pull him from school and put him only in a clinic setting, because that would not be best for him. He deserves a chance to go to school just like any other child, even though his needs are perhaps greater than a large portion of children.

By taking ABA out of schools you're denying our kids a change to be their best selves and that is a real shame. How is denying services to the most vulnerable members of our community ensuring a sufficient standard of care?

Matt:

PLEASE FIND OUR DETAILED COMMENTS AND RECOMMENDATIONS REGARDING THE PROPOSED CHANGES TO APPLIED BEHAVIOR ANALYSIS (ABA) SERVICES IN OKLAHOMA. THESE COMMENTS REFLECT A COMMITMENT TO ENSURING THAT INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES RECEIVE HIGH-QUALITY, EVIDENCE-BASED SERVICES THAT PROMOTE MEANINGFUL OUTCOMES AND ALIGN WITH BEST PRACTICES IN THE FIELD.

ASSESSING THE IMPACT:

HOW PROPOSED GUIDELINE CHANGES THREATEN SERVICE DELIVERY The proposed changes to the guidelines introduce significant barriers to effective service delivery in two critical areas. The new requirements for the restrictive setting exclusions limit access to essential ABA services in diverse environments, while requiring contracted providers to reside in the state of Oklahoma or within 50 miles of the Oklahoma border may create undue network adequacy and access issues for families. Together, these changes threaten to compromise the accessibility, flexibility, and efficacy of ABA services for those who need them most.

1.            SETTING REQUIRING CERTAIN SETTINGS FOR THE DELIVERY OF APPLIED BEHAVIOR ANALYSIS (ABA) SERVICES, PARTICULARLY EXCLUDING SCHOOLS, IS PROBLEMATIC IN STATE POLICY FOR SEVERAL CRITICAL REASONS:

A.           Contradicts the Principle of Least Restrictive Environment (LRE)

The Individuals with Disabilities Education Act (IDEA) requires that children with disabilities receive services in the least restrictive environment (LRE), often in inclusive educational settings. Excluding ABA services in schools directly conflicts with this mandate, as schools are often where children naturally learn and practice critical skills, such as communication, social interaction, and behavior regulation.

B.           Creates Barriers to Accessing Necessary Care

Many children with autism and developmental disabilities require ABA services in school settings to address skill deficits and behaviors in real time within the natural learning environment. Excluding schools creates unnecessary barriers, limiting a child's ability to access the care they need where they need it most.

For families who rely on ABA during school hours due to work or logistical constraints, restricting services to other settings can delay or reduce treatment hours, ultimately impacting progress.

C.           Limits Generalization of Skills

ABA emphasizes teaching skills that generalize across settings (e.g., home, school, community). Excluding school settings prevents BCBAs and RBTs from observing, analyzing, and addressing barriers to generalization in the environment where children spend a significant portion of their day. Skills may not transfer effectively if interventions are only conducted outside the school context.

D.           Undermines Collaborative Care

Schools are critical partners in supporting children with disabilities. Excluding ABA services in schools reduces opportunities for collaboration between behavior analysts, educators, and related service providers, such as speech and occupational therapists. This lack of coordination can hinder the child’s overall progress and success in the educational setting.

E.            Disproportionately Impacts Underserved Populations

Families in rural or low-resource areas may not have access to other treatment settings outside of school. Restricting ABA services to specific settings disproportionately impacts these families, increasing inequities in access to care.

F.            Ignores Clinical Needs

ABA treatment plans are designed based on the individual needs of the child, not the location where the therapy occurs. Arbitrarily excluding schools disregards clinical decision-making and prevents providers from delivering care in the most relevant and effective environments.

2.            IN-STATE RESIDENCY REQUIREMTS (THE NEW PROPOSED REGULATIONS STATE THAT ALL CONTRACTED PROVIDERS MUST RESIDE IN THE STATE OF OKLAHOMA OR WITHIN 50 MILES OF THE OKLAHOMA BORDER)

KEY REASONS THIS IS PROBLEMATIC:

A.           Limits Access to Critical Services:

The requirement exacerbates existing workforce shortages and the lack of Licensed Behavior Analysts in Oklahoma. This will delay care, reduce service availability, and force many individuals to be discharged from treatment, despite the availability of highly qualified out-of-state providers.

B.           Threatens Network Adequacy :

Families already struggle to access ABA therapy due to a limited provider network. Restricting providers further will lead to a network adequacy crisis, where families face denial of services despite clear clinical needs.

C.           Misrepresents the Role of Supervision:

Effective clinical oversight does not depend on physical proximity. Licensed Behavior Analysts (LBAs) oversee care through assessments, treatment plans, data analysis and caregiver training which do not require them to reside in-state.

D.           Reduces Access to Specialized Clinical Talent:

Highly skilled and specialized providers may reside out of state. Limiting access to these providers penalizes families by restricting their ability to receive care from the most qualified professionals.

E.            Lacks Clinical Justification

There is no evidence-based standard supporting a geographic restriction on ABA providers. Treatment decisions, should be driven by clinical need and outcomes, not arbitrary residence rules.

Thank you for the opportunity to provide feedback on the proposed changes. We appreciate your commitment to engaging stakeholders in this important process and value the chance to contribute insights that prioritize effective and equitable service delivery.

Inner Circle Autism Network:

Inner Circle Autism Network (ICAN) is a for-profit organization that provides Applied Behavior Analysis (ABA) services to children diagnosed with autism spectrum disorder (ASD) and their families in Oklahoma and Arkansas. ICAN is accredited as a Behavioral Health Center of Excellence and is an affiliate of the Council of Autism Service Providers (CASP).

On behalf of the behavior analysts we represent, we are grateful for the opportunity to provide comments on APA WF# 24-23 Applied Behavior Analysis (ABA) Changes.

First and foremost, our providers are grateful for the Oklahoma Health Care Authority (OHCA) for taking time to update their ABA policies to better meet the standard level of care and quality services that are widely accepted in the field of ABA.

We specifically support the following proposed revisions to the policy as outlined:

•             Aligning Registered Behavior Technician (RBT) supervision requirements with the Behavior Analyst Certification Board (BACB) minimum expectation of 5%.

•             Updating the requirements for treatment plan goals to address functional limitation in adaptive daily living skills as well as maladaptive behaviors.

•             Acknowledgement that ASD is a condition impacting the individual’s lifespan, not just certain parts of their life, and removing the annual or bi-annual requirement to receive an updated comprehensive diagnostic evaluation.

o             We acknowledge that individuals with autism may experience co-occurring psychological and physiological conditions, and they may present after an initial diagnosis of autism takes place. We do support that reevaluations can highlight opportunities to coordinate care necessary for optimal long-term outcomes.

•             Expanding the list of maladaptive behaviors beyond aggression, self-injury, and property destruction to be more inclusive of the behaviors that might be experienced by the diagnosed individual and their immediate community.

•             Recognizing the importance of being trauma-informed, assent-based, and culturally responsive in the work of ABA, to better generalize and maintain outcomes outside of direct therapeutic times and sessions.

•             Improving upon client safety parameters with the thoughtful inclusion and proposed reporting criteria regarding the use of restraint.

