Vocational Rehabilitation Services Manual C-800: Neurodevelopmental and Psychological Services

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Introduction

Within the scope of Vocational Rehabilitation (VR), services that support individuals with neurodevelopmental or psychological disorders may be available to eligible VR customers.

Neurodevelopmental disorders are a group of conditions with onset in the developmental period, typically early in development. The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence. Neurodevelopmental disorders frequently co-occur with each other. For example, individuals with autism spectrum disorder (ASD) often have an intellectual disability, and many children with attention deficit-hyperactivity disorder (ADHD) have a learning disability, as stated by the DSM-5.

A psychological disorder refers to a spectrum of mental disorders or conditions that influence our emotions, cognitions, and/or behaviors. Psychological disabilities may include depression, anxiety, schizophrenia, and bipolar disorder.

Neurodevelopmental and psychological services may be available through VR only when:

  • comparable benefits or supports are not available; and
  • the service is necessary for the customer to reach his or her identified individualized plan for employment (IPE) goals.

For more information about requirements for using comparable benefits, refer to D-200: Purchasing Goods and Services, D-203-3: Use of Comparable Benefits.

For more information about developing the customer's IPE, refer to B-500: Individualized Plan for Employment and Post-Employment.

As part of VR, neurodevelopmental and psychological services are short-term services that focus on helping the customer achieve competitive integrated employment. When long-term treatment and supports are necessary, the customer must plan to access these ongoing supports and services independent of VR. The VR counselor may work with the customer to provide referral and information about available resources to meet these ongoing needs within the scope of counseling and guidance. For more information, refer to C-100: Counseling and Guidance.

If a counselor has determined that an exception will facilitate a customer’s progress and there is not an approval exception listed in policy, counselors are encouraged to staff the request through their chain of management to the Deputy Division Director for Field Services for consideration. VRSM clearly states when no exceptions are allowed.

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C-801: Legal Authorization

34 CFR §361.48(b)(3)

Federal law requires that, as appropriate to the VR needs of each individual, and consistent with the customer's IPE, VR must ensure that certain VR services are available to assist the individual with a disability in preparing for, securing, retaining, advancing in, or regaining an employment outcome that must be consistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.

(b) Services for individuals who have applied for or been determined eligible for vocational rehabilitation services. As appropriate to the vocational rehabilitation needs of each individual and consistent with each individual's individualized plan for employment, the designated State unit must ensure that the following vocational rehabilitation services are available to assist the individual with a disability in preparing for, securing, retaining, advancing in or regaining an employment outcome that is consistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice:

(5) In accordance with the definition in §361.5(c)(39), physical and mental restoration services, to the extent that financial support is not readily available from a source other than the designated State unit (such as through health insurance or a comparable service or benefit as defined in §361.5(c)(10))."

§34 CFR 361.5(c)(39)(i)(ii)(xiii)–(xiv)

"(39) Physical and mental restoration services mean—

(i) Corrective surgery or therapeutic treatment that is likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment;

(ii) Diagnosis of and treatment for mental or emotional disorders by qualified personnel in accordance with State licensure laws;

(xiii) Mental health services;

(xiv) Treatment of either acute or chronic medical complications and emergencies that are associated with or arise out of the provision of physical and mental restoration services, or that are inherent in the condition under treatment…"

Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. The DSM, Fifth Edition (DSM-5) is the current edition, and the content within this chapter and the associated VR Standards for Providers chapters use terminology as defined in the DSM-5 unless otherwise stated.

Behavior Analyst Certification Board (BACB®)

The Behavior Analyst Certification Board (BACB®) is a nonprofit 501(c)(3) corporation established in 1998 to meet professional credentialing needs identified by behavior analysts, governments, and customers of behavior analysis services. The BACB® adheres to international standards for boards that grant professional credentials. The BACB®'s certification procedures and content undergo regular psychometric review and validation pursuant to a job analysis survey of the profession and standards established by content experts in the discipline as defined by the BACB®.

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C-802: Autism Spectrum Disorder Supports

Autism Spectrum Disorder (ASD) is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication, and repetitive behaviors and hyper- or hypo-reactivity to sensory input as defined by the DSM-5.

ASD Supports are intended to address skills deficits that are barriers to employment for customers who have been diagnosed with ASD or who display diagnostic characteristics of ASD. These supports are the middle ground between clinical intervention and job skills training.

C-802-1: When to Consider Autism Spectrum Disorder Supports Services

Characteristics of ASD that would benefit from ASD Supports, as determined by the VR counselor, are based on the following DSM-5 clinical criteria for diagnosis:

  • Persistent deficits in social communication and social interaction across multiple contexts
  • Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
  • Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language or deficits in understanding and use of gestures, to a total lack of facial expressions and nonverbal communication
  • Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or in making friends, to absence of interest in peers
  • Restricted, repetitive patterns of behavior, interests, or activities
  • Stereotyped or repetitive motor movements, use of objects, or speech (for example, simple motor stereotypes, lining up toys or flipping objects, echolalia, and idiosyncratic phrases)
  • Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal and/or nonverbal behavior (for example, extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, and need to take the same route or eat the same food every day)
  • Highly restricted, fixated interests that are abnormal in intensity or focus (for example, strong attachment to, or preoccupation with, unusual objects, and excessively circumscribed or perseverative interest)
  • Sensory Integration Abnormalities
  • Hyper- or hypo-activity to sensory input or unusual interests in sensory aspects of the environment (for example, apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, and visual fascination with lights or movement)

Note: For a diagnosis of ASD, these symptoms must be present in the early developmental period. However, these symptoms may not fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life.

C-802-2: Autism Spectrum Disorder Supports Referrals

To be referred for ASD Supports, a VR customer must:

  • have a clinical diagnosis of ASD or social communication disorder; or
  • display diagnostic characteristics of ASD as determined by the VR counselor. 

Required Documentation When There Is Not an Autism Spectrum Disorder Diagnosis

If the VR counselor has determined that the customer displays diagnostic characteristics of ASD, and the customer has a clinical diagnosis that otherwise meets the eligibility requirements for VR services, the VR counselor must provide clear documentation that explains why the customer would benefit from short-term ASD Supports to achieve competitive integrated employment.

