016.05.24 Ark. Code R. 004 - Autism Services for Children on Medicaid

SECTION II - APPLIED BEHAVIOR ANALYSIS THERAPY CONTENTS

200.000 APPLIED BEHAVIOR ANALYSIS THERAPY GENERAL INFORMATION

201.000 Arkansas Medicaid Participation Requirements for Applied Behavior Analysis Therapy Providers

201.100 Individual Service Provider Participation Requirements

Individual providers of applied behavior analysis (ABA) therapy services must meet the following requirements to be eligible to participate in Arkansas Medicaid:

A. Complete the provider participation and enrollment requirements contained within section 140.000 of this Arkansas Medicaid manual and enroll as an Arkansas Medicaid provider;

B. Successfully pass the background checks and searches required by Ark. Code Ann. § 20-48-812(c) (1-4); and

C. Meet the credentialing, experience, training, and other qualification requirements for the ABA therapy service under section 202.000 of this Arkansas Medicaid manual.

201.200 Group Service Provider Participation Requirements

A. Group providers of applied behavior analysis (ABA) therapy services must meet the following requirements to be eligible to participate in Arkansas Medicaid:

1. Complete the provider participation and enrollment requirements contained within section 140.000 of this Arkansas Medicaid manual; and

2. Each individual performing ABA therapy services on behalf of the group must complete the individual provider participation and enrollment requirements under section 201.100 of this Arkansas Medicaid manual.

B. A group provider of ABA therapy services must identify the certified practitioner as the performing provider on the claim when billing Arkansas Medicaid for the service.

201.300 Providers in Arkansas and Bordering States

Providers with a principal place of business in Arkansas and within fifty (50) miles of the state line in the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas) may enroll as applied behavior analysis therapy providers if they meet all Arkansas Medicaid participation requirements of this Arkansas Medicaid manual.

201.400 Providers in States Not Bordering Arkansas

Providers with a principal place of business fifty (50) or more miles from the Arkansas state line or in states not bordering Arkansas may enroll as a limited Arkansas Medicaid service provider to serve an Arkansas Medicaid eligible beneficiary by entering into a single case agreement. A provider must enter into a separate single case agreement for each Arkansas Medicaid eligible beneficiary served. A provider will retain their limited service provider status for up to one (1) year after the most recent billed date of service. View or print the provider enrollment and contract package.

202.000 APPLIED BEHAVIOR ANALYSIS THERAPY PROVIDER REQUIREMENTS

202.100 Board-Certified Behavior Analyst (BCBA) Participation Requirements

A board-certified behavior analyst (BCBA) must have board-certified behavior analyst (or more advanced) certification in good-standing from the Behavior Analyst Certification Board.

202.200 Board-Certified Assistant Behavior Analyst (BCaBA) Participation Requirements

A board-certified assistant behavior analyst (BCaBA) must have board-certified assistant behavior analyst certification in good-standing from the Behavior Analyst Certification Board.

202.300 Registered Behavior Technician (RBT) Participation Requirements

A. A registered behavior technician (RBT) must have registered behavior technician certification in good-standing from the Behavior Analyst Certification Board.

B. An individual in the process of completing the training and testing required to receive RBT certification may be provisionally treated as an RBT for purposes of this Arkansas Medicaid manual for up to six (6) months. If the individual has not received RBT certification within six (6) months, then they are prohibited from providing applied behavior analysis therapy services until RBT certification is obtained.

203.000 Documentation Requirements

203.100 Documentation Requirements for all Medicaid Providers

See section 140.000 of this Arkansas Medicaid manual for the documentation that is required for all Arkansas Medicaid providers.

203.200 Applied Behavior Analysis Therapy Service Documentation Requirements

A. Applied behavior analysis (ABA) therapy providers must maintain in each beneficiary's service record:

1. The beneficiary's:

a. Face sheet with the beneficiary's:

i. Full name, address, age, and date of birth;

ii. Parent/guardian name(s) and contact information;

iii. Assigned primary care provider;

iv. Medicaid number; and

v. Any diagnoses, allergies, and medications prescribed;

b. Autism spectrum disorder diagnosis;

c. Applicable medical records;

d. Evaluation Referral;

e. Comprehensive evaluation report(s), and any related testing results and correspondence;

f. Treatment prescription(s); and

g. Individualized treatment plan (ITP), and any required documentation in connection with each update to a beneficiary's ITP;

2. Discharge notes and summary, if applicable; and

3. Any other documentation and information required by the Arkansas Department of Human Services.

B. ABA therapy providers must maintain in each beneficiary's service record the following documentation for all ABA therapy treatment services performed pursuant to section 222.200 of this Arkansas Medicaid manual:

1. Beneficiary's name;

2. The date and beginning and ending time of the ABA therapy treatment session;

3. The location and type of setting where the ABA therapy treatment session was provided;

4. A description of the specific practices, procedures, and strategies within the scope of ABA peer-reviewed literature utilized and the activities performed during each ABA therapy treatment session;

5. Name(s), credential(s), and signature(s) of the personnel who performed ABA therapy treatment services each session;

6. Which ITP goal(s) or objective(s) each practice, procedure, and strategy utilized during the ABA therapy treatment session was intended to address;

7. The criteria and other data collected during the ABA therapy treatment session to measure, monitor, and assess the beneficiary's progress towards their ITP goals or objectives; and

8. Weekly (or more frequent) progress notes signed or initialed by the supervising board-certified behavior analyst describing the beneficiary's status with respect to each ITP goal or objective.

