## Telehealth Policy Shifts and Cross-State Practice ### A. Evolving Telehealth Regulations 1. **Temporary vs. Permanent Waivers** - During the COVID-19 public health emergency, many states enacted **temporary licensure waivers** or compacts that allowed out-of-state providers to practice. Some have ended or been replaced by permanent telehealth statutes. - **Action**: Check each state’s current legislation. States like Florida, for example, have a “Telehealth Provider Registration” process for out-of-state providers; others simply reverted to pre-pandemic rules requiring full licensure. 2. **Interstate Licensure Compacts** - While there’s no universal BCBA-specific interstate compact yet, certain allied health fields (e.g., psychology with PSYPACT) have begun adopting compacts. - **Possibility**: If a BACB or state-led initiative emerges, it could streamline cross-state practice. Until then, you may need to hold multiple licenses if your target states have that requirement. 3. **Medicaid & State Boards** - If serving Medicaid clients, confirm that **state Medicaid** includes ABA telehealth coverage. Some states expanded it, others require in-person components (e.g., initial assessments). - Always check the **licensing board** or behavior analyst board in each state to confirm telepractice rules (like “must be physically located in-state” or “client must be in-state but provider can be out-of-state if licensed”). --- ### B. Payer Policies and Reimbursement 1. **Rate Parity** - Many payers adopted **parity** (equal rates for telehealth and in-person) during the pandemic; some states codified this into law, others let it expire. - **Step**: Contact major payers (e.g., commercial insurers, TRICARE, Medicaid MCOs) to confirm current telehealth rates for ABA CPT codes (97151, 97153, 97155, etc.). 2. **Prior Authorization Nuances** - Some insurers require a separate **telehealth-specific** prior authorization or place-of-service code. You might need a 95 or GT modifier, or POS code 02 (telehealth) vs. 10 (client’s home-based telehealth). - Check each payer’s manual or portal for up-to-date guidelines; they can be quite different even within the same state. 3. **Documentation Requirements** - Ensure your session notes specify **telehealth** as the service modality, along with **start/end times**, platforms used, and location of both client and therapist. - Some payers want you to note **client’s location** at each session (to confirm they are indeed located in a state where you’re licensed or enrolled). 4. **Commercial vs. Medicaid vs. TRICARE** - **Commercial**: Policies can vary widely. Some large insurers maintain strong telehealth coverage; others restrict certain CPT codes or limit hours. - **Medicaid**: State-specific. Generally slower to adopt permanent telehealth expansions, but some states have embraced it fully for ABA. - **TRICARE**: Has autism-related telehealth coverage under the Autism Care Demonstration, but you must follow Tricare East/West or overseas region rules. --- ### C. Scope of Telehealth ABA Services 1. **Assessment & Behavior Plans** - Certain payers or states require **in-person** components for the initial functional behavior assessment (FBA) to ensure accuracy. Others allow a combination of telehealth observation and parent interviews. - If you’re fully remote, double-check whether your state laws or payer contracts allow **tele-FBA** without any in-person observation. 2. **Direct Therapy** - RBTs can often deliver telehealth sessions if the payer policy and supervision framework permit it. The BCBA usually must be readily available for real-time supervision or consultation. - Some insurers limit telehealth to parent training (97156) or BCBA-led sessions (97155), disallowing direct RBT therapy via telehealth. Others are more flexible. 3. **Parent Training** - Telehealth is often well-suited for **parent coaching** and consultation (codes like 97156, 97157). Families can demonstrate techniques in the home environment while the BCBA observes and guides. 4. **Group Telehealth** - If offering group sessions (e.g., multiple families, code 97157 for multiple-family guidance), confirm the platform can handle multiple participants securely and that payer policies cover group telehealth. --- ### D. Administrative & Operational Considerations 1. **Licensure and Staff Logistics** - If multiple BCBAs serve clients in different states, each staff member might need a **state-specific license** if required. - Maintain a spreadsheet tracking **who** is licensed **where**, expiry dates, and continuing education requirements across states. 2. **Technology and HIPAA Compliance** - Use a platform that signs a **Business Associate Agreement (BAA)** for HIPAA compliance—Zoom for Healthcare, TheraPlatform, Doxy.me, or other specialized telehealth solutions. - Implement **secure logins** (preferably multi-factor authentication) and ensure staff never share personal meeting links or join from unsecured public Wi-Fi without a VPN. 3. **Documentation & Consent** - A separate **telehealth consent form** might be needed, explaining potential risks (e.g., connectivity issues), how privacy is handled, and what steps to take in an emergency. - Confirm how you’ll handle if the child has a behavioral meltdown on camera—who’s on-site to ensure safety? 4. **Scheduling & Time Zones** - If you serve families across different time zones, manage staff calendars carefully to avoid missed sessions or confusion. - Also consider how you handle **holiday** or **weekend coverage** if you expand to a broad geographic area. --- ### E. Long-Term Policy Outlook 1. **Tracking Legislative Updates** - Maintain contact with **state ABA associations** or your legal counsel who monitors telehealth legislation. - Post-pandemic, some states made telehealth expansions permanent; others might roll them back or add new restrictions. 2. **Potential Federal Initiatives** - Certain proposals advocate for **interstate licensure compacts** for allied health professionals or expansions of telehealth coverage under federal programs (like Medicare, though it rarely covers ABA). - Keep an eye on any national moves that might simplify out-of-state practice. 3. **Market Competition** - As telehealth remains an option, more **national or online-only ABA providers** may emerge, increasing competition. You might emphasize local ties or hybrid models (combining in-person and telehealth) to differentiate. 4. **Opportunity for Hybrid Models** - If in-person visits remain partially required (e.g., initial assessment), you might adopt a **hybrid approach**: in-person for the first session or major re-evaluations, then telehealth for ongoing therapy or parent coaching. --- ### Key Takeaways - **Check Each State & Payer**: No universal rule for telehealth. Regulations, coverage, and licensure demands vary significantly, so do the legwork for each region you plan to serve. - **Maintain Compliance & Licensing**: If you plan true cross-state practice, ensure every staff member is properly licensed in each state and that your telehealth technology is HIPAA-compliant. - **Billing Nuances**: Understand place-of-service codes, telehealth modifiers (95, GT), and any unique documentation payer wants for remote sessions. - **Hybrid or Fully Remote**: Some BCBAs find a hybrid approach best—certain sessions in person, certain sessions via telehealth. Others go 100% remote, but must carefully handle initial assessments. - **Adapt to Policy Changes**: Post-pandemic telehealth expansions might evolve. Stay connected with professional associations, payer bulletins, and state boards to keep up with shifting policies. By **staying vigilant** about changing telehealth regulations and **proactively adapting** your practice (licensure, billing, documentation, technology), you can safely and effectively expand services beyond traditional geographic limitations—giving clients convenient access to high-quality ABA while maintaining compliance and strong clinical outcomes.