From Codes to Culture: How NYS Is Quietly Eroding Early Intervention
I warned at the time that commercial carriers would never reimburse them. These codes had no standing in pediatric therapy billing. The only plausible reason for inserting them into NYEIS was to create billing pathways for non-licensed, lower-cost providers.
A few months later, I wrote again — “More Road Paving for Paraprofessional EI Services in New York State.” That post analyzed how New York was linking Early Intervention with OPWDD’s Home and Community-Based Services (HCBS) waivers. Services like Family Education & Training or Community Habilitation are commonly delivered by staff with 2- or 4-year human services degrees, not licensed therapists. I pointed out that this was no coincidence: it was the proof-of-concept for moving EI functions into unlicensed hands.
That same post also warned about structural shifts: as the state assumed more control over provider contracting (instead of counties), it gained the power to reshape the workforce. Definitions of “medical necessity” were already tightening. The direction was clear: narrow the therapy services covered, shift functions into paraprofessional domains, and leave families to sort out the fallout.
As I wrote then:
“Families will then be driven out of these State-operated systems and those who have means and resources will seek out services privately. Those who don’t have means will be stuck with what the State is able to provide.”
That was 2012.
2014: Confusion and Denial
By 2014, I revisited the issue. The Level II codes had failed. Claims were denied, confusion spread, and some local programs got slapped for overstepping their scope. What I saw wasn’t a coherent strategy but a fumbling bureaucracy. Still, the impulse remained the same: hollow out direct therapy, reduce reliance on licensed clinicians, and test whether the system could survive on cheaper labor.
2024: The Sniff and Scurry Years
In “Sniff and Scurry Navigate the Red Queen’s Race” (2024), I described how providers in private practice had been forced into a constant treadmill — new billing portals, new rules, delayed payments, systemic friction — just to stay afloat. This isn’t accidental; it’s attrition by design.
As I wrote then, “Predictably, providers are talking about leaving the system, so the State will achieve the objective of back-door cost containment by driving providers out of early intervention.”
That is exactly what has been happening.
The story of EI is not unique. In 2015, I wrote about what I saw as professional abandonment in developmental disability services more broadly. I described conversations in which subject matter experts couldn’t even agree whether OTs should be routinely involved in care plans. I told of school systems that repeatedly cut OT services, year after year, even when children failed to meet their objectives.
That piece forced me to name what was happening: when professionals are squeezed out, people with disabilities are left with nothing. Municipal programs cannot staff full therapy under tight budgets. What remains is diluted, fragmented, or non-existent support.
The same dynamic — a retreat of professional providers, rationalized by cost pressure and program inflexibility — is exactly what is now being paved in EI via codes, culture, and the Pyramid Model.
2025: Enter the Pyramid Model
Now the state is promoting the Pyramid Model — a tiered social-emotional framework sweeping early childhood nationally. The Bureau of Early Intervention itself has circulated flyers for Pyramid Model conferences, encouraging EI providers to join the “early childhood workforce” alongside teachers, childcare workers, and paraprofessionals.
This is not about billing codes anymore. It’s about culture change.
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Universal and targeted supports are assigned to teachers, aides, and paraprofessionals.
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Licensed clinicians are reserved for the narrowest slice of “intensive” cases.
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EI is rebranded as part of a broad early childhood workforce, not a professional therapy system.
It’s cleaner and shinier than the Level II experiment. But the outcome is the same: fewer kids receiving direct care from licensed therapists.
The Two-Tier System
The trajectory is plain:
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2012: Codes → Create billing space for paraprofessionals.
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2014: Confusion → Carriers reject it, but the impulse persists.
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2024: Attrition → Providers walk away, families with resources already bailing.
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2025: Culture → Pyramid Model reframes the workforce, sanctifying paraprofessional delivery.
The result is exactly what I predicted over a decade ago:
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Two tiers of care. Families with resources continue to bail into private therapy. Families without get stuck in a purposely decimated municipal system.
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Counties have no incentive to resist. EI is an unfunded mandate. Property tax caps make it politically toxic. And unless higher SALT deductions are codified, counties will continue to balk.
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This cannot be fixed. This is not a glitch; it’s a design. Back-door cost containment by attrition.
To the Enthusiasts
Some will say: “But the Pyramid Model is evidence-based! It empowers teachers! It’s scalable!”
We’ve heard this song before.
Remember RTI (Response to Intervention) in the schools? On paper, it was revolutionary: tiered supports, early identification, data-driven decision-making. In practice?
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Practitioner roles were hollowed out.
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Kids who should have qualified for individualized services were trapped in Tier 1/Tier 2 interventions that dragged on endlessly.
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Administrators praised efficiency while children lost access to direct care.
RTI was billed as innovation. It became a cost-containment tool. The Pyramid Model is headed the same way.
And cue AOTA, which will inevitably parrot the talking points. They’ll start trumpeting buzzwords like “workload” instead of “caseload.” Here’s the reality:
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Caseload = children actually get therapy.
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Workload = you coach teachers, train paraprofessionals, sit in meetings, and manage “systems” while kids get less direct care.
That language shift is not benign. It’s Kool-Aid for policymakers, and it makes it easier to justify pulling therapists out of direct intervention.
Why I Keep Sounding the Alarm
I don’t write these posts because I think anyone can reverse the trend. They can’t. Counties don’t want these programs. The state doesn’t want to fund them. Families with means will find private therapy. Families without will be left behind.
I write these posts because people inside the system deserve to understand what they are standing in the middle of.
This has been more than a decade in the making. It started with clumsy billing codes. It expanded with waiver linkages. It stumbled through failed reimbursement. It hardened into provider attrition. And now it is polished under a glossy, evidence-based banner - first RTI and now Pyramid Models.
The endgame hasn’t changed: fewer licensed providers, fewer kids with access to direct care, and a widening gap between those who can pay privately and those who can’t.
The alarms have been ringing since 2012. If you’re still in early intervention, you deserve to see clearly where this is heading.
This is all part of a broader shift in which professionals are being written out of disability and educational systems because the needs are too great and the programs are too costly. If you feel the ground shifting below you, you’re not imagining it. You’re seeing the same pattern that has played out in school programs, adult services, and developmental systems.
This is systemic retreat - it is not reform.
The only answer is provider-created direct solutions to families and a willingness to serve everyone. Start your private practice now if you want to help these people.
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