C. ABA therapy providers must maintain in each beneficiary's service record the following documentation for all adaptive behavior treatment with protocol modification services performed pursuant to section 222.300 of this Arkansas Medicaid manual:

1. Beneficiary's name;

2. The name and credentials of the personnel performing the ABA therapy treatment session that the supervising board-certified behavior analyst (BCBA) is observing;

3. The date and beginning and ending time of the adaptive behavior treatment with protocol modification services;

4. The location and type of setting where the adaptive behavior treatment with protocol modification services were provided;

5. A description of any training or assistance provided by the BCBA while performing adaptive behavior treatment with protocol modification services;

6. A narrative of clinical observations and data collected in connection with the beneficiary's progress towards ITP goals or objectives while performing adaptive behavior treatment with protocol modification services;

7. Required documentation in connection with any update to a beneficiary's ITP (see section 224.000(A)(2) of this Arkansas Medicaid manual); and

8. The name and signature of the supervising BCBA that performed the adaptive behavior treatment with protocol modification services.

D. ABA therapy providers must maintain in each beneficiary's service record the following documentation for all family adaptive behavior treatment services performed pursuant to section 222.400 of this Arkansas Medicaid manual:

1. Beneficiary's name;

2. Parent/guardian's name and the name of any other individuals that attended the family adaptive behavior treatment meeting;

3. The date and beginning and ending time of the family adaptive behavior treatment meeting;

4. The location and type of setting for the family adaptive behavior treatment meeting;

5. A summary of the topics discussed at each family adaptive behavior treatment meeting;

6. A description of any training or assistance provided by the BCBA to the beneficiary or parent/guardian at the family adaptive behavior treatment meeting;

7. Any parent/guardian or other individuals' concerns expressed at the family adaptive behavior treatment meeting; and

8. The name and signature of the supervising BCBA that held the family adaptive behavior treatment meeting.

E. Any individual ABA therapy provider must maintain:

1. Verification of their required credentials and qualifications. Refer to section 202.000 of this Arkansas Medicaid manual; and

2. Any written contract between the individual ABA therapy provider and the group ABA therapy provider on behalf of which they provide ABA therapy services.

F. Any group ABA therapy provider must maintain appropriate employment, certification, and licensure records for all individuals employed or contracted by the group to provide ABA therapy services. If an individual ABA therapy provider performs ABA therapy services on behalf of a group ABA therapy provider pursuant to a contract, then a copy of the contractual agreement must be maintained.

204.000 Electronic Signatures

Arkansas Medicaid will accept electronic signatures in compliance with Arkansas Code § 25-31-103 et seq.

205.000 Required Referral to First Connections pursuant to Part C of Individuals with Disabilities Education Act (IDEA)

The Arkansas Department of Education's First Connections program administers and monitors all Part C of IDEA activities and responsibilities for the state of Arkansas. Each ABA therapy service provider must, within two (2) working days of first contact, refer to the First Connections program any infant or toddler from birth to thirty-six (36) months of age for whom there is a diagnosis or suspicion of a developmental delay or disability. The referral must be made to the DDS First Connections Central Intake Unit. Each provider is responsible for documenting that a proper and timely referral to First Connections has been made.

206.000 Required Referral to Local Education Agency pursuant to Part B of Individuals with Disabilities Education Act (IDEA)

A. Each ABA therapy service provider must, within two (2) working days of first contact, refer to the Local Education Agency (LEA) any beneficiary three (3) years of age or older that has not entered kindergarten for whom there is a diagnosis or suspicion of a developmental delay or disability.

B. Each ABA therapy service provider must refer any beneficiary under three (3) years of age they are serving to the LEA at least ninety (90) days prior to the beneficiary's third birthday. If the beneficiary begins services less than ninety (90) days prior to their third birthday, the referral should be made in accordance with the late referral requirements of the IDEA.

C. Referrals must be made to the LEA covering the beneficiary's place of residence.

D. Each service provider is responsible for maintaining documentation evidencing that a proper and timely referral to has been made.

210.000 PROGRAM ELIGIBILITY

211.000 Scope

Arkansas Medicaid will reimburse enrolled applied behavior analysis (ABA) therapy providers for covered ABA therapy services when such services are provided pursuant to an individualized treatment plan to beneficiaries who meet the eligibility requirements of this Arkansas Medicaid manual. Medicaid reimbursement is conditional upon compliance with this manual, manual update transmittals, and official program correspondence.

212.000 Beneficiary Eligibility Requirements

212.100 Age Requirement

A beneficiary must be enrolled in the Child Health Services (EPSDT) Arkansas Medicaid program and between eighteen (18) months and twenty-one (21) years of age to receive applied behavior analysis therapy services.

212.200 Qualifying Diagnosis

A beneficiary must have an autism spectrum disorder (ASD) diagnosis established in accordance with Ark. Code Ann. § 20-77-124, to receive applied behavior analysis therapy services. The ASD diagnosis must be demonstrated by:

A. A delineation of American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders criteria; or

B. The results of one or more formalized ASD evaluation instruments administered by qualified professionals as defined in Ark. Code Ann. § 20-77-124.