•             Including updated service quality review processes and audit expectations to ensure compliance with policy requirements and expectations.

While we applaud OHCA for the strides they are making toward aligning with best clinical practice, we also want to highlight the areas where continued improvement can be made in order to better align policy to feasible everyday practice. The areas of concern are delineated below, with our responses and requests listed below each specific policy area.

317:30-5-311 (b)(5) “All contracted providers must reside in the state of Oklahoma or within 50 miles…”

ICAN recognizes that BCBAs may work in a variety of settings beyond the clinical sphere, including academics, research, and business organization. Despite there being 487 contracted BCBAs in the state, there may very realistically be significantly fewer BCBAs who actively practice and provide services to Oklahoma beneficiaries. As such, ICAN recommends and utilizes providers who live out of state to provide access to services and support for ongoing services by out-of-state providers who provide telehealth-based services.

According to Council of Autism Service Providers (CASP) , telehealth represents a viable solution to address the rising need for Board Certified Behavior Analysts and specifically aims to assist low resource areas (e.g., rural communities).  In addition, disparities in health care access, specifically behavioral health, are magnified for families living in rural areas. Families in rural areas often face barriers to receiving care, including taking time off work, childcare, and associated travel costs. The culmination of these factors combined with the shortage of practitioners precludes them from accessing the critical care they need.

The argument could be made that without access to telehealth services, clients could face not receiving ABA services at all. Families have stated their concerns about the lack of ABA providers in their vicinity. Rural areas across America are critically underserved. This fact, combined with both the rising rate of autism in children, and the nationwide shortage of BCBA practitioners, makes the avenue of telehealth for therapeutic use a viable option for access to quality services.

Inner Circle Autism Network understands that this proposed change may increase the quality of support provided by promoting the employment of BCBAs within the state to provide beneficiaries with in-person services that may be supplemented by telehealth. ICAN employs BCBAs within Oklahoma and provides primarily in-person services. However, in 2024, ICAN initiated a remote caregiver support program in which a BCBA certified for over 10 years with robust experience across settings, including severe in-patient care to provide family guidance (97156) services to families in rural settings with little or no access to in-person ABA services and families transitioning from in-person services to titrate to lesser restrictive supports and promote maintenance of therapeutic gains. Such a proposed change would eliminate the ability to provide necessary services that promote beneficiaries' access to and continued participation in their communities. We propose an amendment of this policy change to continue to allow at minimum, 97156 through telehealth (and subsequently 97151 to render an assessment) by BCBAs licensed in Oklahoma, but residing in other states. Our aim from the beginning in developing this program has been to extend published literature on similar programs  and we can provide outcomes should this program have the ability to continue in Oklahoma. We welcome any continued conversation on the efficacy of allowing telehealth 97156 with BCBAs outside of Oklahoma to extend the reach of all OHCA beneficiaries.

317-5-312(b)(1) “…may include validated measures such as the Vineland Adaptive Behavior Scales or other…”

We recommend a revision of language to this section to more clearly state the expectations for included assessments. An example revision that would both clarify the purpose of the policy and maintain flexibility for providers could be, “The clinical assessment should include at least one (1) standardized assessment, e.g., the Vineland Adaptive Behavior Scales, and may include a curriculum-based assessment.”

317:30-5-312 (c)(4)(J)(ii) “The signature and date of consent of any minor who is age fourteen (14) or older…”

Due to the legal age of consent in Oklahoma being 16 years old, we request the language be kept in its original form of “assent,” as that is most congruent with the BACB Ethics Code for Behavior Analysts .

317:30-5-313 (a)(1) “…a definitive diagnosis of an Autism Spectrum Disorder (ASD) from the following providers within the state of Oklahoma or within 50 miles of the Oklahoma Border

Inner Circle Autism Network supports an individual’s access to quality care across both diagnosis and treatment. As such, a primary concern with this policy is the limiting nature of the distance for access to providers, specifically those in rural or lower socio-economic areas. Quality diagnosticians are not limited to one state, and should wait times exceed a reasonable limit (i.e., greater than three (3) months), the delays in diagnosis can inhibit the individual’s ability to receive timely and effective treatment. We recommend striking the language that limits the location of the diagnostician while maintaining the types of providers.

317:30-5-313 (a)(2)(e) “…OHCA may suggest an updated comprehensive evaluation or clinical assessment during the prior authorization process…”

As stated above, Inner Circle Autism Network supports reevaluation as an individual ages in order to better assess for comorbidities or changes to the individual’s original presentation. However, the language regarding when OHCA may “suggest” a reevaluation is problematic, in that specific parameters for what may trigger a need for reevaluation are not specifically outlined beyond “any significant medical behavioral health changes, or concerns regarding treatment.” We request that this language be clarified with examples of changes and whether the suggestion will limit a beneficiary’s access to services if a reevaluation is suggested but not completed.

317:30-5-313 (b) Frequency and duration

Inner Circle Autism Network appreciates the policy update more accurately acknowledging the essential role of ABA in addressing the symptoms of ASD. ICAN also acknowledges that each individual has the right to access appropriate care specific to their unique presentation. As such, the guidelines presented in this section regarding the limitations of treatment hours only delineated by the diagnostic criteria demonstrate multiple non-quantitative treatment limitations (NQTL). Because of these NQTLs, the parity of services to different beneficiaries is violated as outlined in the Mental Health Parity and Addiction Equity Act (2008).

Additionally, the language used in this section (e.g., “high frequency” (A); “moderate frequency” (B); “targeted/focused frequency” (C); and “maintenance/consultative level” (D)) are not in line with current best practice recommendations. CASP outlines treatment intensity as being either Comprehensive (i.e., greater than 25 hours with multiple treatment domains addressed) or Focused (i.e., less than 25 hours with a limited number of treatment domains addressed).  As such, providers are granted professional flexibility in the type and intensity of service recommendations, based on their direct assessment of the individual’s needs. Because of this, a variety of interventions at various treatment intensities may be recommended, with the specific needs of the individual at the forefront of the recommendation.

We also recommend removing the language that requires specific “atypical or disruptive behaviors” to be present withing “the most recent thirty (30) calendar days,” as some interfering behaviors may be cyclical in nature and present at different points in the month or year, or may only appear in specific contexts. Though they may not consistently happen, these types of behaviors are no less impactful on the individual’s ability to meaningfully participate in their environment when they occur.

 317:30-5-313 (b)(3) “A functional behavior assessment may only be requested…The functional analysis should record…”

This policy references two separate but related types of behavioral assessment. A functional behavior assessment may be conducted via a variety of ways, including predominantly indirect assessment modalities. A functional analysis, however, requires specific training in manipulating environmental variables to specifically evoke maladaptive  or challenging behaviors. While both are within the purview of a BCBA, ICAN recommends that providers who implement a functional analysis undergo additional training and supervision. The implementation of a functional analysis, without proper training or supervision, places both the individual and provider at an increased risk of severe injury due to the evocation of maladaptive behavior.   We recommend adjusting the language used from “functional analysis” to “functional behavior assessment” to be consistent with the first statement in this policy.

