Centers for children with autism fear proposed Medicaid changes may
threaten ability to operate
[December 20, 2025]
By OLIVIA GIEGER/VTDigger
To get himself ready to leave the house each morning, Kingston Emilo
goes through a series of to-dos outlined in little pictures on a story
board. When he puts his socks on, he moves the Velcro square from
“To-Do” to “Done.” He repeats the ritual when putting on his shoes, his
coat, his backpack.
Transitions are hard for the 5-year-old with autism, explained his
mother, Jocelyn Emilo. Visual cues like the story board help Kingston
prepare for what comes next. It’s been crucial to reducing his tantrums
and anxiety around leaving one activity and moving to the next. Their
house is now filled with these story boards, his mom said.
But, she said she never would have realized that her child learns best
this way without the clinical support of the board certified behavior
analyst he sees.
Kingston attends an Applied Behavior Analysis, or ABA, center called
Bounce. The Essex program looks like a preschool, but it’s a clinical
space where he and 46 other students receive personalized ABA treatment
designed to reduce their problem behaviors and increase their skills —
things like articulating their needs and feelings, potty-training and
putting on clothes. Bounce is one of 20 ABA providers in Vermont who
receive Medicaid — nearly half of those are other clinics.
But, proposed changes to Vermont Medicaid billing rules have made
several ABA providers across the state fearful about their ability to
continue doing this work.
On Nov. 10, the Department of Vermont Health Access, which administers
the state’s Medicaid program, alerted ABA providers that starting on
Jan. 1, 2026, the department intends to implement a series of changes.
Of those, one proposal that would prevent billing for two different
providers’ concurrent services has providers and parents reeling. A
public comment period on the proposed changes is open until Dec. 25.
The department hopes that implementing these changes will root out
excess payments. Alex McCracken, communication director at the
Department of Vermont Health Access, said the concurrent billing
essentially duplicates payments.
Those who administer the clinic-based care say the concurrent billing is
necessary to pay two different specialists for their work providing two
different services, and they say the changes could be an existential
threat.
Billing and ABA explained
State law requires private and Medicaid insurance plans to cover
medically necessary, evidence-based treatment of autism spectrum
disorders — including applied behavioral analysis — for children from
birth until they are 21 years old. Young people can receive this
treatment at home, in public schools, remotely or in a center like
Bounce.
ABA centers like Bounce operate by pairing a child, like Kingston,
one-on-one with a behavior technician, someone who stays with them
throughout the day going through lessons, implementing a clinical plan
and noting how the child responds and progresses.
Typically, a board certified behavior analyst assesses a child and then
designs a specific protocol for them to gain skills while reducing
distressing behavior. For instance, a child with autism may hit their
head because they know that doing so will elicit a response and
attention from their caregiver. A provider can work with them on
communication skills so that they can replace the hitting while still
expressing what they need.
Kingston, for example, worked on his ability to adapt to transitions
throughout the day.
But the person who designs the protocol is different from the one who
implements it day to day. The board certified behavior analyst, or BCBA,
needs at least a master’s level training for certification, and in
Vermont, a BCBA needs a license to practice. They are the ones writing
and guiding care decisions. They have many patients under their care.
The behavior technician (also called a BT) works one-on-one with the
child to practice the skills and lessons outlined in the BCBA’s plan,
and this provider does not need a license, formal certification or a
bachelor’s degree.
Elaina Hanson, the clinical director of Bounce, explained that for the
therapy to work, the two roles cannot be separated.
“We can’t function this way. There’s no world where this makes sense,”
she said of the proposed billing changes.
She likened it to seeing both a hygienist and a dentist: The dentist
gives treatment directives and outlines a plan for the patient, even
though the hygienist spends the most time with the patient while they’re
in the office. Both providers get paid.
She’s not sure how Bounce would be able to sustain itself under the new
Medicaid rules. Right now, her clinic is able to submit separate claims
for the behavior technician’s implementation and the BCBA’s guidance of
a child’s therapy plan.
She suspects that when, or if, the Medicaid changes go into effect, the
BCBA will not be reimbursed for the hours they spend with a child. At
Bounce, a BCBA spends about seven hours a week assessing and observing
each individual child.
Hanson estimates that not being able to bill for these services for
Bounce’s Medicaid patients, like Kingston Emilo, would result in a 20%
loss of revenue.
