![\"An](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/12\/bounce-preschool-3-20251216-1200x798.jpg\")
Teachers work with kids at the Bounce ADA Preschool in Essex Junction on Tuesday, Dec. 16. Photo by Glenn Russell\/VTDigger<\/p>\nTeachers work with kids at the Bounce ADA Preschool in Essex Junction on Tuesday, Dec. 16. Photo by Glenn Russell\/VTDigger<\/p>\n
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 \u201cTo-Do\u201d to \u201cDone.\u201d He repeats the ritual when putting on his shoes, his coat, his backpack.\u00a0<\/p>\n
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\u2019s 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.<\/p>\n
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.<\/p>\n
Kingston attends an Applied Behavior Analysis, or ABA, center called Bounce. The Essex program looks like a preschool, but it\u2019s a clinical space where he and 46 other students receive personalized ABA treatment designed to reduce their problem behaviors and increase their skills \u2014\u00a0things like articulating their needs and feelings, potty-training and putting on clothes. Bounce is one of 20 ABA providers in Vermont who receive Medicaid \u2014 nearly half of those are other clinics<\/a>.\u00a0<\/p>\n 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.\u00a0<\/p>\n On Nov. 10, the Department of Vermont Health Access, which administers the state\u2019s 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\u2019 concurrent services has providers and parents reeling. A public comment period<\/a> on the proposed changes is open until Dec. 25.<\/p>\n 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.\u00a0<\/p>\n 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.<\/p>\n Billing and ABA explained<\/p>\n State law requires private and Medicaid insurance plans to cover medically necessary, evidence-based treatment of autism spectrum disorders \u2014\u00a0including applied behavioral analysis \u2014\u00a0for 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.\u00a0<\/p>\n 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.\u00a0<\/p>\n 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.<\/p>\n Kingston, for example, worked on his ability to adapt to transitions throughout the day.<\/p>\n 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\u2019s 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.\u00a0<\/p>\n The behavior technician (also called a BT) works one-on-one with the child to practice the skills and lessons outlined in the BCBA\u2019s plan, and this provider does not need a license, formal certification or a bachelor\u2019s degree.<\/p>\n Elaina Hanson, the clinical director of Bounce, explained that for the therapy to work, the two roles cannot be separated.<\/p>\n \u201cWe can\u2019t function this way. There\u2019s no world where this makes sense,\u201d she said of the proposed billing changes.\u00a0<\/p>\n 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\u2019re in the office. Both providers get paid.<\/p>\n She\u2019s 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\u2019s implementation and the BCBA\u2019s guidance of a child\u2019s therapy plan.\u00a0<\/p>\n 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.\u00a0At Bounce, a BCBA spends about seven hours a week assessing and observing each individual child.\u00a0<\/p>\n Hanson estimates that not being able to bill for these services for Bounce\u2019s Medicaid patients, like Kingston Emilo, would result in a 20% loss of revenue.<\/p>\n \u201cMedicaid 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,\u201d she said. \u201cIt\u2019s the most vulnerable population that would get the brunt of this and with nowhere else to go, because everybody is in the same situation.\u201d\u00a0<\/p>\n However, the Department of Vermont Health Access maintains that the change isn\u2019t meant to alter service or availability for Medicaid beneficiaries.<\/p>\n McCracken, the director of communications for the department, said the way that Medicaid currently bills<\/a> for a BCBA \u201cinherently includes supervision\u201d of the behavior therapist\u2019s implementation.\u00a0<\/p>\n The way that BCBA\u2019s bill for their time with a patient should already account for that fact that it\u2019s two-on-one time \u2014\u00a0and should include the fact that the behavior therapist is with them, she said. The Medicaid billing code for a BCBA\u2019s care stipulates that it \u201cmay include simultaneous direction of technician, face-to-face with one patient.\u201d The way Medicaid sees it, separately billing for both the BCBA\u2019s care and the behavior technician\u2019s care would, essentially, be redundant, McCracken said.\u00a0<\/p>\n Providers still can bill for the behavior therapist as well as the BCBA \u2014\u00a0just not at the same time.\u00a0<\/p>\n 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.<\/p>\n \u201cWe\u2019re not actually changing any of the service availability or availability for members. It is just how the reimbursement and billing works for the provider.\u201d\u00a0<\/p>\n A leak in the house<\/p>\n But providers across the state say that reducing their specialists\u2019 ability to bill will inherently reduce access.\u00a0<\/p>\n \u201cI honestly think this is a mistake,\u201d Hanson, at Bounce, said. \u201cI don\u2019t think anybody\u2019s really understanding what it\u2019s going to look like if this happens.\u201d<\/p>\n 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 \u2014 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.<\/p>\n As their patients reach their goals and phase out of an ABA center\u2019s 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.<\/p>\n But, they intend to take the financial hit until then.<\/p>\n \u201cWe 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,\u201d Cortney Keene said.<\/p>\n The proposed changes have sent the community of ABA providers spiralling. Keene said she is working \u201cliterally all night\u201d to get the word out about these changes before the Department of Vermont Health Access\u2019s public comment period closes on Dec. 25. Providers have set up a voter voice petition<\/a> for people to write to the department. They are writing pleas to legislators and families for help. Kingston\u2019s mom, Jocelyn, has set up her own Change.org<\/a> petition.<\/p>\n \u201cOne of the biggest problems we have is that this happened in silence,\u201d 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.\u00a0<\/p>\n![\"Children](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/12\/bounce-preschool-1-20251216-1200x798.jpg\")
Photo by Glenn Russell\/VTDigger<\/p>\n![\"Children](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/12\/bounce-preschool-2-20251216-1200x798.jpg\")
Photo by Glenn Russell\/VTDigger<\/p>\n![\"Exterior](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/12\/bounce-preschool-4-20251216-1200x798.jpg\")
The Bounce ADA Preschool in Essex Junction seen on Tuesday, Dec. 16. Photo by Glenn Russell\/VTDigger<\/p>\n