317:30-5-313 (b)(4) “…There is no less intensive or more appropriate level of service…”

ICAN acknowledges the cost of ABA services. The policy as stated, however, adopts a “fail first” mentality that will deny appropriate and timely access to care for individuals diagnosed with ASD. If diagnosed and treated early, those in early intervention with any intensity of ABA services are more likely to gain skills commensurate to same-aged neurotypical peers than when receiving a treatment as usual approach.  By requiring individuals to receive potentially less effective services first, the benefactor is assuming a greater cost-burden in the beneficiary’s later life, as the beneficiary would be more likely to necessitate longer term and higher intensity services. We recommend striking this language from the policy.

317:30-5-313 (b)(5) “If the member is exhibiting baseline behaviors (behaviors have not improved within a year of attending at least eighty-five percent (85%) of treatment)…”

ICAN supports client progress in both skill acquisition and behavior reduction. ICAN also recognizes that a reduction in behavior is not limited to a reduction in frequency and/or duration of the behavior. In addition to these dimensions, ICAN providers also consider the magnitude of and environments in which the behaviors may occur. While frequency may not change (e.g., number of self-injurious incidents remains consistent for several months), the magnitude of the behavior may significantly reduce over time (e.g., the baseline topography was banging head against hard surfaces and the updated topography is pushing fingernails into skin and leaving either a red mark or breaking skin). These types of improvements should also be considered in determining ongoing effectiveness of treatment, as the reduction of magnitude of a behavior can be just as impactful on an individual’s life.

317:30-5-314 (a)(1) “…Additional assessments that may be submitted include the:…”

ICAN supports using a variety of assessment tools to best capture the individual’s current skill set and potential needs for the future. The proposed language of this policy is unclear as to whether providers will be restricted to only using the listed assessments or if the listed assessments are exemplary of types of assessments providers may use. We recommend the latter and request an update to the language to indicate that the listed assessments are not comprehensive of what a behavior analyst may use as part of their ongoing assessment of the client’s skills and behaviors.

317:30-5-314 (a)(2)(J) “Document the daily schedule by hour and the staff with credentials that will perform each service...”

Our clients each have their unique schedule when they come to ICAN for direct services. However, due to the nature of operations within an ABA clinic, documenting an hour-by-hour schedule would not be fully reflective of a client’s engagement in their day-to-day therapy. While they have their general schedule, a client’s session may vary day-to-day based on the client’s motivation on that given day, incidental teaching and learning opportunities, and naturally-occurring environmental stimuli (i.e., peers, unique events that only occur on irregular intervals) that are not typically able to be specifically controlled for.

Requiring that staff with specific credentials be listed on the treatment plan and/or authorization request is also limiting to the client’s access to effective and appropriate technicians. Due to turnover rates in our field (industry-wide saw 65% turnover in direct care staff in 2021 ), there is no guaranteed certainty that the staff listed, specifically within the Registered Behavior Technician credential, will remain employed with any company over the course of 6 months. As such, a more reasonable schedule would be a general daily outline of hours (e.g., MWF 8am-12pm, TTh 8am-4pm). This is reflected in the later policy in 317:30-5-315 (1)(C)

Due to the limitations both of these requirements place on providers, we request that this language be struck from the policy.

317:30-5-314 (a)(2)(L) “It is expected that child/youth and parent(s)/guardian(s) attend at least eighty-five percent (85%) of treatment each review period…”

While we support a utilization policy to hold our parents/caregivers accountable to their engagement with services, we do fear that a utilization policy of this magnitude will limit access to care for children and families of lower socioeconomic status, families with multiple children, or families with limited transportation access. It is recommended that an incremental change be proposed with specific steps to monitoring how such a policy may impact the beneficiaries of Oklahoma specifically.

317:30-5-314 (b)(1)(A-C) Settings

ICAN providers agree that one of the primary goals of our treatment is being able to transition our clients to less restrictive interventions and environments. As such, we support that treatment in less restrictive settings should be time limited to support titration and appropriate discharge or services to those less restrictive environments. However, we would request up to 6 months of services in less restrictive environments (i.e., daycare settings, public or private schools) to evaluate care in the setting and monitor the client’s progress in generalization and maintenance of skills as titration occurs in the setting.

317:30-5-314 (b)(2)(A)(i)V)  “Creating materials, gathering materials”

Per the CMS guidelines for the CPT code 97155 , , creating and gathering materials is not a covered service under the billing guidelines. We request clarification of appropriate activities with the use of the 97155 code.

317:30-5-314 (b)(2)(C)  “The functional behavior assessment is reimbursed…”

We request clarification on the language used here to better indicate the CPT code referenced with this policy. As stated with the description provided, the code best referenced would be 97152, behavior identification supporting assessment, which is not currently covered by OHCA policies. If the language is meant to encompass the full behavior skills assessment that occurs prior to treatment, we would recommend a shift in language to better match that meaning, as is better referenced with the CPT code 97151, behavior identification assessment. We also request that all codes for assessment (97151, 97152, 0362T) be covered under OHCA policies to better support robust assessment of both skill and behavior deficits.

317:30-5-314 (b)(3) Exclusions to Treatment, specifically (B)“ABA addressing goals only related to performative social norms that do not significantly impact health, safety, or independence.” & (L)“ABA authorized for toilet learning/toilet training…”

All health, safety, and tasks related to independence  are related in some way to the individual’s social environment and that environment’s social norms. An individual’s ability to be included, accepted, and involved in their social environment is directly tied to their ability to maintain their safety and the safety of others in their environment. Individuals with aggression, self-injury, or property destruction are more likely to be excluded from typical peer groups and activities  The resultant isolation may result in further increases in suicidal attempts or successes in individuals with autism.  Helping teach individuals how to function in their social environment allows the individual increased opportunities to contact reinforcement through their natural social community, thus increasing connectedness with their community and potentially reducing negative outcomes.

We request clarification regarding how OHCA defines “performative social norms.” If the definition is, in essence, the process of making an individual with autism appear or look “normal” through the reduction of physical or vocal stereotypic behaviors, forced eye contact, or other skills that are considered “normal,” ICAN supports the removal of these skills as necessary. If there are alternative definitions of a performative social norm that would impact a beneficiary’s access to appropriate social communication or interaction supports, we tentatively request that this language be struck from the policy.

Further, toileting is an area where an already vulnerable population potentially increases their risk of harm or abuse in the future if toileting is not mastered to the individual’s highest level possible. Toileting procedures through the use of shaping, differential reinforcement, set schedules of reinforcement, and visual aides help support an individual’s access to a higher level of independence. ICAN supports medical co-treatment should additional supports be necessary to ameliorate barriers to gaining appropriate levels of independence with toileting.

317:30-5-315 (2-3, 6) “To receive an increase in RBT hours…”

ICAN agrees that parental involvement is imperative to generalization of progress into less restrictive environments (i.e., home, community settings). However, tying a beneficiary’s ability to increase treatment if indicated during their course of treatment to their parent/guardian’s ability to participate in parent training represents an unrealistic treatment limitation. The policies requiring either 1 or 2 hours of parent training per week prior to authorizing an increase in direct service hours does not take into account the barriers that already exist for many families in accessing services. This policy unfairly favors those of higher socioeconomic standing and disproportionately affects those of lower socioeconomic status who may have limited ability to participate due to a variety of factors (e.g., conflicting work schedules, multiple children, lack of transportation or access to effective communication methods).