This case note must include:

  • the clinical diagnosis that supports the customer's eligibility for VR services;
  • a statement that the customer does not have an official diagnosis of ASD; and
  • a statement, based on the VR counselor's professional experience, that the customer requires ASD Supports to be successful in reaching a competitive integrated employment outcome.

Documentation by the VR counselor also must include examples of each of the three characteristics of ASD that the customer must display to benefit from ASD Supports without a diagnosis of ASD:

  • "Persistent deficits in social communication and social interaction across multiple contexts" (The VR counselor must document at least three examples.)
  • "Restricted, repetitive patterns of behavior, interests, or activities" (The VR counselor must document at least three examples.)
  • "Sensory Integration Abnormalities" (The VR counselor must document at least two examples.)

All customers referred for ASD Supports must display deficits in specific skills that are:

  • required for obtaining or maintaining employment;
  • a direct result of autism; and
  • outside the role of job skills training.

Customers who participate in ASD Supports are not required to participate in clinical intervention such as Applied Behavior Analysis (ABA) or psychotherapy.

C-802-3: Description of Autism Spectrum Disorder Supports

The ASD Supports service may be:

  • offered individually and/or in a group or a combination of both;
  • provided only after an IPE has been developed;
  • combined with employment services as long as it does not duplicate services;
  • provided to the customer as well as to parents, caregivers, school staff, and other pertinent people in the customer's life when successful employment is unlikely without their participation; and
  • provided in addition to other provided services, including those through special education or Section 504 of the Rehabilitation Act of 1973, as amended (for example, when the customer is in high school).

For additional information about ASD Supports, refer to the following guidance documents:

  • ASD Supports
  • ASD Supports Compared to Similar Services

C-802-4: Autism Spectrum Disorder Provider Qualifications

To be linked in ReHabWorks (RHW) as a provider of ASD Supports, the provider must be credentialed as one of the following:

  • Employment Specialist with a verified Autism Endorsement from University of North Texas Workplace Inclusion and Suitable Employment (UNTWISE)
  • Certified Special Education Teacher
  • Licensed Specialist in School Psychology (LSSP)
  • School Speech Pathologist

The ASD Supports service is not a contracted Employment Specialist Service, therefore ASD Supports is not required to be in the provider's contract. However, before starting this service, the employment specialist directly working with the customer must be individually linked in RHW through vendor services.

Before an employment specialist is linked, it must be verified that he or she holds a current Autism Endorsement through UNTWISE.

Exception

A provider can be linked in RHW upon proof of alternative qualifications approved by the State Office Program Specialist for Autism and Intellectual and Developmental Disabilities.

C-802-5: Required Autism Spectrum Disorder Support Forms

VR1879, Referral Form for Services for Neurodevelopmental Disorders

After it is determined that ASD Supports is the appropriate service, the VR counselor completes VR1879, Referral Form for Services for Neurodevelopmental Disorders Referral, and submits the completed form to the provider. The VR counselor must enter a case note into RHW confirming that the form was completed and stating when it was submitted to the provider.

VR1880, Autism Spectrum Disorder Supports Plan

After the ASD Supports referral is accepted by the provider and the initial consultation with the VR counselor has taken place, the provider completes an initial contact with the customer and completes a basic assessment of the customer's needs. The result of this needs assessment is documented in VR1880, ASD Supports Plan.

VR1880, ASD Supports Plan:

  • identifies new specific skills deficits to address;
  • includes five or fewer specific skills that are targeted in that plan; and
  • ensures that there is not a duplication of services.

The skills identified in VR1880, ASD Supports Plan, must:

  • be directly related to the diagnosis characteristics of ASD identified by the VR counselor;
  • be clearly outside of the role of job skills training;
  • make each identified skill measurable; and
  • include the recommended hours that ASD Supports services are provided individually, in a group setting, or both.

VR1880, ASD Supports Plan, must be reviewed and approved by the VR counselor before ASD Supports begin. (As part of the review, the VR counselor must ensure that the skills needs identified in VR1880 meet the required criteria in C-802-2: ASD Supports Referrals. If they do not, then ASD Supports may not be appropriate. The VR counselor consults with the State Office Program Specialist for Autism and Intellectual and Developmental Disabilities as needed.)

For information about payment requirements, refer to D-200: Purchasing Goods and Services.

When reviewing VR1880, the VR counselor ensures that the plan is reviewed and determines whether identified skills needs meet the required criteria in C-802-2: ASD Supports Referrals. Payment to the provider is issued when the ASD Supports Plan and invoice have been received and approved by the VR counselor.

Billable time for the ASD Supports Plan is not to exceed five hours and may include, but not be limited to, the following:

  • Consultation with the VR counselor
  • The initial meeting with the customer and/or guardian
  • Email or phone correspondence with related parties
  • Brief needs assessment to identify skills deficits
  • Completion of the plan

VR1881, Autism Spectrum Disorder Supports Time Log and Progress Report

VR1881, ASD Supports Time Log and Progress Report, must be completed to document each hour that is billed. The report must be submitted each time an invoice is submitted. With the information that is documented in VR1881, the VR counselor must be able to evaluate the progress that is being made and all issues that are addressed.

The ASD Supports Time Log and Progress Report must:

  • include the beginning level of the identified skill;
  • include the level that indicated that the skill has been mastered;
  • include the current level of the identified skill; and
  • not exceed more than two hours of indirect service time.

C-802-6: Autism Spectrum Disorder Supports Settings, Fees, and Allowable Hours

Autism Spectrum Disorder Supports Settings

ASD Supports may be provided individually, in a group setting, or in a combination of both. If service is provided in a group setting, a 1:6 counselor-to-customer ratio must not be exceeded.

Autism Spectrum Disorder Supports Fees

Individual service fee for direct and indirect time is $46.00 per hour.

Group service fee for:

  • direct time is $23.00 per hour per person; and
  • indirect time is $46.00 per hour.

Documentation is completed for each customer participating in a group. Therefore, indirect time is billed at the individual service fee.