212.300 Referral to Evaluate

A. Applied behavior analysis (ABA) therapy services require an initial evaluation referral signed and dated by:

1. The beneficiary's Arkansas Medicaid assigned primary care provider (PCP);

2. A substitute physician in accordance with section 171.600 of this Arkansas Medicaid manual; or

3. An affiliated physician or PCP operating under the same Arkansas Medicaid group provider as the Arkansas Medicaid assigned PCP.

B. An initial evaluation referral is required to be completed on a form DMS-641 ER "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Evaluation Referral." View or print the form DMS-641 ER.

C. A DMS-641 ER evaluation referral is only required to perform the initial comprehensive evaluation related to ABA therapy services.

D. No evaluation referral is required for an ABA therapy provider to perform a comprehensive reevaluation necessary to demonstrate a beneficiary's continued eligibility for ABA therapy services (see section 212.500(B) of this Arkansas Medicaid manual).

E. When a beneficiary has an active treatment prescription for ABA therapy services pursuant to a DMS-641 TP and switches to a new ABA therapy provider, the new provider is not required to obtain or maintain in the beneficiary's service record a DMS-641 ER since any evaluation performed by the new provider would not be the beneficiary's initial comprehensive evaluation for ABA therapy services.

F. If a beneficiary becomes ineligible for ABA therapy services at any time, then another, new DMS-641 ER evaluation referral and initial comprehensive evaluation is required prior to restarting ABA therapy services.

212.400 Treatment Prescription

A. Applied behavior analysis (ABA) therapy services require a treatment prescription signed and dated in accordance with the following:

1. A beneficiary's initial treatment prescription must be signed and dated by the beneficiary's Arkansas Medicaid assigned primary care provider (PCP).

2. A beneficiary's renewal treatment prescription must be signed and dated by:

a. The beneficiary's Arkansas Medicaid assigned PCP;

b. A substitute physician in accordance with section 171.600 of this Arkansas Medicaid manual; or

c. An affiliated physician or PCP operating under the same Arkansas Medicaid group provider as the Arkansas Medicaid assigned PCP.

B. Unless a shorter time is specified on the treatment prescription, a treatment prescription for ABA therapy services is valid for:

1. Up to six (6) months for a beneficiary from eighteen (18) months to eight (8) years of age; and

2. Up to twelve (12) months for a beneficiary from eight (8) to twenty-one (21) years of age.

a. Age is determined based on the beneficiary's age as of the date of the treatment prescription.

C. A treatment prescription for ABA therapy services must be on a form DMS-641 TP "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Treatment Prescription." View or print the form DMS-641 TP.

D. Beneficiaries who are already receiving ABA therapy services pursuant to an active treatment prescription (on a DMS-693 form) as of January 1, 2025, are not required to obtain a new treatment prescription on a form DMS-641 TP until their existing treatment prescription expires.

E. A new DMS-641 TP treatment prescription is not required when a beneficiary changes PCPs. An existing treatment scription would remain valid through its date of expiration if it was valid at the time originally signed.

212.500 Comprehensive Assessment

A. Applied behavior analysis (ABA) therapy services must be medically necessary as demonstrated by the results of a comprehensive evaluation completed by a board-certified behavior analyst (BCBA). An autism spectrum disorder (ASD) diagnosis alone is not sufficient documentation to demonstrate medical necessity.

1. An initial comprehensive evaluation must be performed to demonstrate initial eligibility for ABA therapy services.

2. Once a beneficiary is receiving ABA therapy services, a comprehensive reevaluation must be performed at least every:

a. Six (6) months for beneficiaries from eighteen (18) months to eight (8) years of age; and

b. Twelve (12) months for beneficiaries from eight (8) to twenty-one (21) years of age.

B. The initial comprehensive evaluation and each comprehensive reevaluation report must include the following information:

While all the following information must be included in any comprehensive evaluation report, there is not a required order or format in which the comprehensive evaluation report must be prepared.

1. The beneficiary's:

a. Name, age, and date of birth;

b. Assigned primary care provider; and

c. Supervising board-certified behavior analyst (BCBA);

2. A summary of available background history on the beneficiary, including without limitation:

a. Pertinent medical, mental, and developmental history, including any medications prescribed to ameliorate behaviors;

b. The primary language spoken in the beneficiary's home;

c. Whether the beneficiary is currently enrolled in a public or private school or is home-schooled;

d. Any additional types of services the beneficiary is known to be currently receiving (i.e. Occupational Therapy, Physical Therapy, or Speech-Language Pathology, Early Intervention Day Treatment services, behavioral health services, etc.);

e. Beneficiary's response to any prior treatment(s) performed by the current ABA therapy provider, which in the case of a comprehensive reevaluation for ABA therapy services must include:

i. The date the beneficiary started receiving ABA therapy services from the current provider, and if there have been any gaps in ABA therapy treatment services since services started with the current provider;

ii. A summary of specific individualized treatment plan goals or objectives met since the beneficiary's immediately preceding comprehensive evaluation;

iii. A summary of communication, social, self-help, or other adaptive behavioral skill improvements or acquisitions specific to the beneficiary's targeted area(s) of functional deficit since the beneficiary's immediately preceding comprehensive evaluation;

iv. A summary of specific replacement behaviors, tasks, or activities successfully implemented since the beneficiary's immediately preceding comprehensive evaluation;

v. A list of specific interfering behaviors minimized or eliminated since the beneficiary's immediately preceding comprehensive evaluation; and

vi. Any available direct or indirect evidence of the beneficiary's replacement behaviors, problem behavior reduction or elimination, or skill acquisition in targeted area(s) of deficit transitioning across natural environment settings since the beneficiary's immediately preceding comprehensive evaluation;