We request this language be struck from the policy, as it violates the beneficiary’s access to appropriate treatment as outlined in the Early & Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit  and in the MHPAEA.

317:30-5-315 (12) “Extension requests may only be submitted seven (7) calendar days prior to the end date of the most recent request…”

The current submission requirements do not allow sufficient time for continuity of care should their be an adverse determination made for the beneficiary’s services. We request an update to this timeline to reflect 21 calendar days, as is comparable in both other jurisdictions and private provider policies, to better facilitate continuity of care for our clients.

317:30-5-316 (2) “…(other than what is allowable under the functional behavior assessment procedure code).”

As stated above, the language pertaining to a specific CPT code is unclear whether the policy is referencing the 97151 or 97152 code. We request a clarification of the description used in the policy to better reflect the corresponding CPT code referenced.

317:30-5-317 (9) “In the event of death or serious injury (i.e., bruising, scratches, etc.)…”

ICAN maintains compliance of reporting incidents involving clients that result in any form of injury both internally and to families. We also hold all our providers to the standard of services being visible to all staff, clients, families, and potential visitors in our clinical settings. We request clarification for the examples of “serious injury,” as bruising and scratches are more typically considered less severe forms of injury when compared to broken bones and/or loss of consciousness, for example.

317:30-5-318 Service Quality Review

ICAN supports the use of quality overview and compliance monitoring in the ongoing treatment of our clients. As such we have a multi-departmental Quality Assurance & Performance Improvement team who meet regularly to review incidents or policies to improve our internal quality.

We request clarification and expansion of these policies to address:

1.            The inclusion of Board Certified Behavior Analyst, specifically, on the SQR team who has direct experience providing ABA services;

2.            The process in which a SQR may be triggered;

3.            The specific process of an SQR, including timelines for reviews, communication expectations both by the reviewers and the reviewees; and

4.            The specific criteria that would result in a recoupment, full or partial.

Although our concerns are extensive across multiple areas of the policy, ICAN is grateful to OHCA for working toward the improvement of ABA policies in their state to ultimately work to improve the lives of children with autism.

ICAN providers look forward to being a resource for this policy and future policies that impact behavior analysts, the implementation of ABA, and the autism community of Oklahoma. 

Aurora:

I am concerned that leaving the schools to only allow these services up to 3 months will be very damaging to a lot of autistic children needing these services. Also there is a BCBA shortage nation wide. How are these companies supposed to provide services if the bcba’s can’t do it over telehealth. It’s not logical

Brye:

My son is 7 years old non verbal. His rbt goes to school with him throughout the day and assists him in a tremendous way, he has come so far in such a short amount of time. Take that a way and there is no way my son will do as well as he has been so far. His rbt has been great and changed his life. If it were limited to just an in home service there is no way he would have progressed as quickly and learned the life skills he has. Aba in school helps kids cope and learn the skills needed to function outside of the home.

Brianne:

As a RBT, school sessions are necessary and beneficial to everyone. Not being able to be in school takes away our ability to help them transition and interact socially with others. 

Bonnie :

I Do not feel that taking away in school ABA therapy is a good idea because schools like verden public schools in verden Oklahoma DO NOT CHANGE CHILDREN WITH DISABILITIES they leave them in shitty clothes and call the parents from WORK to come get them. The ABA therapist my son has DOES NOT DO THAT

Charmayne:

The proposed rule's exclusion of highly-qualified out-of-state BCBAs could have a significant negative impact on children in Oklahoma who rely on Applied Behavior Analysis (ABA) therapy. ABA therapy is a critical treatment for children with autism and other developmental disorders, and access to skilled, experienced BCBAs is essential for effective care.

By restricting the pool of available professionals, the rule could result in a further shortage of providers, leading to longer waitlists and delays in service. This could prevent children from receiving timely interventions, which are crucial for maximizing progress and developmental outcomes. In some cases, children may face disruptions in their care if local providers are unavailable or unable to meet the growing demand.

Additionally, the exclusion of out-of-state BCBAs could limit access to a more diverse range of treatment approaches and specialized expertise. Children with complex or unique needs may benefit from providers who have specialized experience that isn't readily available in-state. Without this broader access to qualified professionals, children may not receive the individualized care they require, potentially hindering their progress.

Ultimately, the proposed rule will place unnecessary barriers in the way of children receiving critical therapy, reducing the availability of services and limiting the quality of care they can access.

Alanna:

I’m worried my child will lose important services if our BCBA can’t work with us because of the 50-mile rule. My child has made so much progress with their help, and it would be hard to find someone else nearby.  Finding a qualified provider within 50 miles who can meet my child’s specific needs is not guaranteed. Please reconsider this policy to ensure children like mine continue to receive the critical support they need.

Leigh:

Restricting contracted providers to professionals residing within a 50-mile radius of Oklahoma's borders will further exacerbate the shortage of qualified BCBAs in the state. With rising rates of autism and increasing demand for ABA services, this restriction unnecessarily limits the pool of professionals available to provide care, creating greater challenges for families seeking services. Removing these geographical restrictions would better support Oklahoma's ability to attract a robust workforce.

In addition, requiring ABA professionals to transfer responsibilities to school staff within a short timeframe is unrealistic and places undue pressure on educators who often lack sufficient behavioral training. This approach reduces the effectiveness of ABA interventions and contributes to workforce burnout and turnover, ultimately harming both the workforce and the students relying on these services.

Rianna:

The proposed residency restrictions for contracted providers will exclude many qualified professionals from serving Oklahoma families, worsening service gaps and reducing access to care. Given the increasing need for ABA services due to rising autism diagnoses, Oklahoma must adopt a more inclusive policy to attract and retain qualified professionals from beyond the 50-mile radius.

Similarly, limiting ABA services in schools to a three-month period undermines the ability of BCBAs to address complex behavioral challenges effectively. Short timelines hinder collaboration and the delivery of meaningful support, discouraging qualified professionals from working in Oklahoma and exacerbating workforce instability. Policies should support the ongoing presence of ABA services in schools to meet the needs of students and educators.

Lacey:

I greatly appreciate the opportunity to provide comments regarding the proposed Rule Impact Statement APA WF #24-23 My largest concern is regarding the following section: 317:30-5-311. (b) (5) All contracted providers must reside in the state of Oklahoma, or within 50 miles of the Oklahoma border as per OAC 317:30-3-89 through 92.

While I understand the intent of this rule to prioritize local provider access, by doing, so this will greatly impact and significantly limit the availability of Applied Behavior Analysis (ABA) therapy services in Oklahoma for an extremely vulnerable population.

1. Shortage of In-State BCBA Resources: Oklahoma faces a critical shortage of Board Certified Behavior Analysts (BCBAs) licensed and actively providing services within the state. Many licensed BCBAs residing in Oklahoma are not practicing locally, often due to employment in non-clinical roles or relocation for work opportunities. Implementing this proposed rule could worsen the existing scarcity by excluding qualified out-of-state providers who are both willing and able to serve Oklahoma families.

