Effective February 6, 2016, applied behavioral analysis (ABA) therapy is covered for the treatment of autism spectrum disorder (ASD) for members 20 years of age and younger. ABA therapy is the design, implementation, and evaluation of environmental modification using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement, and functional analysis of the relations between environment and behavior. Coverage applies to dates of service (DOS) on or after February 6, 2016, for all IHCP programs, subject to limitations established for certain benefit packages.
ABA therapy is available to members from the time of initial diagnosis through 20 years of age when it is medically necessary for the treatment of ASD. ABA therapy services require prior authorization (PA), subject to the criteria outlined in Indiana Administrative Code 405 IAC 5-3. PA requests must include, at a minimum, the following:
Individual’s treatment plan and supporting documentation
Number of therapy hours being requested and supporting documentation
Other documentation as requested to support medical necessity
Treatment plans must include measures and progress specific to language skills, communication skills, social skills, and adaptive functioning. The individual treatment plan must be specific to the individual’s needs and include justification and supporting documentation for the number of hours requested. The number of hours must give consideration to the individual’s age, school attendance requirements, and other daily activities. The treatment plan must include a clear schedule of planned services and must substantiate that all identified interventions are consistent with ABA techniques.
Generally, ABA therapy is limited to a period of 3 years and should not exceed 40 hours per week. Services beyond these limitations may be approved with PA when the services are medically necessary.
Initial course of ABA therapy An initial course of ABA therapy is subject to PA and is covered when all the following criteria are met:
A diagnosis of ASD has been made by a qualified provider.
The individual has completed a comprehensive diagnostic evaluation performed by a qualified provider.
The individual is 20 years of age or younger.
The goals of the intervention are appropriate for the individual’s age and impairment.
Documentation is provided that describes an individual treatment plan developed by a licensed or certified behavior analyst and includes all the following:
The identified behavioral, psychological, family, and medical concerns Measurable short-term, intermediate, and long-term goals that are based on standardized assessments relative to age-expected norms and that address the behaviors and impairments for which the intervention is to be applied Note: The goals should include baseline measurements, progress to date, and an anticipated time line for achievement, based on both the initial assessment and subsequent interim assessments over the duration of the intervention.
Plans for parent/guardian training and school transition
Documentation that ABA services will be delivered by an appropriate provider licensed or certified as a behavior analyst (see Provider requirements). Providers completing the comprehensive diagnostic evaluation must use a standardized assessment tool. Additionally, the evaluation must include a recommended treatment referral for ABA therapy that specifies the projected length of treatment. ABA therapy assessments and reassessments do not require PA. PA for the initial course of therapy may be approved for up to six months. To continue providing ABA therapy beyond the initial authorized time frame, providers must submit a new PA request and receive approval. Continued courses of ABA therapy
Continuation of ABA therapy beyond the initial course is subject to PA and may be approved if all the following criteria are met:
The individual has met the criteria for an initial course of ABA.
The individual treatment plan is updated and submitted, as required.
Developmental testing was conducted no later than two months after the initial course of ABA treatment began, to establish a baseline in the areas of social skills, communications skills, language skills, and adaptive functioning.
The individual treatment plan includes age- and impairment-appropriate goals and measures of progress in social skills, communication skills, language skills, and adaptive functioning.
For each goal in the individual treatment plan, the following is documented: Progress to date
Anticipated time line for achievement of each goal based on both the initial assessment and subsequent interim assessments over the duration of the intervention
Clinically significant progress in social skills, communication skills, language skills, and adaptive functioning is documented.
Provider requirements For purposes of the initial diagnosis and comprehensive diagnostic evaluation, a qualified provider includes any of the following:
Licensed health service provider in psychology (HSPP)
Other behavioral health specialist with training and experience in the diagnosis and treatment of ASD ABA therapy services must be delivered by an appropriate provider.
For the purposes of ABA therapy, appropriate providers include:
Licensed or board-certified behavior analyst, including bachelor-level (BCaBA), master-level (BCBA), and doctoral level (BCBA-D) behavior analysts
Credentialed registered behavior technician (RBT) Services performed by a BCaBA or RBT must be under the direct supervision of a BCBA, BCBA-D, or an HSPP. Services performed by a BCBA must be under the direct supervision of a BCBA-D or HSPP.
Services do not meet the criteria for medical necessity or do not qualify as ABA therapy services, such as the following:
Services that focus solely on recreational or educational outcomes
Services that are duplicative, such as services rendered under an Individualized Educational Program (IEP)
Services performed by an RBT in the home setting or school setting
The original publication incorrectly stated “Services performed by a BCBA must be under the direct supervision of a BCBA-D or HSPP.” This sentence is incorrect. BCBAs can perform ABA therapy services independently. Further, IHCP billing requirements were clarified to indicate that ABA services rendered by a BCBA-D, BCBA, BCaBA, or RBT must be billed under the NPI of an IHCP-enrolled physician or HSPP, because behavior analysts are not currently enrolled independently. BT201605 should be disregarded
corrected bulletin can be found here: http://provider.indianamedicaid.com/ihcp/Bulletins/BT201606.pdf