Autism care providers worry that up to a thousand families might lose services under a decision by Colorado’s health department to exclude an accreditation group for behavior technicians.

The move by Department of Health Care Policy and Financing followed a new ruling that requires these professionals to be licensed in order to provide care to Medicaid patients.

According to a memo sent to pediatric behavioral therapy providers in August, all behavior technicians in the state are now required to hold national registration as a Registered Behavior Technician (RBT). The deadline for technicians to receive this accreditation was extended from April to Oct. 31 of this year, after which only providers with RBT certifications would be allowed to provide autism treatment services to children covered by the state’s Medicaid program, Health First Colorado.

Dr. Doreen Granpeesheh, CEO of the Center for Autism and Related Disorders, said behavior technicians are a critical resource for children on the autism spectrum undergoing a type of therapy known as applied behavior analysis or ABA.

Critics have argued it unnecessarily punishes harmless behaviors common among people with autism and can lead to increased anxiety, stress and depression.

Others, like Granpeesheh, argued ABA helps children on the spectrum learn essential skills and can reduce harmful behaviors. She said behavior technicians act as mentors to children going through ABA and often build close relationships with their clients as they teach them basic communication, interpersonal and life skills.

There are three national certifications available for behavior technicians: Applied Behavioral Analysis Technician or ABAT; Board Certified Autism Technician or BCAT; and Registered Behavior Technician or RBT.

Granpreeseh said her centers, which have locations around the country including several in Colorado, use BCAT for their behavior technicians.

“In my opinion, it’s a little bit stronger,” she said. “Their test is a little bit harder, and it has some additional regulations that we think provide additional safety.”

However, according to Granpeesheh, the state health department is only allowing behavior technicians in Colorado to obtain their license through the ABAT or RBT, and despite her efforts to contact them, she has not received an answer as to why, she said.

“The BCAT is equivalent or better in every possible category you can imagine, so there’s really no reason … we have no idea why it was excluded,” she said.

Granpeesheh said she reached out to Gina Robinson, the health agency’s senior policy advisor and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program administrator, throughout the month of October ahead of the deadline, but all she was told was that the agency would be providing more details soon. She said the department never did.

“We’re still kind of up in the air; we don’t know where this is going or what this is all about,” she said. “We’re basically just trying to find someone who will respond to us and tell us what’s going on. There are other organizations that are also complaining – because this is not just our organization. It affects 1,000 BCATs in the state.”

It’s estimated that about 1,000 families of children on the autism spectrum who receive Medicaid benefits could lose services if the state doesn’t accept BCAT-accredited behavior technicians. Granpeesheh said she agrees with the state’s decision to regulate the field, as many other states have done, but Colorado is the only one so far that has excluded BCAT.

Anahita Lake-Khosravi, a psychologist at Empowered Living Collective in Denver, agrees that behavior technicians should have to go through some form of standardized training, as long as it isn’t proving to be too much of a barrier:

“I do think that it makes sense for this to be how it is so that not just anybody off the street can come in and provide care for autistic individuals without having some sort of buy-in,” she said. “It’s a tough one because gatekeeping puts this barrier behind it, but ultimately we want people who are invested, who understand this world, and have knowledge of this world, to be able to work with these kids best.”

Granpeesheh said she and other ABA providers have three requests to the health department: accept the BCAT — and if the state doesn’t, it should provide a grace period for organizations to get their behavior technicians certified with one of the other forms of accreditation — and extend the compliance deadline.

If none of those things happens, Granpeesheh said her group will have to let their staff go and hire new behavior technicians who have been certified through ABAT or RBT, as it would simply be too expensive to have all of their current behavior technicians go through a new certification process.

“This is very costly,” she said. “I think about all the people who might lose their jobs. We have about 70-80 BCATs, and they would all lose their job unless they decide to go back and get another certification, and while they’re getting the certification, they can’t work.”

About two weeks after HCPF’s deadline has passed, Granpeesheh said CARD facilities are still operating as normal until they hear more.

“We’re not modifying any of our services because we don’t want to abandon any of our people, but we are worried about them,” she said. “We’re just hoping that even if they don’t clarify or approve the BCAT, they’ll give an extension.”

Many of the children who receive therapy services for autism attend facilities several hours a week, sometimes for years, and form close bonds with their behavior technicians. According to Granpeesheh, there is evidence to show that when children on the spectrum have their therapy services stopped or paused for any reason, their behavior often regresses.

“It’s not easy for children to start ABA services. That in and of itself is difficult, and they become close to their behavior techs — they learn who these people are, they learn to trust them. Imagine if a child suddenly loses his teacher, and this is a one-to-one teacher,” she said. “This is someone who’s been working with you, and that person is just gone. Even if after a month that person is replaced with someone else, that transition itself is damaging.”

Granpeeseh said she’s worried that her clients who are on Medicaid won’t have anywhere else to go if they can’t go to her center.

“These are Medicaid families where both parents are working, and where is the child gonna go if they’re not at our center?” she said. “There’s a lot of repercussions to the family. What are they gonna do? They have to go to another agency, and even if another agency has gotten all of its staff certified with the other credential, there will definitely be a gap in services for all of these children, and that’s huge.”

Lake-Khosravi also noted the impending difficulties Medicaid families will already face in the new year, including a recent decision by the state to require prior authorization for therapy for Medicaid recipients after a certain number of sessions.

“There are a lot of changes in our world happening in the new year, and with autistic kids, they’re not just struggling with autism. There’s often other diagnoses and struggles that they’re experiencing, so they need as much support as possible,” she said. “I see families who are just torn apart and broken down because of the struggles of their autistic kids.”

On its website, the Colorado Association of Behavior Analysts (COABA) also expressed worried about the state agency’s ruling, particularly about the impact it could have on staffing in a field that already has a workforce shortage.

“The statewide shortage of registered behavior technicians means most providers cannot comply with the memo without disrupting medically necessary services,” the organization said. “As a result, patient care is likely to be disrupted to detrmimental effects to vulnerable children on Medicaid.”

COABA said it is “in contact” with officials at the state health agency and the Attorney General’s Office and has sent a formal letter challenging the legality of the state’s memo under the Administrative Procedure Act, which requires agencies to publish proposed rules and allow for public comment.

The state agency did not respond to requests for comment.