2. Network Capacity Effects: Restricting contracted providers to only those who reside within Oklahoma or a limited border zone would drastically diminish network capacity. Currently, many families rely on out-of-state providers from neighboring regions to access timely and high-quality ABA therapy. Limiting these professionals would lead to delays in service delivery, longer waitlists, and fewer opportunities for early intervention—crucial for successful autism treatment outcomes.

3. Autism Rates Vastly Increasing: The prevalence of autism has surged over the past decade, with consistent year-over-year increases in diagnoses nationwide and within Oklahoma. This growing demand for ABA services has outpaced the capacity of in-state providers. To fill this gap, families have relied on out-of-state professionals. Restricting provider eligibility without addressing the disparity between demand and supply risks creating a crisis for families needing care.

4. Implications and Considerations for the future: Beyond limiting family access to care, the proposed rule may discourage qualified providers from seeking licensure or work opportunities in Oklahoma, exacerbating the existing workforce shortage. Collaborative solutions that expand provider networks, rather than restrict them, are essential to addressing the needs of Oklahoma’s growing population of individuals with autism.

Resolutions to consider:

1.            Expand the provider eligibility radius to include all providers within the United States, not just those within 50 miles of the Oklahoma border.

2.            Conduct a thorough assessment of ABA therapy network capacity to align resources with the rising demand for services.

My other greatest concern is regarding section 317:30-5-314. (b) Service Limitations.  (1) Settings. The following limitations apply to where ABA services are provided: (A) ABA services are not allowed in a daycare setting or school setting, without OHCA approval. If approved, it will be time-limited to three (3) months or less. The BCBA shall create and submit a treatment plan that identifies the goals outlined to assist school staff 12 with the members without ABA staff being present throughout the school year. (B) The treatment plan should show a titration of services to school paraprofessionals/staff through the duration of the prior authorization.

Service Limitations in School and Daycare Settings:

We recognize the intent of the rule to foster collaboration; however, we believe adjustments are needed to address the unique role of ABA services in school environments:

ABA’s Role in Behavioral Support

ABA therapy focuses on behavioral and skill deficits that hinder a child’s ability to engage in education and daily activities. It complements, rather than duplicates, educational services by targeting behavioral goals, such as:

•             Reducing disruptive behaviors (e.g., aggression, self-injury, elopement).

•             Teaching functional communication and social skills.

•             Enhancing independence in daily routines (e.g., transitions, following instructions).

Collaboration and Flexibility

The three-month time limit on ABA services in school settings restricts BCBAs’ ability to implement meaningful, lasting interventions. Effective behavioral strategies require:

•             Comprehensive assessments and gradual implementation.

•             Consistent monitoring and adjustment of strategies.

•             Sustained training and oversight for school staff, especially in light of high turnover rates.

Increasing Demand for Behavioral Support As autism diagnoses rise, schools face greater challenges in managing complex behaviors. ABA services provide essential support that eases stress on educators and fosters better outcomes for all students. Restricting access to ABA risks:

o             Overburdening teachers and paraprofessionals.

o             Greater classroom disruptions.

o             Missed developmental opportunities for children with autism.

Resolutions

1.            Extend the allowable duration of ABA services in schools to at least six months, with options for renewal based on progress and need.

2.            Clearly distinguish between ABA interventions and educational services, emphasizing their complementary roles.

3.            Foster collaboration between schools, BCBAs, and OHCA to create clear, sustainable guidelines for behavioral support integration

4.            Allow flexibility in titration plans to reflect the varying capabilities and needs of school staff

In conclusion, ABA services are crucial for addressing behavioral challenges that hinder educational access and participation. Limiting these services risks leaving children without the necessary support to thrive. I urge reconsideration of the proposed restrictions to ensure Oklahoma’s children and families receive the care they need.

Trinnyce:

Restricting contracted providers to a 50-mile radius around Oklahoma unnecessarily limits the state's ability to address its critical shortage of BCBAs. Expanding the pool of eligible professionals, including out-of-state providers, would help meet the growing demand for ABA services and ensure timely access to care for families.

At the same time, restricting ABA services in schools by imposing short time limits prevents providers from delivering sustained, impactful interventions. With schools facing increasing behavioral challenges, limiting ABA services diminishes the capacity to address escalating demands effectively and increases burnout among school staff. Allowing for longer-term, flexible support from ABA professionals is essential to meet these challenges.

Angel:

Stopping ABA services in a daycare or school setting can have a harmful impact on a child with ASD for several reasons. One significant reason is the loss of consistent skill-building opportunities in natural environments.

ABA services often focus on helping children with ASD develop and generalize skills, such as communication, social interaction, and self-regulation, in real-life settings like a daycare or school. These environments provide unique opportunities to practice and reinforce these skills with peers and adults in a structured yet dynamic context. If ABA services are discontinued:

Generalization of Skills May Decline:

Skills learned in a therapy room may not automatically transfer to other settings. Without ABA support in a daycare or school, the child may struggle to apply their skills in group activities, peer interactions, or classroom routines.

Increased Risk of Behavioral Challenges:

ABA services often provide strategies to manage challenging behaviors. Without these supports, a child may experience increased frustration, anxiety, or sensory overload, leading to more frequent and severe behavioral incidents.

Missed Social Opportunities:

ABA therapists facilitate social skill development, such as turn-taking, initiating play, and responding to peers. Losing these structured interventions may hinder the child's ability to form meaningful relationships or participate in group activities.

Interrupted Progress:

Consistency is crucial for children with ASD. Abruptly stopping services can lead to regression in skills, reduced motivation, and difficulty re-establishing routines when services resume.

Increased Burden on Teachers and Caregivers:

Educators and daycare staff may not have the specialized training to address the unique needs of a child with ASD. Without ABA support, the child may not receive the individualized attention they need to thrive, and staff may struggle to meet their needs effectively.

Continuing ABA services in these settings ensures the child has the necessary support to succeed, integrate, and build essential skills in their daily environments.

Restricting out-of-state BCBAs reduces access to essential services, disrupts care continuity, and disproportionately harms children in underserved areas. Policies should aim to expand access to qualified professionals rather than restrict it, ensuring that all children with ASD receive the support they need to thrive.

For Example:

Case Study: A Child in a Rural Community

Scenario:

Mia, a 5-year-old with ASD, lives in a rural area where there are no local BCBAs available. Her parents secured services with an out-of-state BCBA who supervises her ABA therapy remotely. The BCBA works closely with Mia's family and her local RBT (Registered Behavior Technician), helping her develop communication, social, and adaptive skills.

Impact of Restricting Out-of-State BCBAs:

Interrupted Progress:

If the state limits out-of-state BCBAs, Mia loses her current provider. The family struggles to find another BCBA within a reasonable distance. As a result, her therapy is disrupted, and she begins to regress in areas like functional communication and social skills.

Loss of Expertise:

Mia’s out-of-state BCBA has specialized training in addressing her specific challenges, such as self-injurious behaviors and nonverbal communication. Without access to this expertise, her new provider may lack the skills to effectively manage her unique needs.