3. A summary of one (1) or more interviews with the parent(s), caregiver(s), or other individuals involved in the life of the beneficiary, as appropriate, which should include:

a. The date the interview was held;

b. The beneficiary's current functioning, skill deficits, and problem behaviors (long-term and recent);

c. The family's current needs and concerns;

d. Any recent family or home stressors and changes; and

e. Any other pertinent information concerning the beneficiary and their suspected area(s) of deficit as it relates to their typical daily activities;

i. Lack of interview summary is excused if there is documented parent/caregiver refusal or unavailability after reasonable attempts;

4. The results of one of the nationally recognized skills-based assessment instruments accepted by the Department of Human Services (View or print the list of accepted assessment instruments):

a. Assessment instrument(s) not included on the accepted list may be administered as a supplement to (but not a replacement for) the administration of one of the accepted instruments;

b. It is recommended that when possible and appropriate the same instrument(s) be used for each beneficiary's comprehensive evaluation to establish a benchmark and allow for direct comparison of beneficiary scoring over time.

5. If there is a targeted interfering behavior(s), the administration and results of a functional behavior assessment;

6. The location(s) and setting(s) where the BCBA conducted direct observation of and data collection on the beneficiary;

7. The BCBA's analysis of the beneficiary's current skill and functional strengths, deficits, delays, limitations, and barriers across at least the following domains, including the basis for how the BCBA reached those conclusions for each domain (i.e. direct observation, medical file review, parent interview, etc.):

a. Communication and language;

b. Social behavior and play;

c. Independent play and leisure;

d. Self-help and daily living skills;

e. Sleeping and feeding;

f. Classroom and academic skills; and

g. Interfering behavior(s) resulting in harm to self, acting as barrier to learning, or limiting access to community;

i. If there are no deficits or concerns in a specific domain (or no interfering behaviors), then that fact should be noted.

8. A detailed description of the area(s) of functional skill deficits and delays, beneficiary limitations, and interfering behavior(s) that are to be addressed by ABA therapy services;

a. It will not automatically be deemed medically necessary for each beneficiary area of deficit to be addressed by ABA therapy services.

9. The BCBA's recommendations on the frequency, duration, and intensity of ABA therapy services;

10. The BCBA's interpretation of the beneficiary's medical history, family history, parent or other caregiver interviews, assessment instrument results, and direct observation and data collection that justifies the BCBA's recommendations on the frequency, duration, and intensity of the ABA therapy services;

11. A recommended individualized treatment plan (ITP) with goals and objectives to address each targeted area of deficit, functional limitation, and problem behavior included on the ITP;

12. The recommended setting(s) for ABA therapy treatment service delivery and how and why the treatment service delivery setting(s) are appropriate for the beneficiary;

13. The parent, guardian, or other family member or caregiver home program, which should include a written description of:

a. The specific intervention practices and strategies to be implemented by the parent/caregiver; and

b. During what typical activities and in what setting(s) those practices and strategies are to be performed;

14. The schedule of family adaptive behavior treatment service meetings between the supervising BCBA and parent/guardian with an explanation of why the scheduled frequency and duration of family adaptive behavior treatment service meetings is appropriate for the beneficiary; and

15. The signature and credentials of the BCBA who performed and completed the comprehensive evaluation report. A BCBA is certifying to each of the following conditions when signing a comprehensive evaluation report recommending ABA therapy services for the beneficiary:

a. The beneficiary's ASD diagnosis is the primary contributing factor to their developmental or functional delays, deficits, or problem behaviors that are to be addressed by ABA therapy services;

b. The level of complexity of the beneficiary's condition is such that ABA therapy services can only be safely and effectively performed by or under the supervision of a BCBA; and

c. There is a reasonable expectation that ABA therapy services will result in meaningful improvement of the beneficiary's developmental or functional delays, deficits, and problem behaviors because the beneficiary exhibits:

i. The ability to learn and develop generalized skills to assist with their independence; and

ii. The ability to develop generalized skills to assist in addressing problem behaviors.

220.000 PROGRAM SERVICES

221.000 Non-covered Services

A. Arkansas Medicaid will only reimburse for those services listed in sections 222.000 through 223.000, subject to all applicable limits.

B. Covered services are only reimbursable when delivered in accordance with the beneficiary's individualized treatment plan. See section 224.000.

C. All ABA therapy services must be delivered by a single ABA therapy provider. Transitioning, alternating, or coordinating ABA therapy services concurrently among multiple ABA therapy service providers is prohibited.

1. For group ABA therapy providers, this means all ABA therapy services must be performed by individual providers affiliated with the same group.

2. This provision does not eliminate or in any way restrict a beneficiary's right to select or change their choice of ABA therapy service provider.