For example, each participant requires:

Allowable Hours for Autism Spectrum Disorder Supports

The VR counselor may authorize up to 20 hours of ASD Supports.

Authorization of additional hours require documentation that the customer has:

  • mastered the skills identified on the current VR1880, ASD Supports Plan;
  • made measurable improvement on the skills identified on VR1880, ASD Supports Plan, but needs more time to master skills; or
  • additional needs for skills development that have been identified.

For each 20 hours authorized, VR1880, ASD Supports Plan, must be updated by the provider and submitted to the VR counselor for review and approval. The VR counselor documents whether the updated ASD Supports Plan is approved in an RHW case note and notifies the provider of the decision.

The total number of hours for ASD Supports may not exceed 120 hours over a lifetime of the case.

Exceptions to the 20-hour Limit

When necessary and clearly documented by the VR counselor, an exception can be made to the limitation of authorizing no more than 20 hours of ASD Support services at a time. For example, if a provider is conducting a summer social and vocational skills group that requires 30 hours, the VR counselor documents this as the justification for the exception in a RHW case note.

No additional review or approval is necessary for this first exception.

If more than one exception to the 20-hour limit is determined necessary for the same customer, the VR Supervisor must approve the additional hours. Approvals are limited to no more than 20 hours at a time and must be clearly documented.  

Note: At any time in the process, the VR counselor may staff the case with the regional point of contact for the Neurodevelopment Disorders team for guidance and support on the provision of services.

VR Supervisor approval is also required to purchase any of the following assessments or services more than once:

  • ABA Evaluation (Social Skills or FBA)
  • ASD Supports Plan
  • Autism Psychological Battery
  • Environmental Work Assessment (EWA)

C-802-7: Telehealth for Autism Spectrum Disorder Supports

When considering telehealth options for customers, refer to VRSM D-221: Telehealth Options.

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C-803: Applied Behavior Analysis

Applied Behavior Analysis (ABA) is the science of applying experimentally derived principles of behavior to improve socially significant behavior. ABA takes what is known about human behavior and uses it to develop and apply strategies that are intended to bring about real-world, meaningful change in the individual's behavior. In ABA, behaviors are defined in observable and measurable terms to assess behavioral changes over time. These behaviors are then analyzed within a real-world environment to identify factors that are influencing the behavior and assess how these factors and/or behaviors can be modified.

ABA is provided through three main services:

  • Pre-ABA Needs Determination
  • Social Skills
  • Challenging Behavior

ABA is provided by professionals who meet provider qualifications that are outlined in C-803-5: Applied Behavior Analysis Provider Qualifications.

C-803-1: When to Consider Applied Behavior Analysis

ABA is used to increase skills deficits and decrease behavior excesses that are an impediment to employment.

ABA is used to treat neurodevelopmental disorders such as:

  • ASD;
  • ADHD;
  • Intellectual developmental disorder;
  • Anxiety disorders; and
  • Schizoid personality disorder (characteristics displayed are very similar to ASD).

ABA is not recommended for the following:

  • Depression (without the presence of a neurodevelopmental disorder)
  • Bipolar disorder (without the presence of a neurodevelopmental disorder)
  • Schizophrenia
  • Personality disorders (except Schizoid personality disorder)
  • Sexual deviation
  • Addiction disorders (such as drugs and alcohol)

ABA can, but is not limited to:

  • decreasing maladaptive behavior;
  • increasing social and communication skills;
  • increasing self-regulation and emotional intelligence;
  • increasing problem solving and executive functioning; and
  • increasing vocational and life skills.

ABA must:

  • evaluate and treat the environment a behavior and/or a skills deficit is occurring;
  • evaluate and treat the customer, as well as pertinent individuals directly involved in the customer obtaining and maintaining employment; and
  • generalize learned skills in the employment environment.

C-803-2: Applied Behavior Analysis Referrals

A customer must meet the following two conditions to be referred to ABA:

  • Have a developmental disorder diagnosis
  • Display a maladaptive behavior and/or social skills deficit that creates a barrier to obtaining and/or maintaining employment

The VR counselor must submit VR1879, Referral Form for Services for Neurodevelopmental Disorders, to the provider to initiate services.

C-803-3: Pre-Applied Behavior Analysis Needs Determination

Pre-ABA Needs Determination is a service:

  • intended to assist a VR counselor when he or she is unsure as to which ABA service, if any, is needed; and
  • designed to triage the customer's needs and determine the appropriate service.

The provider must:

  • observe the customer in person; and
  • provide a brief written report of service recommendations.

The report must include information on, but not limited to:

  • interviews, observations, record reviews;
  • service recommendation; and
  • why, or why not, a service is recommended.

Billable time may include the following, but is not to exceed three hours:

  • Phone calls, emails, and record reviews
  • Observation of the customer and interviews with pertinent individuals
  • Writing and reviewing service recommendations with the VR counselor

C-803-4: Social Skills

Social skills are for customers who:

  • have a social skills deficit and/or display maladaptive behavior; and
  • do not have significant challenging behaviors, such as aggression.

The provider must first conduct one of the following:

  • Individual assessment
  • Group assessment (group assessment must be for the purpose of attending a social skills group); however, if the VR counselor is unsure of which social skills assessment is needed, purchasing a Pre-ABA Needs Determination is recommended

Individual Social Skills Assessment

An Individual Social Skills Assessment is intended to be a comprehensive evaluation of a customer's social skills abilities and is most appropriate when a customer has:

  • a social skills deficit that requires individualized intervention; and
  • the identified deficit is not appropriate to treat in a group setting.

This assessment is intended to provide a comprehensive evaluation of the following, but is not limited to:

  • basic and advanced social and communication skills;
  • self-regulation and emotional intelligence; and
  • problem solving and executive functioning.

The provider must:

  • observe the customer in at least two environments, such as the provider's office, the customer's home, or the community; and
  • reflect the type of environment that the suspected social skills deficit occurs in.