Increased Wait Times:

Due to a lack of in-state providers, Mia is placed on a waiting list for services. Months go by without intervention, leading to missed developmental milestones and increased stress for her family.

Family Burden:

Mia's parents consider relocating to a larger city where services are more readily available. This decision disrupts their lives, affects their employment, and separates them from their support network.

Inequity in Access:

Families in rural or underserved areas are disproportionately impacted by such restrictions. Mia’s situation highlights how limiting out-of-state providers can exacerbate disparities in access to quality care for children with ASD.

Whitney:

Oklahoma has a limited number of qualified service providers residing within the state. There is a growing number of individuals diagnosed with Autism each year. There are far more individuals in need of services than providers available to give those services. Many individuals with high needs rely on service providers outside the state of Oklahoma to receive essential daily care. High quality ABA services provided consistently and in a timely manner help individuals with Autism and their families engage meaningfully with their environment. Without access to ABA, many individuals and their families are confined to their homes due to behavioral concerns in community settings. There is also a growing need to behavioral support in the school setting. I am a BCBA with previous experience as a special education teacher. I can personally attest that teachers and paraprofessionals are not adequately trained in behavior analytic practices. The lack of training and proper understanding of behavior analytic principles in the school setting leads to an increased risk of injury to individuals with Autism, other students, teachers, and paraprofessionals.

Caitlin:

As an out-of-state provider, I've witnessed the service limitations faced by Oklahoma families. Many report difficulty finding providers and in-state BCBAs, leaving children and adults without support. Telehealth has been a vital alternative for rural and underserved areas. Restricting contracted providers to Oklahoma residents or those within a limited border zone will drastically reduce network capacity. Many families rely on out-of-state providers for timely, high-quality ABA therapy. Limiting access to these professionals will cause service delays, longer waitlists, and reduced early intervention opportunities—all critical for positive autism treatment outcomes. I urge reconsideration of these policies to ensure continued support for those seeking services.

Additionally I would like to express concern over the recent changes for in-school services. The current rule places undue strain on school staff who often lack the necessary training to address complex behaviors, resulting in classroom disruptions that negatively impact all students' learning and development. Please consider Establishing clear guidelines recognizing ABA as a complementary support to, not a replacement for, educational services. Allow services to foster stronger partnerships between schools, BCBAs, and OHCA to ensure effective and sustainable implementation of behavioral strategies.

Jessenia:

These new changes have really impacted our family as well and don’t think it is fair for those kids needing ABA services like my son. He just started with ABA in July and has already improved tremendously and was doing so well at school with his ABA tech with him but now that they are taking those services away we have had no choice but to homeschool . Although he has come a long way it’s only been a short period time and without ABA services at school he will digress and all the hard work that had been put in would be for nothing.  So now we have to make new accommodations in my family as a whole to be able to accommodate homeschooling so he can still get some sort of ABA services at least. 

Stacy:

I am writing as a concerned parent regarding the recently proposed updates to the ABA policies, particularly the restrictions on telehealth services. While I understand the intent behind these changes, I believe they may unintentionally limit access to essential services for families like mine.

For a long time, I struggled to find a BCBA in my area to provide the necessary services for my child. The lack of available local providers left my family in a challenging position, delaying critical intervention for my child’s development. Telehealth became the solution we desperately needed, allowing us to access qualified professionals and ensure continuity of care.

Telehealth has not only bridged the gap in access but has also been instrumental in helping my child achieve measurable progress. The flexibility it offers has allowed us to receive consistent and effective ABA therapy without the added stress of long travel times or provider shortages.

Limiting telehealth services under the new policy could potentially undo the progress we’ve made and create significant barriers for families in rural or underserved areas. I respectfully request that OHCA reconsider the restrictions on telehealth services for ABA therapy and ensure that this vital option remains accessible for families in need.

Families like mine rely on these services to provide the best possible care for our children. I urge you to consider the unique challenges faced by parents and caregivers when finalizing these policies.

Thank you for your time and attention to this matter. I hope that OHCA will work to ensure that every child has equitable access to the care they need, regardless of their location.

Jerry:

As a BCBA residing in California, I wish to express my concerns regarding the new policy requiring all providers delivering Applied Behavior Analysis (ABA) services to reside in Oklahoma or within 50 miles of its border. This limitation significantly restricts the availability of qualified professionals for families in need, especially in underserved and rural areas of Oklahoma where access to ABA services may already be scarce. Many families benefit from the flexibility of telehealth services, which allow them to connect with experienced clinicians who might otherwise be geographically inaccessible.

Operating on Pacific Standard Time (PST), I am uniquely positioned to offer flexible scheduling that accommodates the needs of families and staff in Oklahoma. For instance, I am available to meet as late as 10:00 PM CST, which aligns with 8:00 PM PST in my local time. This extended availability has been invaluable for families juggling work and other commitments, allowing them to participate in meaningful consultations and caregiver training sessions after their regular schedules. Families have expressed great satisfaction with this flexibility, as it enables consistent support and communication critical to achieving positive outcomes.

The use of telehealth for ABA services has proven to be an effective mode of intervention. It facilitates timely access to high-quality care, reduces transportation barriers, and provides a sustainable model for ongoing parent and caregiver training. Moreover, for families in Oklahoma, accessing BCBA services via telehealth from out-of-state providers can increase the pool of skilled professionals, ensuring diverse expertise and improved outcomes for children diagnosed with Autism Spectrum Disorder.

Restricting out-of-state telehealth services may inadvertently exacerbate inequities in care, particularly for those who rely on Medicaid, by creating bottlenecks and extending wait times for services. I urge the OHCA to reconsider this policy and prioritize the needs of Oklahoma's families by embracing a model that values flexibility, accessibility, and evidence-based practices.

Stephanie:

As a parent this is beyond ridiculous my son being able to have his aba therapy at school helps in so many ways especially because that's where he has most issues the sessions have helped him so much and my son once his routine is messed with or anything changes my son acts out it messes with him and to stop aba therapy on the spot not even giving parents a chance to find a new location or figure out the changes to make for their child and i can just imagine how this will affect other kids with autism it's unbelievable how much children aren't important to the higher up maybe it's because it doesn't affect them but the children deserve better now i can thank the state when my son begins to start acting up and doesn't get his proper help due to being a single mother of 2 that by the time im out of work clinics close or having therapy at home that he can't even get the right amount of hours because all that we can do is from 5:30-7:30 for my son to have to have dinner late or not want to work with the therapist because he's home and rather do other things rather pay attention where as in school he can interact with other kids and work with others i believe aba therapy has helped in the school because other kids in the school can learn what my child is learning how to cope, share, communicating, expressing themselves, etc this is a huge mistake and so many kids and even parents will be affected red so badly with this 

Amber:

ABA providers are already in high demand and short supply nationwide. Adding residency restrictions further limits the availability of care. Transitioning to new providers—or waiting for one—can disrupt therapy, create stress for families, and cause regression in the child's development.Families might need to travel farther to reach in-state providers, which increases costs and logistical challenges.

For working parents or low-income families, this requirement imposes additional strain, reducing their ability to maintain consistent therapy schedules for their children. The rule prioritizes geographic boundaries over the best interests of the client, which goes against the principles of person-centered care.