D. A beneficiary receiving Autism Waiver services is prohibited from receiving ABA therapy services.

222.000 Covered Services

222.100 Behavior Identification Assessment Services

A. A provider may be reimbursed for medically necessary behavior identification assessment services, which include the following components:

1. Performing the annual comprehensive evaluation, which includes:

a. Administering an assessment instrument(s);

b. Conducting the parent/guardian interview; and

c. Completing the accompanying annual comprehensive evaluation report; and

2. Developing the initial individualized treatment plan (ITP).

a. Updating or revising an existing ITP is an adaptive behavior treatment with protocol modification service (see section 222.300 of this Arkansas Medicaid manual).

B. Behavior identification assessment services medical necessity:

1. Medical necessity for behavior identification assessment services is established by:

a. For a beneficiary's initial comprehensive evaluation, an initial evaluation referral on a form DMS-641 ER "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Evaluation Referral" (see section 212.300 of this Arkansas Medicaid manual). View or print the form DMS-641 ER; or

b. For a beneficiary's required comprehensive reevaluations, an active treatment prescription for applied behavior analysis therapy services on a DMS-641 TP that is expiring within sixty (60) days of the date of the comprehensive reevaluation.

2. An evaluation referral on a DMS-641 ER is only required to perform a beneficiary's initial comprehensive evaluation.

C. Behavior identification assessment services must be performed by a board-certified behavior analyst (BCBA) enrolled with Arkansas Medicaid.

D. All behavior identification assessment services must be prior authorized in accordance with section 240.000 of this Arkansas Medicaid manual).

E. Behavior identification assessment services are reimbursed on a per unit basis. The unit of service calculation should only include face-to-face time spent by the BCBA with the beneficiary and/or parent/guardian conducting a comprehensive evaluation and any non-face-to-face time spent by the BCBA preparing the accompanying comprehensive evaluation report and developing the beneficiary's initial ITP. Updating an existing ITP is considered an adaptive behavior treatment with protocol modification service. View or print the billable behavior identification assessment services procedure code and description.

222.200 Applied Behavior Analysis Therapy Treatment Services

A. A provider may be reimbursed for medically necessary applied behavior analysis (ABA) therapy treatment services. ABA therapy treatment services are techniques and methods designed to minimize a beneficiary's developmental or functional delays, deficits, or maladaptive behaviors so that the beneficiary's ability to function independently across their natural environments is maximized.

ABA therapy treatment services include the following components (not all of which may be billable):

1. Performing ABA therapy treatment services in accordance with the beneficiary's individualized treatment plan (ITP);

2. Collecting data and recording session notes in accordance with the ITP; and

3. Reporting progress and concerns to the supervising board certified behavioral analyst (BCBA), as needed.

B. ABA therapy treatment services medical necessity:

1. Medical necessity for ABA therapy treatment services is initially established by:

a. The results of an initial comprehensive evaluation; and

b. A treatment prescription on a DMS-641 TP "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Treatment Prescription" (see section 212.400 of this Arkansas Medicaid manual). View or print the form DMS-641 TP.

2. The continued medical necessity of ABA therapy treatment services must be demonstrated by:

a. The results of a comprehensive reevaluation;

b. A treatment prescription on a DMS-641 TP "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Treatment Prescription" (see section 212.400 of this Arkansas Medicaid manual); and

c. One of the following:

i. The beneficiary's demonstrated progress toward one or more of the following:

A. Acquiring new communication, social, self-help, or other adaptive behavioral skills in the targeted area(s) of deficit;

B. Minimizing or eliminating targeted problem behavior(s); or

C. Reducing targeted area(s) of functional deficit or delay (as demonstrated by assessment instrument scores over time); or

ii. A list of variables that impacted the beneficiary's response to their ABA therapy treatment services and a detailed description of how those variables prevented the beneficiary's anticipated progress towards their ITP goals and objectives since the beneficiary's immediately preceding comprehensive evaluation.

3. Notwithstanding anything to the contrary contained in this section 222.200, ABA therapy treatment services cease to be medically necessary if:

a. A beneficiary is not demonstrating progress toward ITP goals or objectives over time; or

b. Targeted skill acquisition, replacement behaviors, and problem behavior elimination are unable to be transitioned across a beneficiary's natural environment settings over time.

i. The transitioning of targeted skill acquisition, replacement behavior(s), and problem behavior(s) elimination across the beneficiary's natural environment settings (outside of treatment sessions) can be demonstrated through documented beneficiary, parent, teacher, or other caregiver feedback (verbally, in writing, or through assessment/survey responses, i.e. Vineland Adaptive Behavior Scales), pictures, videos, and other sources, when properly supported by beneficiary progress observed during treatment sessions in a clinic or other non-natural environment settings.

ii. The transitioning of targeted skill acquisition, replacement behavior(s), and problem behavior(s) elimination across the beneficiary's natural environment settings is not required to be demonstrated through in person observation by the supervising BCBA in a beneficiary's natural environment.

C. ABA therapy treatment service delivery requirements:

1. ABA therapy treatment services must be performed by a:

a. BCBA;

b. Board-certified assistant behavior analyst (BCaBA) who is supervised by a BCBA in accordance with section 222.300(C) of this Arkansas Medicaid manual; or

c. Registered behavior technician (RBT) who is supervised by a BCBA in accordance with section 222.300(C) of this Arkansas Medicaid manual.