The report must include, but is not limited to:

  • initial reported concerns;
  • dates, times, and summary of interviews;
  • results of direct and indirect observations, assessments, and data collected;
  • current home life and future living plans;
  • employment goals and any other interests related to postsecondary options;
  • current and past education, pertinent medical conditions, medicines, and therapies;
  • identified skills deficit targeted to increase goals and mastery of criteria;
  • current baseline for targeted skills deficit;
  • any procedures, strategies, and supports needed to master identified goals;
  • method in which progress is monitored; and
  • recommended number of treatment hours and whether it is provided individually, in a group setting, or both.

Billable time must not exceed 12 hours and may include the following:

  • Activities required to complete the assessment
  • Phone calls, emails, review of records, meeting with VR counselor
  • Writing and/or reviewing report with VR counselor, customer, or pertinent others (report must be reviewed either in person or by phone unless otherwise directed by the VR counselor)

Group Social Skills

A Group Social Skills plan is a broad and brief evaluation for the purpose of attending a social skills group; however, the VR counselor must ensure that the provider has, or will have, an available social skills group appropriate for the customer before purchasing this service.

Group Social Skills is most appropriate when a customer:

  • is not in need of a comprehensive social skills assessment; and/or
  • has demonstrated that he or she is able to acquire skills in a group environment and not require more than a 1:6 VR counselor to customer instructional setting.

The plan is intended to be a brief evaluation of, but is not limited to, the following:

  • Basic and advanced social and communication skills
  • Self-regulation and emotional intelligence
  • Problem solving and executive functioning

The provider must create a social skills plan for each customer participating in the social skills group.

The plan must include brief information on, but not limited to, the following:

  • Interviews and informal assessments and their results
  • How progress is monitored and frequency of progress reported
  • Recommended number of treatment hours
  • Treatment goals and proposed mastery of criteria

Billable time is paid at the level of the provider's individual rate, and time spent may include the following, but is not to exceed three hours:

  • Activities required to complete the assessment
  • Phone calls, emails, review of records, meeting with VR counselor
  • Writing and reviewing the plan

C-803-5: Challenging Behavior Services

Challenging Behavior services are for customers:

  • who have significant, persistent maladaptive behaviors that occur in more than one environment; and
  • for whom the cause of a maladaptive behavior is unknown.

A provider must first conduct a behavior assessment that is an in-depth evaluation of problem behavior; however, if a VR counselor is unsure if a behavior assessment is needed, purchasing a Pre-ABA Needs Determination is recommended.

Functional Behavior Assessment

A Functional Behavior Assessment (FBA) is intended to be a detailed, thorough evaluation of why a problem behavior is occurring.

The provider must:

  • observe the customer in at least two environments, such as in the provider's office, the customer's home, or the community; and
  • reflect the type of environment that the suspected challenging behavior occurs in.

The FBA section of the report must include the following details, but is not limited to:

  • initial reported behavior concerns;
  • targeted behaviors for assessment;
  • dates, times, and summary of interviews;
  • results of direct and indirect observations, assessments, and data collected;
  • current home life and future living plans;
  • employment goal and any other interests related to postsecondary options;
  • current and past education, pertinent medical conditions, medicines, and therapies;
  • preference assessments;
  • setting events;
  • precursors;
  • proposed function of behavior; and
  • findings and recommendations.

The results of the FBA section may conclude that treatment is not necessary or that treatment can be provided by another professional (such as an Employment Specialist with the Autism Endorsement). If this occurs, completion of the Behavior Intervention Plan (BIP) section is unnecessary. The provider must only submit the FBA section and bill for hours used to complete it.

Behavior Intervention Plan

A Behavior Intervention Plan (BIP) uses the findings of the Functional Behavior Assessment (FBA) to create a treatment plan.

The BIP section of the report must include, but is not limited to, the following:

  • Identified challenging behavior targeted for reduction
  • Replacement behavior goal and mastery of criteria for each challenging behavior
  • Identified skills deficit targeted to increase goals and mastery of criteria
  • Current baseline for targeted challenging behavior and/or skills deficit
  • Any procedures, strategies, supports needed to master identified goals
  • Method in which progress is monitored
  • Recommended number of treatment hours and whether treatment is provided individually, in a group setting, or both

Billable time may include the following, but is not to exceed 15 hours:

  • Activities required that result in the recommended components of the FBA report and/or BIP report
  • Phone calls, emails, review of records, meeting with the VR counselor
  • Writing and/or reviewing the report with the VR counselor, customer, or pertinent others (report must be reviewed either in person or by phone, unless otherwise directed by the VR counselor)

Intervention

After an assessment is submitted and approved by the VR counselor, intervention:

  • may be provided individually, in a group setting (the ratio between facilitators and customers cannot be greater than one therapist to six customers), or both; and
  • ordinarily does not to exceed 60 intervention hours over the lifetime of the case,

If more than 60 intervention hours over the lifetime of the case are required, the VR counselor must:

  • consult with the state office neurodevelopmental specialist; and
  • document the justification in an RHW case note

Hours that are completed for a Pre-ABA Needs Determination or an assessment are not included in the 60-hour limit.

Billable direct hours may include direct intervention that is provided either individually, in a group setting, or both, but are not to exceed 60 hours.

Billable indirect hours may include the following, but are not to exceed three hours per month:

  • Meetings, phone calls, and emails exchanged with the VR counselor
  • Collecting and graphing data and writing progress reports
  • Group indirect hours paid at the level of provider's individual rate (indirect hours are for an individual in a group, for example, a record review, graphing data, or writing a progress report)

C-803-6: Applied Behavior Analysis Provider Qualifications

There are five levels of approved providers that can provide ABA services to VR customers.

Levels of Providers:

  • Board Certified Behavior Analyst (BCBA-D®)—doctorate level
  • Board Certified Behavior Analyst (BCBA®)—master's level
  • Board Certified Assistant Behavior Analyst (BCaBA®)—bachelor's level
  • Registered Behavior Technician (RBTTM)
  • Graduate student in behavior analysis program

The following services are completed by a BCBA-D® and BCBA®:

  • Pre-ABA Determination
  • Assessment
  • Intervention

Board Certified Assistant Behavior Analyst, Registered Behavior Technician, and Graduate Student Requirements

BCaBA®s, RBTtms, and graduate students must be supervised by a BCBA® and are only permitted to provide individual or group intervention services.