Denying access to qualified providers solely based on location undermines the quality and continuity of care that clients deserve. A significant percentage of these children live in rural areas or near the border, where local ABA providers are scarce. Losing access to providers beyond the 50-mile radius could leave children without care. may unintentionally harm the very families it aims to support. Expanding provider eligibility criteria would better serve Oklahoma's diverse population, ensuring that families across the state can access the care they need without unnecessary barriers. The focus should remain on improving access, quality of care, and continuity of care for all clients, regardless of where their providers reside.

Jessenia:

These new changes have really impacted our family as well and don’t think it is fair for those kids needing ABA services like my son. He just started with ABA in July and has already improved tremendously and was doing so well at school with his ABA tech with him but now that they are taking those services away we have had no choice but to homeschool . Although he has come a long way it’s only been a short period time and without ABA services at school he will digress and all the hard work that had been put in would be for nothing.  So now we have to make new accommodations in my family as a whole to be able to accommodate homeschooling so he can still get some sort of ABA services at least. 

LaDonna:

These changes would be disastrous to autistic kids and the progress that has been made! Having an ABA therapist in the school system has been so successful for my grandson. To deny him of this continued progress and so many other kids out there is an outrage and such an injustice to special needs kids. 

Angela:

I am writing this on be half of my four-year-old autistic son, as is my responsibility as a parent, in favor of keeping ABA Therapy in schools. The purpose of ABA Therapy is to produce important changes in human behavior. This is something that may be prevented in the absence of ABA Therapy in schools, where a child’s behavior is naturally different than that of at home. My son heavily benefits from the important one-on-one interaction that comes with the understanding and support being provided in his ABA sessions. When you remove this, and try to implement it in an at-home environment, or replace it with someone under qualified, the outcome changes for the worse. Putting a child in their own private space, then teaching them to act differently than comfortable creates a sense of unease and brings about other harmful behaviors. There are many reasons as to why my son needs the services provided in the ABA. He met the requirements needed such as being diagnosed with Autism, showing aggressive behaviors towards himself and others along with destruction of property and personal belongings. He receives thirty hours of ABA therapy within two weeks, in school as this is the only availability due to: the lack of permitted time at home, the lack of comfortability with having someone in his space, and shuts down when disruptions occur in his at home routines.

Please keep us in mind when making your final decision.

Nate:

With the lack of bcba in my area telehealth fixed that issue since my child has bcba out of state. It will ruin our routine and make the situation harder on us parents everywhere. Don’t take this away from us.

Kaylynn:

I am writing as a concerned parent of a child who is currently receiving ABA therapy. I recently learned about the proposed policy that would require Board-Certified Behavior Analysts (BCBAs) to be located within 50 miles of Oklahoma in order to provide services, and I wanted to share my concerns about the potential impact this could have on my child’s care.

My family is currently receiving services from an out-of-state provider, and this change would cause a significant disruption in my child’s therapy. Losing access to these services would mean my child would likely be placed on a waitlist, delaying crucial early intervention that is vital to their development.

Additionally, families like mine, who reside in areas without adequate local resources, face challenges in traveling long distances to receive therapy. This policy could effectively limit access to care for many children who are already receiving treatment that is essential for their progress.

I urge the board to consider the profound impact this decision could have on families like mine and the children who depend on consistent, high-quality care. I sincerely hope that you will take this into account and find a way to allow out-of-state providers to continue serving children in need of ABA therapy.

Shayla:

As a parent of a child with autism, I am deeply concerned about the recent changes to Oklahoma state laws that restrict BCBAs from providing telehealth services. Families like mine, especially in rural areas, already face significant challenges in accessing care due to the shortage of qualified BCBAs in our state. For children with autism, timely and consistent access to ABA  which crucial for their development. Telehealth has been a lifeline for us, bridging the gap between our needs and the limited availability of local providers. Removing this option not only disrupts care but also creates barriers for families who cannot regularly travel long distances to urban centers.

How can you ensure that the children receive the support they need when there aren’t enough BCBAs to meet the demand in person? What steps can be taken to address this shortage while still allowing families to access telehealth services that are proven to work? This decision places undue strain on parents and children alike, and I urge lawmakers to consider the real-world impact on families in Oklahoma.

Jerry:

As a concerned BCBA, I find it deeply unfair and targeted that the Oklahoma State Health Authority is disallowing out-of-state BCBAs from servicing clients in Oklahoma. Many of us have worked hard to obtain our licenses in Oklahoma and have been providing high-quality care to families for years. This policy not only disrupts the progress of the clients we currently serve but also undermines the dedication and expertise we’ve brought to the state. I’ve had significant success training parents and supervising RBTs through telehealth without any issues—so why is this change necessary now?

This policy will also take away jobs from many skilled BCBAs who have been effectively supporting Oklahoma families remotely. Instead of eliminating our ability to work, I urge policymakers to consider alternative solutions. For example, we could travel to our clients in Oklahoma on a quarterly or monthly basis, or work alongside an in-state BCBA who could conduct 25% of the required supervision while we cover the rest remotely. These compromises would allow families to continue receiving consistent, high-quality care without losing the progress they’ve made. Please reconsider this restrictive policy for the sake of both clients and providers.

sidnie

i adamantly oppose this specific exclusion & feel like it is unethical. my nephew, michael, has greatly benefitted from ABA/RBT assistance in the school to improve his verbal communication & social skills. he requires strong prompting to succeed in the classroom. please reconsider this exclusion, thank you for your consideration. 

Jessica:

With this change has cause me to keep doing epic charter school so my son can still be able to get his full hours of Aba therapy so that he won’t miss hours in an actual school setting.so this new policy is bull 

Chris:

This is in response to circulation letter APA WF #24-23. While reading over the exclusion in treatment section it was pretty shocking. The very first exclusion would be an ABA addressing academic goals. Reading farther down I see that ABA support in a school to provide support would be restricted as well. That is not only shocking but embarrassing when you take into consideration that our state of Oklahoma ranks 49th in education already. From my own personal experience as a former resident of California, I can say that Oklahoma has up until this time blown California out of the water in the care and support provided to both of my children that have autism. For a place that takes such tremendous pride in their education system, it was a complete joke how my kids were geared for success in their school system in my previous state.

  While attending California schools I would get calls and emails multiple times a week as well as student suspension from class because the teachers and aides were having issues in class that they couldn’t handle. With this proposal to eliminate in school support services I can only imagine that this would be the case as well here in Oklahoma. My student that has received in school support here in Oklahoma has done so much better while having that assistance of his ABA. The coping strategies and other assistance have helped him so much in class. He can now get through the school day and be successful in education. He also isn’t potty trained so while he’s at school he’s received support from his ABA in potty training as well. I have read that this is another area that will be cut as. That is just disappointing. If he were to have an accident at school I’d hate to imagine him being made fun of or bullied over it and it leading to a disruption of his education and further affect his mental health. Due to his disability the State of Oklahoma has had no issues providing diapers for him but now we’re going to remove the support in school for him in attempting to overcome his disability? That just makes no sense.