2. ABA therapy treatment service delivery must be performed on a one-on-one basis with a qualified BCBA, BCaBA, or RBT working with a single beneficiary throughout the entire ABA therapy treatment service session.

3. Group ABA therapy treatment service delivery is prohibited.

D. All ABA therapy treatment services must be prior authorized in accordance with section 240.000 of this Arkansas Medicaid manual.

1. The amount of ABA therapy treatment services performed during a week cannot exceed the prescribed or authorized number of units per week.

2. Prescribed or authorized units of ABA therapy treatment services not performed during a week due to beneficiary illness, beneficiary unavailability, or any other reason do not carryforward and cannot be made up in earlier or later weeks.

3. A week for these purposes is Monday through Sunday.

E. A single clinician cannot perform more than fifty (50) billable hours of ABA therapy treatment services per week.

F. ABA therapy treatment services are reimbursed on a per unit basis. The unit of service calculation should only include time spent delivering face-to-face ABA therapy treatment services directly to the beneficiary. View or print the billable applied behavior analysis therapy treatment procedure code and description.

222.300 Adaptive Behavior Treatment with Protocol Modification Services

A. A provider may be reimbursed for medically necessary adaptive behavior treatment with protocol modification services. Adaptive behavior treatment with protocol modification services involve the in-person observation of applied behavior analysis (ABA) therapy treatment service delivery by a supervising board-certified behavior analyst (BCBA), which may include the following components:

1. Actively training or assisting a board-certified assistant behavior analyst (BCaBA) or registered behavior technician (RBT) under the BCBA's supervision with the delivery of services to a beneficiary during an ABA therapy treatment session;

2. Educating and training a BCaBA or RBT under the BCBA's supervision on how to:

a. Collect the required data; and

b. Record the service session notes necessary to assess the beneficiary's progress towards individualized treatment plan (ITP) goals and objectives;

3. Conducting clinical observation of and data collection on the beneficiary's progress towards ITP goals and objectives during an ABA therapy treatment session delivered by a BCaBA or RBT under the BCBA's supervision; and

4. Adjusting and updating the ITP as required.

a. A BCBA delivering direct one-on-one ABA therapy treatment services to a beneficiary (i.e. not supervising a BCaBA or RBT perform an ABA therapy treatment session) is not considered an adaptive behavior treatment with protocol modification service under this section 222.300, and must be billed as an ABA therapy treatment service pursuant to section 222.200 of this Arkansas Medicaid manual.

B. Medical necessity for adaptive behavior treatment with protocol modification services is established by a treatment prescription for ABA therapy treatment services on a DMS-641 TP "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Treatment Prescription" (see section 212.400 of this Arkansas Medicaid manual).

C. Each BCaBA or RBT performing ABA therapy treatment services must be supervised by a BCBA who is responsible for the quality of the services rendered:

1. A supervising BCBA must be an enrolled Arkansas Medicaid provider.

2. A supervising BCBA must meet the following minimum in-person observation thresholds for each BCaBA or RBT under their supervision:

a. Five percent (5%) of the total ABA therapy treatment hours performed by the BCaBA or RBT; and

b. One (1) hour of ABA therapy treatment delivery performed by BCaBA or RBT every thirty (30) days.

3. When not directly observing an ABA therapy treatment session, a supervising BCBA must be on-call and immediately available to advise and assist throughout the entirety of any ABA therapy treatment session performed by a BCaBA or RBT under their supervision. Availability by telecommunication is sufficient to meet this requirement.

4. A supervising BCBA must review and approve the data collection and progress notes completed by a BCaBA or RBT under their supervision prior to submitting a claim for any ABA therapy treatment services delivered.

5. A supervising BCBA is limited to the lesser of the following supervision caseload limits:

a. A maximum combined total of twelve (12) BCaBAs and RBTs at any given time; or

b. A caseload of BCaBAs or RBTs requiring no more than twenty-five (25) hours of billable adaptive behavior treatment with protocol modification services per week.

D. Adaptive behavior treatment with protocol modification services must be performed by a BCBA enrolled with Arkansas Medicaid.

E. All adaptive behavior treatment with protocol modification services must be prior authorized in accordance with section 240.000 of this Arkansas Medicaid manual.

F. Adaptive behavior treatment with protocol modification services are reimbursed on a per unit basis. The unit of service calculation should only include time spent supervising, observing and interacting in-person with the beneficiary and BCaBA or RBT under the BCBA's supervision during an ABA therapy treatment session. View or print the billable adaptive behavior treatment with protocol modification services procedure code and description.

222.400 Family Adaptive Behavior Treatment Services

A. A provider may be reimbursed for medically necessary family adaptive behavior treatment services. Family adaptive behavior treatment services are quarterly or more frequent meetings between the beneficiary's parent(s)/guardian(s) or other appropriate caregiver and the supervising board-certified behavior analyst (BCBA), where the supervising BCBA:

1. Discusses the beneficiary's progress;

2. Provides any necessary technical or instructional assistance to the parent/guardian in connection with applied behavior analysis therapy service delivery;

3. Answers any parent/guardian or beneficiary questions and concerns; and

4. Discusses any necessary changes to the beneficiary's individualized treatment plan.

B. Medical necessity for family adaptive behavior treatment services is established by a treatment prescription for ABA therapy treatment services on a DMS-641 TP "Applied Behavior Analysis Therapy Services for Medicaid Eligible Beneficiaries from 18 months to 21 Years of Age Treatment Prescription" (see section 212.400 of this Arkansas Medicaid manual).

