For the first time, Colorado state agencies will have the ability to regulate autism therapy centers and require their employees to get certified.
, signed by Gov. Jared Polis last week, will create a board to license providers of applied behavior analysis, with unlicensed practice classified as a misdemeanor. The new law also allows the state to treating at least three children.
Applied behavior analysis, known as ABA, involves breaking down skills step-by-step and rewarding children for desired behaviors. Parents of children with severe autism have credited it with helping them learn to communicate and perform self-care, while autistic adults sometimes describe it as damaging to their mental health.
The ABA sector has grown rapidly in recent years, fueling concerns about whether states have enough oversight of what their Medicaid dollars are buying. A federal audit found Colorado may have paid nearly $80 million to providers without documentation to prove they provided the services — a concern auditors also raised in other states. The new law, however, doesn’t specifically address billing and documentation.
About 500 clinics operate in Colorado, with roughly 2,000 analysts and 8,000 technicians, . Analysts have a master’s degree and develop a child’s care plan, while technicians, who provide most of the hands-on therapy, didn’t have to complete specific training before the bill passed.
In a signing statement, Polis said the bill would protect children and ensure staff safety.
“This bipartisan bill is an example of how we can come together, listen and collaborate to solve difficult issues. I thank the sponsors, advocates and parents for doing the hard work to find the best path forward,” he said.
The fiscal note estimated the bill would cost between $2.3 million and $3.1 million each of the next three years, and require between 19 and 25 employees to implement.
Spending on ABA has shot up nationwide since the federal Centers for Medicare and Medicaid Services began requiring state Medicaid plans to cover it in 2014, with greater increases as private-equity firms began buying centers.
Former employees of practices bought by private equity reported pressure to spend less time developing individual plans for patients and to either see more clients or increase billable hours with each, .
In 2024, Colorado’s Medicaid program , and the state’s Department of Health Care Policy and Financing proposed lowering rates paid to providers and allowing more opportunities to look for improper payments. The legislature ultimately didn’t adopt those recommendations.
An audit by the Office of the Inspector General found Colorado may have overpaid providers by $77.8 million, and could owe the federal government $42.6 million for its share of the Medicaid payments. The inspectors took a small sample of payments and determined most were either definitely or potentially improper, mostly due to a lack of documentation. The state disputes the auditors’ methodology and said Colorado likely owes less, or perhaps nothing.
State-level audits in Nevada and Massachusetts had similar findings, as did one of payments through Tricare, which covers military members and their families. The U.S. Department of Justice also recently with paying kickbacks to parents to enroll children in autism therapy they apparently didn’t need.
The bill’s sponsors said the bill would preserve access to ethical providers, while putting controls on those focused more on profit than children’s well-being.
“Right now, the ABA landscape is uneven,” Rep. Kyle Brown, a Louisville Democrat and one of the sponsors, said during a legislative committee hearing in May.
Representatives for the Colorado Department of Human Services supported the bill, saying it would allow them to investigate complaints, which in recent years included allegations ranging from one center hiring a sex offender to serving children raw chicken and providing excessive medication.
Medicaid will have to pay for services by technicians still completing their licensure for up to 45 days. The Colorado Department of Health Care Policy and Financing, which runs the state’s Medicaid program, asked for a shorter grace period than the 60 days initially included in the bill, while ABA providers wanted at least 90 days.
“We’d like to give people time to move through the (certification) process at a reasonable pace,” said Will Martin, a board member of the . Overall, however, the provider trade association and heads of individual facilities who spoke to the legislature said they supported the bill.
A found the evidence around ABA pointed to improvement in appropriate behavior, intelligence quotient scores and language skills, but that studies were small and prone to bias, allowing for low certainty that it works. Insurance is more likely to cover it than other types of therapy, though, making it the most accessible option for families.
Traci Collins, an autism self-advocate in Colorado, said ABA itself is problematic, regardless of how well-trained the providers may be. While an autistic person’s “meltdowns” may be frightening to people around them, they’re a sign that the person needs something, such as treatment for pain or the removal of something that overstimulates them, she said.
ABA “is something that teaches what we are doesn’t matter, that we are only worthy of love or even affection when we are willing to stop doing the behaviors that are natural to us, that compliance with authority figures is our most important characteristic,” she said in an email.