Before providing this service:

  • this level of provider must identify the supervisor; and
  • the identified supervisor is required to complete all actions under "Special Requirements for Supervisor."

Additional Graduate Student Requirements

Before being linked to provide services, a graduate student must:

  • submit a transcript showing proof of enrollment in a graduate-level behavior analysis program at an accredited university set forth by BCBA® or enrolled in a graduate program that contains the acceptable graduate coursework in behavior analysis set forth by BCBA®;
  • if the graduate program is completed, be actively engaged in his or her supervised fieldwork hours required for board certification and/or have met all requirements that qualify him or her to sit for the board exam;
  • continue supervision until board certified if he or she does not pass the board exam or does not take the board exam; and
  • in all scenarios, identify his or her supervising BCBA®.

Additional Requirements for a Supervisor of a Board-Certified Assistant Behavior Analyst, Registered Behavior Technician, or Graduate Student

The identified supervisor must be a BCBA® or BCBA-D® and meet the following conditions:

  • Become a VR provider (see D-200: Purchasing Goods and Services)
  • Hold a current board certification
  • Meet the 2015 BACB® standards for supervision
  • Meet the standards for conducting supervision set forth by BACB®
  • Sign all progress reports verifying that the content of the progress reports are complete and valid
  • Intervention provided met supervision requirements set forth by BACB®

Billing Supervision of Applied Behavior Analysis Providers

Supervision of professionals who are providing ABA is a billable service, but only while conducting intervention hours (not for Pre-ABA determination or an assessment).

Supervisors may bill up to three hours a month per customer and are paid at their level of provider rate per the service they are supervising. For example, if provider supervises a customer in a group intervention, provider will be paid at their group level of provider rate.

C-803-7: Required Provider Documentation

To receive payment for ABA assessment services, the provider completes an assessment report that must be submitted and approved by the VR counselor prior to payment.

To receive payment for ongoing ABA intervention, the provider must submit a progress report at least once a month that is approved by the VR counselor.

To receive payment for supervision of ABA providers, the supervisor must submit a brief summary report that includes the following information:

  • Dates and times that supervision took place
  • Total hours of supervision that reflect the required five percent set forth by BACB®
  • Type of supervision conducted (type must meet the standards set forth by BACB®)

C-803-8: Applied Behavior Analysis Fees

Fees for all ABA services are as follows:

Level of Provider

Pre-Needs Determination and Assessments

Individual Intervention

Group Intervention

Level 1: BCBA-D

$125.00 per hour

$125.00 per hour

$45.00 per hour

Level 2: BCBA

$79.53 per hour

$79.53 per hour

$33.00 per hour

Level 3: BCaBA

N/A

$37.50 per hour

$18.75 per hour

Level 4: RBT

N/A

$37.50 per hour

$18.75 per hour

Level 5: Graduate Student

N/A

$37.50 per hour

$18.75 per hour

Note: If a BCBA® and a BCBA-D® conduct an assessment or provide intervention, the provider must bill at the BCBA® provider rate.

When completing reports and submitting billing, the following descriptions must be used as defined:

  • Direct Hours are time spent in person with the customer or actively training a pertinent individual who has direct involvement with the customer for obtaining and maintaining employment.
  • Direct Observation of a behavior in the naturally occurring environment and the conditions that occur. Measurement tools such as a scatterplot or ABC chart may be used.
  • Indirect Hours are time spent providing services other than in-person support, such as meetings with the VR counselor, phone calls, emails, collecting and graphing data, and writing progress reports.
  • Indirect Observation may include, but not be limited to, interviews with customers or pertinent individuals in their life, informal assessments, or questionnaires.

VR Supervisor approval is required to purchase any of the following assessments or services more than once:

  • any neurodevelopmental or psychological assessment
  • ABA Evaluation (Social Skills or FBA)
  • ASD Supports Plan
  • Autism Psychological Battery
  • Environmental Work Assessment (EWA)

C-803-9: Telehealth for Applied Behavior Analysis

When considering telehealth options for customers, refer to VRSM D-221: Telehealth Options.

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C-804: Psychological Services

Psychological Services are services provided to eligible individuals who have clinically diagnosed psychiatric conditions that are defined within the DSM-5.

Psychological Services are provided only:

  • when comparable benefits, such as community centers or indigent care services, are not available;
  • when prescribed by a licensed psychologist or psychiatrist;
  • when clinically necessary to achieve a planned employment outcome; and
  • to individuals whose psychological disorders:
    • are stable or slowly progressive; and
    • can be corrected or stabilized within a reasonable time.

Individuals must continue to meet the eligibility criteria for specific conditions, as defined in B-300: Determining Eligibility, to continue to receive Psychological Services that are purchased with VR funds.

For information on the Comprehensive Vocational Evaluation System (CVES), refer to B-403-3: Comprehensive Vocational Evaluation System.

C-804-1: Psychological Services Provider Qualifications

Psychological Services may be purchased from:

  • physicians skilled in the diagnosis and treatment of mental or emotional disorders licensed by the Texas Medical Board;
  • psychologists licensed by the Texas State Board of Examiners of Psychologists;
  • clinical social workers who are licensed by the Texas State Board of Social Worker Examiners;
  • professionals who are licensed by the Texas State Board of Examiners of Professional Counselors;
  • psychiatric–mental health clinical nurse specialists and psychiatric–mental health nurse practitioners licensed by the Texas Board of Nursing;
  • physician assistants licensed by the Texas Physician Assistant Board; or
  • marriage and family therapists (LMFTs) who are licensed by the Texas State Board of Examiners of Marriage and Family Therapists.

Psychological Services may be provided by an intern who is working under the supervision of a licensed provider. When provided by an intern, Psychological Services are paid at the payment rate for the provider that is supervising the intern. Additional payments are not permitted for the time spent providing the supervision.

C-804-2: Psychological Services Limits

Psychological Services are limited to the purchase of psychotherapy and outpatient psychiatric treatment. VR does not pay for inpatient psychiatric treatment. No exceptions to this policy are allowed. VR customers who need this level of treatment must be referred to the local mental health authority.