C. Family adaptive behavior treatment services must include the participation of the parent/guardian or other appropriate beneficiary caregiver.

D. Family adaptive behavior treatment services must be performed by a BCBA enrolled with Arkansas Medicaid.

E. All family adaptive behavior treatment services must be prior authorized in accordance with section 240.000 of this Arkansas Medicaid manual.

F. Family adaptive behavior treatment services are reimbursed on a per unit basis. The unit of service calculation should only include time spent collaborating face-to-face with the parent/guardian. View or print the billable family adaptive behavior treatment services procedure code and description.

223.000 Telemedicine Services

A. The following services may be delivered through telemedicine:

1. Adaptive behavior treatment with protocol modification services.

2. Family adaptive behavior treatment services.

B. All other covered applied behavior analysis (ABA) therapy services must be conducted inperson.

C. Parental/guardian consent is required prior to telemedicine service delivery.

D. All telemedicine services must be delivered in accordance with the Arkansas Telemedicine Act, Ark. Code Ann. § 17-80-401 to -407, or any successor statutes, and section 105.190 of this Arkansas Medicaid manual.

E. All covered services delivered through telemedicine must be delivered in a synchronous manner, meaning through real-time interaction between the practitioner and beneficiary, parent/guardian, or other practitioner via a telecommunication link.

F. ABA therapy services delivered through telemedicine in compliance with this section 223.000 are reimbursed in the same manner and subject to the same limits as in-person, face-to-face service delivery.

224.000 Individualized Treatment Plan

A. The supervising board-certified behavior analyst (BCBA) must develop an individualized treatment plan (ITP) for each beneficiary.

1. A beneficiary's ITP should be updated by the supervising BCBA as necessary based on beneficiary progress or lack thereof, but at a minimum must be updated the sooner to occur of:

a. Every twelve (12) months; or

b. When the beneficiary has shown no progress towards ITP goals or objectives in six (6) months.

2. The supervising BCBA must document each time a beneficiary's ITP is updated, which at a minimum must include a listing of each specific change and why the change was necessary.

B. Each ITP must include the following:

1. A written description of each goal or objective (see subsection C. below for specific ITP goal or objective requirements);

2. A description of the specific practices, procedures, and strategies within the scope of ABA peer-reviewed literature anticipated to be utilized and the activities anticipated to be performed as part of applied behavior analysis therapy treatment services;

3. The specific criteria and other data that will be collected on each ITP goal or objective during treatment service delivery to monitor and measure the beneficiary's progress, which must at a minimum include the following for each goal and objective included on an ITP:

a. The beneficiary's baseline measurement for the goal or objective's criteria when the goal or objective was first included on the ITP;

b. The beneficiary's measurement for the goal or objective's criteria on the beneficiary's immediately preceding comprehensive evaluation report;

c. The beneficiary's current measurement for the goal or objective criteria;

d. The beneficiary's anticipated progress toward each goal or objective between now and the next comprehensive evaluation;

e. The level of measurement that will be considered mastery of the goal or objective criteria (i.e. the condition(s) under and proficiency with which a behavior or skill must be demonstrated for the goal and objective to be considered completed);

i. The mastery of any goal or objective criteria must include the transferring of the goal or objective outcome across the beneficiary's natural environments;

f. The estimated goal or objective mastery date or timeframe at the time the goal or objective was first included on the ITP;

g. The estimated goal or objective mastery date or timeframe at the time of the immediately preceding comprehensive evaluation;

h. Current estimated goal or objective mastery date or timeframe; and

i. If the estimated goal or objective mastery date or timeframe is extended, a narrative must be included that:

i. Identifies the date that the mastery date or timeframe was extended;

ii. Identifies the barriers to mastery that required the extension; and

iii. Describes the modifications to practices, procedures, and strategies that were made to address the lack of progress;

4. The discharge criteria for the beneficiary transitioning out of prescribed ABA therapy services, which must also include the following information:

a. The beneficiary's original anticipated discharge date from ABA therapy services when ABA therapy services were initiated with the current provider (for a beneficiary already receiving ABA services as of January 1, 2025, as of the beneficiary's next ITP update after January 1, 2025);

b. The beneficiary's anticipated discharge date from ABA therapy services as of the beneficiary's immediately preceding comprehensive evaluation report;

c. The beneficiary's current anticipated discharge date from ABA therapy services;

d. Always include each of the following as standalone, additional objective discharge criteria:

i. When a beneficiary is failing to progress toward ITP goals and objectives over time; and

ii. If targeted skill acquisition, replacement behaviors, and problem behavior elimination are unable to be transitioned into the beneficiary's natural environments over time; and

5. When appropriate, include a positive behavior support plan for interfering behavior(s).

a. The use of punishment procedures in positive behavior support plans is expressly prohibited.