“Medicaid is the backbone of this whole system, not just for us, but for
every company. The vast majority of clients are Medicaid beneficiaries,
and so without them, everything kind of crumbles,” she said. “It’s the
most vulnerable population that would get the brunt of this and with
nowhere else to go, because everybody is in the same situation.”
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 However, the Department of Vermont
Health Access maintains that the change isn’t meant to alter service
or availability for Medicaid beneficiaries.
McCracken, the director of communications for the department, said
the way that Medicaid currently bills for a BCBA “inherently
includes supervision” of the behavior therapist’s implementation.
The way that BCBA’s bill for their time with a patient should
already account for that fact that it’s two-on-one time — and should
include the fact that the behavior therapist is with them, she said.
The Medicaid billing code for a BCBA’s care stipulates that it “may
include simultaneous direction of technician, face-to-face with one
patient.” The way Medicaid sees it, separately billing for both the
BCBA’s care and the behavior technician’s care would, essentially,
be redundant, McCracken said.
Providers still can bill for the behavior therapist as well as the
BCBA — just not at the same time.
McCracken said the change is meant to ensure that Medicaid pays for
the time that its beneficiaries spend receiving care, rather than
the time providers spend administering it.
“We’re not actually changing any of the service availability or
availability for members. It is just how the reimbursement and
billing works for the provider.”
A leak in the house
But providers across the state say that reducing their specialists’
ability to bill will inherently reduce access.
“I honestly think this is a mistake,” Hanson, at Bounce, said. “I
don’t think anybody’s really understanding what it’s going to look
like if this happens.”
Cortney and Chris Keene are both BCBAs and run an ABA clinic in
White River Junction. They employ four other BCBAs, one assistant
BCBA, and 26 registered behavior technicians — enough so that each
one of the 22 children who receive care there will always have an
adult with them. Each BCBA has about five patients on their
caseload.
As their patients reach their goals and phase out of an ABA center’s
care, they can enter traditional education settings. In the coming
year, Cortney Keene said, she and her husband are going to have to
think critically about whether they can afford to take on new
Medicaid patients when their current caseload phases out.
But, they intend to take the financial hit until then.
“We are not planning on dropping them immediately. That is against
everything in how we do business, how we believe to treat our
families. It is just against all of our ethics,” Cortney Keene said.
The proposed changes have sent the community of ABA providers
spiraling. Keene said she is working “literally all night” to get
the word out about these changes before the Department of Vermont
Health Access’s public comment period closes on Dec. 25. Providers
have set up a voter voice petition for people to write to the
department. They are writing pleas to legislators and families for
help. Kingston’s mom, Jocelyn, has set up her own Change.org
petition.
“One of the biggest problems we have is that this happened in
silence,” Chris Keene said. He was especially surprised because he
felt like ABA centers and Vermont Medicaid have historically had a
strong, collaborative relationship. When the department proposed
these changes, Keene felt like they came out of nowhere.
The department is, in part, trying to keep up with federal oversight
of Vermont Medicaid. Under President Donald Trump, the executive
branch and Congress have particularly focused on “waste, fraud, and
abuse” in Medicaid.
“In order to ensure that we’re safeguarding the ABA benefit, we want
to be extra sure that we’re compliant with all federal regulations,
because there has been this increased scrutiny nationwide,”
McCracken said. She hopes that a “proactive” change can protect the
program from facing more tangible threats from the federal
government.
“Ultimately, these are changes we have to make, and we will be there
to support providers through the process, but we don’t believe these
will have a great impact on the services that members are able to
access,” she said.
Chris Keene said he thinks rooting out abuse is like dealing with
leaky pipes.
“Instead of going to pinpoint and target where the leaks are, this
is bulldozing the house. Sure, you’re gonna wipe out waste, fraud
and abuse, but you’re actually gonna wipe out your entire support
structure and set it back for years,” he said, adding that ABA
providers, like him and his wife, are the ones who could help find
the leaks and better protect the system.
Keene and his wife both worried that removing eligibility for
concurrent billing will actually open the door for abuse, since it
prevents the master’s-level providers from directing the care that
the behavior technicians implement.
“If there’s not a qualified health professional overseeing something
like that, you run the risk of poor implementation of programming
that’s not being run as written. That could harm a child,” Cortney
Keene said.
It’s something she worries about when serving one of the most
vulnerable patient bases in the state.
“Almost all of our kids have failed somewhere else first, and that’s
why they land with ABA. They’re kicked out of daycare. They’re
kicked out of childcare. Parents pull them out of school,” she said.
“One of the really critical aspects is it works when nothing else
works.”
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