Outpatient sessions with qualified providers are limited to:

  • a maximum of 15 individual sessions;
  • a maximum 30 group sessions; or
  • some combination of the two.

Exceptions require VR Supervisor approval.

Visits to a psychiatrist for medication monitoring only are not subject to these limitations but are subject to limitations on outpatient treatment. For further information, see C-700: Medical Services.

Requests for psychological or neuropsychological tests not listed in the Maximum Affordable Payment Schedule (MAPS) require consultation with the Regional Psychological Consultant (RPC).

Actions that are contrary to the advice of the RPC require VR Manager approval.

Evaluation or treatment of customers by the RPC requires approval by the VR Supervisor.

For policies, procedures, and restrictions that apply to the purchase of prescription medications, refer to C-703-24: Prescription Drugs and Medical Supplies.

C-804-3: No-Show Payments

A "no-show" is defined as a customer who fails to appear for a scheduled appointment without giving prior notice of cancellation to the provider. When a VR customer is a no-show for a scheduled appointment with a psychiatrist, social worker, licensed professional counselor, or psychologist for a service under VR sponsorship, the provider may claim a service fee equal to 50 percent of the usual and customary fee, or the allowable MAPS fee, whichever is less. For additional information about paying for no-show service, refer to D-204-5: No-Show Payments.

The VR counselor must contact customers who are no-shows for a scheduled appointment with a psychiatrist, social worker, licensed professional counselor, or psychologist to discuss the missed appointment and the importance of keeping future appointments. The VR counselor must document this contact as a counseling and guidance case note in RHW.

C-804-4: Psychological Consultants

Regional psychological consultant’s responsibilities include:

  • Provide updates on DSM-5 diagnoses and new treatment modalities for behavioral health conditions within the region when requested by the State Office Program Specialist for Veterans and Behavioral Health.
  • Provide technical assistance to peer psychologist within their assigned region.

For additional duties and responsibilities please see VRSM B-101-7: Consultants.

C-804-5: Telehealth for Psychological Services

When considering telehealth options for customers, refer to VRSM D-221: Telehealth Options.

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C-805: Wellness Recovery Action Plan Program

The Wellness Recovery Action Plan (WRAP) program is a specialized program for adults with severe mental illness. Participants learn strategies to monitor, reduce, or eliminate uncomfortable or dangerous physical symptoms, emotions, and feelings. The program's primary goal is to help customers identify and learn to use wellness tools (coping strategies and resources) when they experience triggers or early warning signs that their mental health is worsening.

C-805-1: Wellness Recovery Action Plan

A participant in Wellness Recover Action Plan (WRAP) services writes his or her own WRAP, or comprehensive plan, to help manage his or her own illness.

C-805-2: Wellness Recovery Action Plan Service Delivery

WRAP services can be delivered either individually or in a group setting. In group settings, the ratio between WRAP facilitators and customers cannot be greater than one WRAP facilitator to eight customers. WRAP services can be provided remotely when the VR counselor has indicated approval of remote service delivery on the VR3380, Wellness Recovery Action Plan (WRAP) Referral. Refer to the VR Standards for Providers (VR-SFP) 3.6.4.1 Remote Service Delivery.

WRAP facilitators who work with customers must follow the Copeland Center's values and ethics, processes, and concepts. Facilitators must use the evidence-based model recognized by the Substance Abuse and Mental Health Services Administration. Facilitators follow the WRAP Facilitator's Training Manual and use the PowerPoint presentation slides and CD found in the training manual during presentations. The three-day WRAP curriculum may be approved in consultation with the VR counselor.

C-805-3: Wellness Recovery Action Plan Referrals

A customer who can benefit most from a WRAP learns how to use wellness tools to manage his or her disability.

This is a customer who:

  • is in recovery or has difficulty staying in recovery;
  • has a severe mental illness;
  • has a goal of competitive integrated employment; and
  • needs help to identify wellness tools.

The customer learns how to use wellness tools to move forward in recovery by developing natural supports, coping skills, and self-management skills.

For information on appropriate WRAP referrals, see VR-SFP Chapter 12: Wellness Recovery Action Plan, 12.1 Wellness Recovery Action Plan Service.

C-805-4: Wellness Recovery Action Plan Facilitator Qualifications

Refer to VR-SFP Chapter 12: Wellness Recovery Action Plan, 12.2 Staff Qualifications .

C-805-5: Wellness Recovery Action Plan Outcome

The WRAP outcome is achieved when the customer has:

  • attended and actively participated in all sessions of curriculum-mandated WRAP program; and
  • completed his or her individual WRAP.

For more information see VR-SFP Chapter 12: Wellness Recovery Action Plan, 12.3.3 Outcomes Required for Payment.

C-805-6: Wellness Recovery Action Plan Fee

The fee for successful achievement of the WRAP outcome can be paid only one time per customer for the life of the case. See VR-SFP Chapter 12: Wellness Recovery Action Plan, 12.3.3 Outcomes Required for Payment.

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C-806: Substance Use Disorders Services

Substance use disorders are defined in the DSM-5 as a pathological pattern of behaviors related to the use of a substance or substances.

Substance Use Disorders Services refers to services that are provided for individuals who are eligible for VR services and who have been clinically diagnosed with a substance use disorder that is defined in the DSM-5. Substance use disorders that are specific to the use of caffeine or tobacco do not meet the criteria of creating a substantial impediment to employment for the purpose of eligibility for VR services.

Substance Use Disorders Services are provided only:

  • when comparable benefits, such as services provided by community centers or indigent care organizations, are not available;
  • when prescribed by a licensed psychologist or psychiatrist;
  • when clinically necessary to achieve a planned employment outcome; and
  • to individuals whose psychological disorders:
    • are stable or slowly progressive; and
    • can be corrected or stabilized within a reasonable time.

C-806-1: Substance Use Disorders and Eligibility for VR Services

VR counselors assess customers to ensure that each customer has a basic understanding of substance use and abuse. VR counselors discuss any history of substance use and decide how to proceed with each case based on that history. To be eligible for VR services, customers with substance use disorders must produce proof that demonstrates regular participation in a treatment program or express a willingness to participate in therapeutic treatment. The customer must be participating in treatment if he or she is actively using substances.

