Teachers work with kids at the Bounce ADA Preschool in Essex Junction on Tuesday, December 16, 2025. Photo by Glenn Russell/VTDigger
For Jennifer Beane-Edgar, seeing her son learn how to express his needs has been revelatory.
“He went from being totally non-speaking, non-communicating, not engaging (and) kind of withdrawn into himself to being able to play and interact with peers,” she said of her 6-year-old.
Sam has profound autism. The diagnosis means he needs help with daily tasks like going to the bathroom or having a snack. It’s likely he will need 24/7 support for the rest of his life, his mother said.
After being discharged from a daycare that couldn’t keep up with his high needs, Sam started attending an early intervention clinic for children with autism. The clinic, Keene Perspectives, in Hartford, is one of many in Vermont that specializes in Applied Behavior Analysis, or ABA, therapy. The therapy focuses on building up helpful behaviors — like communication or toileting — and decreasing problem behaviors — like running into the street or biting and scratching.
“The amount of growth that I’ve seen is immeasurable. It’s incredible,” Beane-Edgar said.
Sam does puzzles and plays games. He has started repeating words and can communicate his needs through something called a Picture Exchange Communication System, which uses little illustrations to express things like “I want,” “bathroom,” “water,” “play.”’
Yet Sam’s progress stalled in February when Keene Perspectives informed his mother that it was discharging him from the clinic, six months earlier than he was supposed to transition into public school.
It comes as Keene Perspectives and the nearly 20 other ABA providers in Vermont race to adapt to a change in how Vermont Medicaid pays for its services. The shift has caused a drastic drop in revenue for many ABA providers — one that some say threatens their ability to continue providing services altogether. Yet, Medicaid says the change is an essential way to protect against fraud and safeguard its ability to pay for ABA services in general. Though the changes were set in motion late in 2025, they are now colliding with a Congressional inquiry into the state-federal health insurance program.
At Keene Perspectives, Sam follows the specific protocol a clinician called a board certified behavior analyst, or BCBA, has designed for him. A BCBA has graduate-level training and licensure as a health professional. Sam spends his days one-on-one with a behavior technician who stays with him to implement the clinical guidance and lessons that the BCBA has designed. The behavior technician position is an entry-level, paraprofessional role that requires far less training.
As part of the protocol, the BCBA spends a portion of the day with a child, such as Sam, and the behavior technician, monitoring how the client responds to treatment and where his plan needs to be altered.
Until the end of 2025, Medicaid paid ABA Centers for both the behavioral technician’s and the BCBA’s time. This January, Medicaid instituted new changes that no longer allow providers to bill for both the BCBA and behavior tech’s concurrent services.
This concurrent billing, explained Grace Johnson, a Medicaid policy analyst for the Vermont Agency of Human Service’s Medicaid Policy Unit, was simply not “correct coding.”
She and her colleagues identified ABA as the primary area where the state is already acting to avoid potential federal investigations into Medicaid fraud, waste and abuse in Vermont.
Under President Donald Trump, the federal government has increasingly scrutinized how states spend money in the state-federal partnership health coverage program. Johnson noted that last summer, the federal government found Wisconsin had paid $18.5 million for “improper” ABA billing claims.
She said Vermont Medicaid wants to reduce its vulnerability to federal probes by ensuring that its payments are in line with federal guidelines.
Cortney Keene, a BCBA who founded and runs Keene Perspectives with her husband, Chris Keene, said that about half the clinic’s client base are Medicaid patients. Their revenue has dipped about 16% in January and February, she said.
Medicaid’s billing for ABA services works in a lump sum, so providers submit the number of hours a client spends receiving services, rather than the specific services provided. So, if a child attends a clinic like Keene Perspectives for 10 hours a week, working with a behavior technician, Medicaid will reimburse the clinic for 10 hours of time — even if two of those 10 hours are spent with a behavior technician and the licensed BCBA, who is guiding and writing the protocol. Previously, those 10 hours could have been reimbursed as 12, to reflect the two hours of the BCBA’s time, on top of the behavior technician’s.
“Honestly, the structure of our work is too complex for a behavior technician to do with fidelity, the way it should be done, without BCBA oversight,” Keene said. “We’re ethically required to provide services in that structure. You have to have two people there for a portion of the time to make sure it’s done right.”
So the Keenes’ process remains the same. BCBAs still design protocol and observe how a child responds to it, they just aren’t reimbursed for their time.
The same is true at Little Royals Early Intervention Center, an ABA center in Williston. It was important, explained Celia O’Flaherty, a BCBA and the center’s clinical director, to maintain that standard of care.
But it has resulted in a 17% drop in income for the center and a drop in what they are paid for some individual clients that ranges from 15%-50%.
“The 50% feels staggering to us,” O’Flaherty added.
She and the Keenes both know of clinics that are already looking at closing their doors entirely.
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For now, Little Royals is expanding services and bringing in income through other routes — contracting clinicians with schools, for instance, is something O’Flaherty expects to help keep them afloat.
Little Royals hasn’t yet had to discharge Medicaid clients or stop taking on new ones.
However, Keene Perspectives has already started to respond to the income loss by scaling back their number of clients.
The Keenes are already in the process of discharging half of those Medicaid patients — Beane-Edgar’s son Sam, among them.
“We’re fighting to maintain our skills. We’re certainly not really building any additional skills at this point,” Sam’s mother said.
Sam has already started to attend speech therapy and occupational therapy at the public school in the mornings, before his mother shuttles him over to Keene Perspectives for the afternoons.
It’s a constant coordination and changing schedule that prohibits Beane-Edgar from being able to maintain any kind of stable employment.
Cortney Keene also worries about how this may displace the high need for care onto parents or schools, which she sees as having far fewer resources and training to accommodate autistic children’s needs. “They come here because they have medical necessity for these services. That medical necessity did not go away,” she said.
Johnson, the Medicaid policy analyst, said that her colleagues at the Agency of Human Services are monitoring how providers are responding by watching how they can or cannot continue to provide services.
Coincidentally, the Medicaid team has launched a study of its ABA rates, as a result of legislation passed last year.
Johnson pointed to it, though, as a potential solution for providers who are struggling to meet their needs in light of these changes.
“If the reimbursement that was happening was insufficient, the rate study would address that,” she said.
O’Flaherty, at Little Royals, too, said that were the rates to change to actually reflect the amount of work that goes into each hour a child spends receiving care, it would alleviate the financial strain the center is facing.
“If this is our new reality, then there needs to be a rate change,” she said.
Alex McCracken, a spokesperson for the Department of Vermont Health Access, which also oversees the implementation of Vermont Medicaid, stressed that her department will also continue to monitor how providers respond to the change in billing rules implemented at the beginning of the year. Three months is still early to see the impact of a billing change, she said.
The department wants to ensure the changes “are not creating an undue strain on patients and families,” McCracken said. “Our primary concern is making sure that members have access to clinically appropriate care for their needs. So we are very plugged into how to protect and maintain that access.”