 ABA support is essential in schools for the success of our children. Removing this support puts the burden of care for these students on the teachers and aides to not only teach these children but navigate the ever changing world of mental health and try to avoid daily emergencies inside the minds of these children. We live in a state that has a teacher shortage already and an inability to retain teachers. This decision would only create an even harder playing field to attract teachers and entice the next generation of students to want to choose the teaching profession in Oklahoma. I ask that you please follow the Oklahoma Standard and do not pass this proposal. I ask that you remember that the Oklahoma Standard is to serve those in need, help their neighbors, and be the difference and positively affect the outcome. 

A.H:

I appreciate the opportunity to provide feedback on the proposed Rule Impact Statement APA WF #24-23. I have concerns about certain sections of the proposal and believe they may limit access to critical services for Oklahoma families, particularly in the areas of Applied Behavior Analysis (ABA) therapy.

My initial comment is related to section 317:30-5-314. I have concerns about restrictions on ABA services in schools, specifically the three-month time limit and the requirement for school staff to gradually take over behavioral interventions. ABA services are crucial for addressing behavioral challenges that hinder a child’s ability to succeed in school. Limiting the duration of services may not allow enough time for meaningful progress. Additionally, school staff often lack the training and resources to take over ABA interventions effectively. I recommend extending the allowable duration of ABA services in schools, clarifying the distinction between ABA and educational services, and enhancing collaboration between schools and BCBAs. Schools are not providing ABA services, which is a significant distinction between what we are able to provide compared to schools.

My next concern is with 317:30-5-311. I am concerned that restricting contracted providers to those residing in Oklahoma or within 50 miles of the state border will limit access to qualified ABA therapists. The shortage of in-state Board Certified Behavior Analysts (BCBAs) already makes it difficult for families to find services, and this rule could worsen the problem. Many families currently rely on providers from neighboring states to meet their needs, and limiting the pool of available professionals could lead to longer waitlists and delays in service delivery. I recommend expanding the provider eligibility to include professionals from across the United States and addressing the capacity needs of the ABA therapy network to meet the growing demand for services.

ABA services are vital for children with autism and other developmental disabilities, particularly in school settings. I urge you to reconsider the proposed limitations to ensure continued access to these critical services for Oklahoma families. Autism rates are increasing, and these changes create a barrier to valuable and needed services for families.

Thank you for your consideration. 

Kari:

After reviewing the proposed changes to soonercare coverage for ABA I have to say that we are doing a diservice to this vulnerable population.  I agree parent training is imporant how ever often times these children are in a single parent household. Limiting the number of times the parent can afford to take off to do parent training without affecting their income. As far as the in school rule three months is not enough time to make lasting change, and school rescourses are limited to maintian behavior plan. At three months we may have seen a reduction in behaviors how ever they may not be in generlization at this time and we could see regresssion shortly after services end because contingences are not able to be maintained due the the high levels of students to staff ratio. 

Lauren:

ABA providers do not assist the client with academics nor do they participate in academic activities. The ABA provider is solely there for behavior management and proper social and communication skill acquisition. This means that the ABA provider is necessary to manage behavior, assist the student through transitions, prompt the student with difficult tasks, teach task initiation skills, and coach appropriate behavior through social interactions and situations.

There are autistic students who cannot be successful in the school environment without additional 1:1 behavioral support. Denying coverage in the school setting ostracizes these students and does not allow them to be in their least-restrictive environment nor are they able to generalize skills appropriately to this environment. Receiving services in the natural environment of their school is beneficial for clients to learn appropriate social skills. Denial of school services hinders their ability to be successful in the educational setting as well as hindering natural social opportunities.

Additionally, restricting services to outside of schools often leads to reductions or delays in treatment hours which ultimately impacts a client’s progress and leads to  needing ABA services for a longer period of time. Without behavioral interventions in place, autistic students are often suspended or parents are called to pick the student up when a maladaptive behavior occurs. This negatively impacts families that have two working parents or families in rural areas. If there are no ABA clinics in the area, how would a child go about receiving services during the day while their parents are working? It is not feasible for families to quit their jobs or relocate to another area just to receive ABA services. Quality services must be available throughout the entire state and in all environments to ensure effective and appropriate skill acquisition and behavior reduction.

With each child being different and requiring an individualized treatment plan, it is not reasonable to suggest that only 3 months of school services be covered. Some children will need support for longer than 3 months and placing an arbitrary length of time on these services ignores their clinical and medical needs. Schools are critical partners to collaborate with and this would reduce the opportunity for appropriate collaboration, which ultimately impacts the child’s quality of life. Denying coverage of services in particular environments does not ensure a sufficient standard of care. It instead severely limits a child’s ability to receive appropriate and effective services which impacts not just their current independent functioning and quality of life but the independent functioning and quality of their entire lives.

Jorja:

I am an RBT that works in school with a Client that needs ABA services. I think it is very important for everyone to stay on top of the ever changing rules and regulations in ABA policies and keep the child in mind. 

Kim:

I am writing to express my deep concern regarding the proposed changes under APA WF# 24-23 related to Applied Behavioral Analysis (ABA) services. These changes pose significant challenges for families like mine, who rely on ABA therapy to provide essential support for children with developmental needs.

My son has been receiving ABA therapy under the supervision of a Board Certified Behavior Analyst (BCBA) and a dedicated Registered Behavior Technician (RBT). This therapy has been instrumental in his development, helping him acquire essential life skills, manage daily challenges, and achieve milestones that once seemed unattainable.

The sudden nature of these changes has placed an immense burden on families, disrupting access to care and threatening the progress our children have made. Denying or limiting these services is not only a disservice to children in need but also undermines the future potential of our communities and state.

I urge you to reconsider the changes proposed under APA WF# 24-23 and work with families, providers, and stakeholders to find solutions that ensure continued access to quality ABA therapy. The well-being and future success of countless children depend on it.

Thank you for your attention to this urgent matter.

Samantha:

In regards to the issue at hand, I am here to express my concerns. My nephew, who is special needs, needs to continue to have the current BCBA that he has now. It has taken my cousin months to find one that has allowed her son to advance and learn and for that to be taken away due to the BCBA being out of state would be absolute blasphemy. These kids have a routine and see the same BCBA and have been able to grow a relationship with them, to which is crucial for their learning. Many parents have busy schedules and with the lack of BCBAs able to provide telehealth in the state, this could cause more stress on the parents. In turn, it could make it difficult for them to get appointments and could possibly discourage them from finding help for their kids. I know some parents who have had to move out of state just to provide their kids with the proper help. So please, do not deny these kids of the help that they deserve. 

Leslie:

Regarding 317:30-5

ABA is currently not a component of the IEP documentation or routine school day for children in the public school system. Norman Public Schools for example has 1 BCBA employed by the district. The BCBA is newly certified and has no direct supervisory role of ABA trained staff to serve the more than 1500 students with an IEP. While the aspiration to train school staff in ABA should be the goal, schools are currently no where near equipped to accommodate the children diagnosed with Autism. A 3 month authorization does little to train staff as teachers/paras constantly change. The continuity of care is at risk for these students further limiting their access to services. This ruling is also in violation MHPAEA which speaks to no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.