Treatment options for substance use disorders that may be available through the customer's community include, but are not limited to, the following:

  • Inpatient or outpatient services
  • Intensive outpatient programs
  • Partial hospitalization programs
  • Therapy and counseling
  • Continuing care programs
  • Alcoholics Anonymous (AA)
  • Narcotics Anonymous (NA)
  • Church sobriety programs
  • Community center sobriety programs

There is usually no cost associated with outpatient services provided by AA, NA, or church and community center sobriety programs.

The customer must make the decision to discontinue using substances and choose the method of recovery. If a customer with a substance use disorder applies for VR services and is not currently in treatment, the VR counselor assists the customer in finding treatment options in his or her community and allows the customer to make the choice to engage in treatment. The VR counselor may use random drug testing to verify that the customer is abstaining from drug use.

A customer who has previously participated in treatment and has been substance free without aftercare or support services is generally not considered to have a substantial impediment to employment. If the VR counselor determines that a substantial impediment to employment exists (such as frequent loss of employment due to substance use), the VR counselor must document how and why the customer has not been able to make satisfactory progress to obtain or retain employment due to substance use.

Eligibility for VR Services

Customers with conditions diagnosed or related to a substance use disorder must be participating in, be willing to participate in, or have successfully completed an inpatient or outpatient substance use disorder treatment program before receiving VR services connected with an individualized plan for employment (IPE). The VR counselor must verify the treatment.

VR counselors decide whether continuation of therapeutic treatment is adequate as a support or if new or additional interventions are needed. Below are some issues for the VR counselor to consider when working with a customer diagnosed with a substance use disorder.

The customer must:

  • recognize that a substance use disorder is a disability and participate in a group treatment program or individual counseling; under medical supervision if appropriate;
  • maintain consistent and regular attendance, and demonstrate progress in completing his or her treatment program;
  • demonstrate a commitment to recovery, as evidenced by making progress in completing their treatment program;
  • make satisfactory progress toward addressing issues related to his or her overall functioning by advancing in various stages of treatment;
  • acknowledge that he or she is seeking VR services for assistance with employment and is committed to and demonstrates the actions to maintain sobriety; and
  • be available to participate in the VR process for the purpose of acquiring or maintaining employment.

VR counselors must move a case forward if the customer is making progress in his or her recovery and demonstrates an ability to participate in VR services.

For additional information about eligibility criteria for specific conditions, refer to B-300: Determining Eligibility.

Counseling and Guidance

Early in the case, the VR counselor schedules regular contacts with the customer to provide guidance, including ongoing recovery and aftercare activities to prepare for engaging in employment. The VR counselor makes a schedule for verifying sobriety and customer participation in treatment. When considering the needs of the customer, the VR counselor must remain flexible regarding a customer's abstinence before the initiation of VR services.

A period of VR counseling and guidance under the IPE may be initiated to resolve disability adjustment issues and plan or refine services and strategies that support recovery and lead to employment. Documentation of counseling and guidance progress is required every 180 days at a minimum.

In comorbid cases when substance use disorders co-occur with serious and persistent mental illness, the VR counselor must address all diagnoses simultaneously.

Relapse

VR counselors must understand that relapse is considered a natural symptom of the disease; therefore, it is incumbent upon the VR counselor to remain actively engaged with the customer to assist with recovery if a relapse occurs.

Temporary episodic setbacks or relapses are evaluated on an individual basis in terms of the continuing rehabilitation plan. If the VR counselor determines that the customer has relapsed due to substance use after eligibility is determined, the VR counselor helps the customer reengage with his or her treatment or aftercare program.

Triggers are external events that cause an intense and emotional reaction. The VR counselor must help the customer identify triggers and develop strategies to help the customer succeed with his or her current IPE. Triggers are identified by asking questions about situations or events that led up to the customer's most recent relapse episode.

In the event of a relapse through counseling and guidance, the VR counselor:

  • ensures that the customer contacts his or her sponsor, if applicable (most programs have an accountable individual working with the customer);
  • helps the customer identify triggers (such as family, environment, and life situations) that cause relapse; and
  • helps the customer create a plan that identifies what the customer will do when triggers occur.

For detailed information about working with individuals with substance use disorders, refer to the Counselor Desk Reference (CDR) Chapter B14: Substance-Related and Addictive Disorders .

C-806-2: Substance Use Disorders Services and Limits

VR may provide Substance Use Disorders Services, including, but not limited to, the following:

Detoxification

Detoxification (detox) is a process used to assist the recovering individual through the acute effects of the substance he or she was using. This usually consists of hospitalization, medication, and nutritional assistance.

VR does not pay for detoxification services.

Methadone Treatment

Methadone treatment uses daily doses of methadone to replace the drug in order to prevent withdrawal symptoms and relapse. This is usually performed at medically supervised clinics. Methadone treatment does not include AA or NA practices.

VR does not pay for methadone treatment or related services.

C-806-3: Documentation of Sobriety

VR counselors must look at a case in its entirety and assess documentation that supports a customer’s progress and his or her evidence of commitment to recovery. The VR counselor must regularly evaluate the customer's case to assess whether an individual needs additional supports to be successful with his or her IPE.

Treatment or Supports to Maintain Sobriety

One of the following must be verifiable and provided by the customer to the VR counselor to ensure that the customer is actively participating in treatment and/or receiving support to maintain sobriety:

  • AA and/or NA logs and a supporting letter from the customer's AA or NA sponsor
  • Records from licensed treatment sources
  • Information from a probation or parole officer
  • Drug test results from testing performed within 30 days

When a customer participates in a treatment or support program that is not provided by VR Substance Use Disorders Services, the VR counselor may consult with the State Office Program Specialist for Veterans and Behavioral Health to ensure that documentation exists to show that the customer continues to make progress toward sobriety and employment.

The VR counselor may request that the customer submit to a clinical drug test if sobriety is unable to be documented.

VR counselors may use urine and blood screenings to verify a customer's sobriety and eligibility for VR services. VR does not pay for hair follicle drug screenings.

