by James C. Sherlock

Parents, grandparents, and other caregivers of autistic children must understand who will actually be treating the child and monitor the services so that the rules of the insurer, which are important to the child’s outcome, are followed.

Many of the Board Certified Applied Behavioral Analysts (BCABA) licensed in Virginia live in other states. Some BCABAs who live in Virginia advertise their services statewide. That means neither will be providing in-person services to many of their clients.

An additional concern is that many billing errors and some fraud identified in state Medicaid programs for autism services stem from disregard for the required provider hierarchy in patient care, both in treatment and in billing.

Medicaid will be used as an example, but private health insurers generally follow the same hierarchy of services and payment rules.   

In the case of Virginia Medicaid, to qualify for reimbursement, all service delivery must comply with:

1. The licensed clinician’s scope-of-practice guidelines; and
2. The rules of the Virginia Medicaid Applied Behavior Analysis (ABA) program.

Caregivers’ concerns should mirror those of Virginia Medicaid

Virginia Medicaid sent a letter to all ABA service providers in December 2025. That letter pointed out specific issues that needed to be addressed. Those issues are as important to caregivers as they are to Medicaid and private health insurers. They include:

1. Services provided in a clinic or office setting without documented clinical justification for the location in the Individual Service Plan (ISP) are not covered. 
2. Service authorization requests for more than 20 hours per week require significant detailed documentation and justification.
3. Only Licensed Behavioral Analysts (LBAs), Licensed Assistant Behavioral Analysts (LABAs), and Licensed Clinical Psychologists have delegation authority for non-licensed staff to deliver ABA services under their supervision. 
4. Initial assessments must be conducted in person by an LBA, LABA or LMHP in order for ABA services to be reimbursable by Medicaid.
5. Service authorization requests for ABA services provided through telemedicine require detailed documentation and justification.

Clinical hierarchy

1. Independent Practitioners (Supervisory & Delegating Authority) are at the top of the chain and are the only ones authorized to conduct initial assessments, develop Individual Service Plans (ISPs), and delegate tasks to subordinate staff.

• Licensed Behavior Analysts (LBAs): Have a Master’s degree, a Board Certified Behavior Analyst (BCBA) certification, and a license issued by the Virginia Board of Medicine. LBAs have primary clinical responsibility and can supervise Licensed Assistant Behavior Analysts (LABAs), technicians, and unlicensed staff.
• Licensed Clinical Psychologists: Have the same delegating and supervisory authority for ABA services as LBAs.

2. Mid-Level Practitioners (Supervised Practice) provide treatment under the direct supervision of an LBA or a Licensed Clinical Psychologist.

• LABAs: Have a Baccalaureate degree, a Board Certified Assistant Behavioral Analyst (BCaBA) certification, and a Virginia state license.  Provide direct services and supervise technicians under LBA oversight.
• Licensed Mental Health Professionals (LMHPs) & Trainees: Includes Licensed Professional Counselors (LPCs), Licensed Clinical Social Workers (LCSWs, and their trainees involved in clinical treatment.

3. Technician Level (Direct Implementation) provides one-on-one ABA interventions, requiring direct supervision from an LBA or authorized professional.

• Registered Behavior Technicians (RBTs): Certified technicians providing direct services under LBA supervision.
• Unlicensed Personnel: Includes unregistered technicians and trainees providing direct care.

Bottom line

For the best treatment outcomes for the child, caregivers may wish to:

• Determine the treatment rules of the child’s public or private insurer. If using private pay, specify Medicaid’s rules in a contract with the provider.
• If Medicaid is the insurer, find out the name and phone number of the Medicaid Managed Care Organization (MCO) case manager.
• Inquire who will be responsible for treating the child at each location and at each level of the hierarchy. Write down the contact information for each.
• Participate in treatment whenever possible.
• Check to see that the treatment is under the direct supervision of an independent practitioner and that the delegation rules are followed.
• Inquire only with the independent practitioner about any questions or concerns.
• File a complaint with Medicaid or their private health insurer if their rules are not followed in the child’s treatment.

Next, this series will discuss the complex subject of autism services in Virginia schools.