VR counselors must be aware of the psychological, behavioral, and physical signs of drug use. Signs that would warrant a drug screening include, but are not limited to:

  • Psychological signs
    • Unexplained changes in personality or attitude
    • Sudden mood changes, irritability, anger outbursts, or inappropriate laughing
    • Paranoia
  • Behavioral Signs
    • Poor attendance at or chronic tardiness for work
    • Decline in performance/productivity
    • Acting isolated, withdrawn, or secretive
  • Physical signs
    • Dilated pupils or bloodshot eyes
    • Tremors
    • Fidgeting/inability to sit still
    • Drastic change in appearance, such as inappropriate clothing and grooming

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C-807: Dual Diagnosis

The term "dual diagnosis" is often used interchangeably with the terms comorbidity, co-occurring illnesses, concurrent disorders, comorbid disorders, co-occurring disorder, or dual disorder. It is used to describe the condition of an individual who is diagnosed with both a psychological disorder and a substance use disorder.

C-807-1: Treatment for Dual Diagnosis

When an individual has been clinically diagnosed with dual diagnosis, effective treatment involves addressing both the substance use disorder and the psychological disorder. Treatment that only one condition or the other (rather than both) has been found to be less effective than integrated treatment of both types of disorders at the same time in the same setting. Therefore, integrated treatment is suggested to improve outcomes for both disorders, which should also lead to the chances of a better employment outcome for individuals with comorbid disorders.

The Substance Abuse and Mental Health Services Administration (SAMHSA) identifies the following evidence-based practices for treating individuals with co-occurring disorders. More information about these practices can be found on the SAMHSA website.

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C-808: Supportive Residential Services

The goal of Supportive Residential Services (sometime referred to as halfway house services) is to assist customers who are in recovery to maintain stability, control, and abstinence from use of substances so they can gain competitive integrated employment. This contracted service is intended to provide a supervised, stable living environment, with additional supports to assist the customer in pursuit of a successful competitive integrated employment outcome in a timely manner.  See VR Standards for Providers (VR-SFP) Chapter 11: Supportive Residential Services for Persons in Recovery for additional details and provider specifications.

If an individual is currently in a Supportive Residential Service facility and is seeking services from VR, they must fully comply with the facilities policies and procedures. The customer also must meet, and continue to meet, the substance use disorder eligibility requirements for VR. For more information, refer to C-806-1: Substance Use Disorder and Eligibility for VR Services.

C-808-1: Substance Classifications

VR only supports customers with substance use related to the following classifications:

  • Alcohol—Usually composed of ethanol or ethyl liquid that when ingested acts as a psychoactive drug that acts as a depressant on the central nervous system (Caron 2016)
  • Cannabis—Dried flowering tops of cannabis stavia plant. Smoked or ingested to induce psychotomimetic effects to the central nervous system, usually goes under the name "marijuana"
  • Hallucinogens—Plant or synthetic compounds capable of causing functional disturbances in the form of psychoses, mainly hallucinations
  • Inhalants—Chemical vapors that are inhaled for delusional effects on the central nervous system
  • Phencyclidine—Intravenous antiseptic that causes delusions and hallucinations, usually goes under the name "PCP" or "angel dust"
  • Opioids—A pain-attenuating peptide, synthetic or natural, that triggers the brain to release analgesia
  • Sedatives—Usually a combination of drugs used to calm or relax patients
  • Stimulants—A drug or other substance used to accelerate or excite the central nervous system 

Drug classifications that do not qualify for rehabilitation services:

  • Caffeine—A stimulant made of a crystalline compound that affects the central nervous system (Farlex)
  • Tobacco—Prepared leaves of certain plants; some having narcotic properties, used for chewing, smoking, or sniffing 

Note: Supportive Residential Services are NOT intended to serve as a medical detox. For additional information regarding VR-sponsored medical services, refer to C-700: Medical Services.

C-808-2: Description of Supportive Residential Services

Supportive Residential Services may include the following:

  • Personal social adjustment training—can assist with changing behaviors that have led to relapse and can reinforce participation in recovery treatment
  • Room, board, and supervised living—allows the individual recently in recovery to have a supervised environment in which to maintain sobriety while also saving money earned on a job to obtain a new residence
  • Coping skills—help the individual in recovery learn to deal with work and social difficulties without drugs or alcohol
  • Connecting with local resources—helps the individual become connected with medical and treatment programs to enable continued stability after leaving the halfway house and after VR services are completed
  • Seeking employment—can assist the individual in recovery by providing:
    • job leads;
    • job seeking skills training;
    • job-interviewing skills training;
    • résumé development; and
    • job placement services.

C-808-3: Supportive Residential Service Referrals

Refer to VR-SFP Chapter 11: Supportive Residential Services for Persons in Recovery, 11.4.2 Process and Procedure for more information about required processes and procedures to refer an eligible VR customer to Supportive Residential Services.

C-808-4: Supportive Residential Services Limits

VR does not sponsor Supportive Residential Services until:

  • after the customer has been determined eligible for VR services; and
  • the service is included on the customer's IPE or IPE amendment.

VR may purchase up to 90 days of residential treatment, in 30-day increments, when the customer demonstrates progress toward established goals and objectives as outlined in the treatment plan and VR3384, Supportive Residential Services Progress Report.

The customer must participate in a recovery program, abide by residential rules, and be actively working toward mastering work-readiness skills or obtaining competitive integrated employment for additional time to be approved. 

If there is a need for VR-sponsored residential services for more than 90 days:

  1. the VR Supervisor's review and approval is required in 30-day increments for continued sponsorship to ensure that the customer is continuing to make measurable, predefined progress toward established goals and objectives; and
  2. VR3472, Contracted Service Modification Request must be submitted and approved prior to services being authorized.

For additional information, see D-210-4: Completing VR3472, Contracted Service Modification Request.

C-808-5: Standards for Supportive Residential Services

For more information about specific standards for providers of Supportive Residential Services, including staff qualifications, facility requirements, program requirements, and fees, refer to VR-SFP Chapter 11: Supportive Residential Services for Persons in Recovery.

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Last Verified: July 14, 2022

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