C. ITP goals and objectives must comply with the following:

1. All ITP goals and objectives must:

a. Be specific to the beneficiary;

b. Be observable;

c. Be measurable, with a clear definition of what level of measurement the beneficiary must reach for the goal or objective to be considered mastered or completed;

d. Written in the form of a:

i. Specific new communication, social, self-help, or other adaptive behavioral skill the beneficiary is working toward successfully performing (skill acquisition goal);

ii. A replacement behavior the beneficiary is working toward successfully implementing (replacement behavior goal);

iii. Interfering behavior the beneficiary is working toward reducing (behavior reduction goal); or

iv. Caregiver skill, task, or activity towards which the beneficiary's parent or other caregiver is working toward successfully performing (parent goal); and

e. Include a target duration or date for each ITP goal or objective to transfer to the beneficiary's natural environment.

2. Each behavioral reduction ITP goal or objective must have one (1) or more skill acquisition or behavior replacement ITP goal(s) or objective(s) tied directly to it;

3. Each behavior replacement ITP goal or objective must be tied directly to a behavior reduction ITP goal or objective;

4. Each skill acquisition ITP goal or objective should be tied directly to a behavioral reduction ITP goal or objective unless:

a. It is the rare situation where an ITP contains only skill acquisition goals and objectives; and

b. The supervising BCBA includes detailed clinical rationale in the ITP for why ABA therapy services are appropriate for a beneficiary that has no targeted behavioral reduction goals or objectives;

5. The total number of goals and objectives included on a beneficiary's ITP must:

a. Correlate with and support the frequency, intensity, and duration of the prescribed ABA therapy services;

b. Be supported by the comprehensive evaluation; and

c. Be clinically appropriate for the beneficiary.

6. Maintenance of an existing functional skill or eliminated interfering behavior is not an appropriate ITP goal or objective unless functional skill or behavioral regression is a medically recognized symptom of the beneficiary's underlying diagnosis.

a. If maintenance of an existing functional skill or eliminated interfering behavior is included as an ITP goal or objective, then there must be a detailed narrative included in the ITP explaining why maintenance is an appropriate ITP goal or objective for the beneficiary.

7. ITP goals and objectives must be designed and implemented so that skill acquisition, behavior replacement, or interfering behavior elimination the beneficiary is working toward is progressively transitioned into natural environments over time.

a. It may be appropriate (particularly in cases involving extreme interfering behaviors) for initial goals and objectives to involve demonstrating skill acquisition or behavior modification in a clinic or other controlled setting; however, ITP goals and objectives must be designed so that the desired skill gains and behavior modification are progressively transferred into the beneficiary's natural environments.

b. For example, a beneficiary's ITP goals and objectives could be incrementally updated over time from demonstrating skill acquisition, behavior replacement, or interfering behavior elimination in a specially modified clinic room, to a standard clinic room, to a simulated natural environment, and then into their natural environment as the beneficiary accomplishes the ITP goal or objective across each of the progressively less controlled environments.

230.000 PRIOR AUTHORIZATION

231.000 Prior Authorization for Applied Behavior Analysis Therapy Services

A. Prior authorization is required for an applied behavior analysis (ABA) therapy provider to be reimbursed for ABA therapy services.

B. View or print instructions for submitting a prior authorization request for ABA therapy services.

232.000 Administrative Reconsideration and Appeal

An applied behavioral analysis (ABA) therapy provider may submit a request for administrative reconsideration and appeal of a prior authorization denial in accordance with sections 160.000, 190.000, and 191.000 of this Arkansas Medicaid manual and the Arkansas Administrative Procedures Act, Ark. Code Ann. §§ 25-15-20, et seq.

250.000 REIMBURSEMENT

251.000 Method of Reimbursement

A. Covered services use fee schedule reimbursement methodology. Under fee schedule methodology, reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service under Arkansas Medicaid. The maximum allowable reimbursement for a service is the same for all applied behavior analysis (ABA) therapy providers.

B. The following standard reimbursement rules apply to all ABA therapy services:

1. A full unit of service must be rendered to bill a unit of service.

2. Partial units of service may not be rounded up and are not reimbursable.

3. Non-consecutive periods of service delivery over the course of a single day may be aggregated when computing a unit of service.

4. Time spent preparing a beneficiary for services or cleaning or prepping an area before or after services is not billable.

5. Unless otherwise specifically provided for in this Arkansas Medicaid manual, concurrent billing is not allowed. It is considered concurrent billing when multiple practitioners bill Medicaid for services provided to the same beneficiary during the same time increment.

6. Rest, toileting, or other break times between service activities is not billable.

7. Time spent on documentation alone is not billable as a service unless otherwise specifically permitted in this Arkansas Medicaid manual.

251.100 Fee Schedules

A. Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. View or print the applied behavior analysis therapy fee schedule.

B. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.

C. Fee schedules and procedure codes do not guarantee payment, coverage, or the reimbursement amount. Fee schedule and procedure code information may be changed or updated at any time.

SECTION II - AUTISM WAIVER CONTENTS

200.000 AUTISM WAIVER GENERAL INFORMATION

201.000 Arkansas Medicaid Participation Requirements for Autism Waiver Providers

201.100 Individual Service Provider Participation Requirements

Individual providers of Autism Waiver services must meet the following requirements to be eligible to participate in Arkansas Medicaid:

A. Complete the provider participation and enrollment requirements contained within section 140.000 of this Medicaid manual;

B. Meet the credentialing, experience, training, and other qualification requirements of the applicable Autism Waiver service under section 202.000 of this Medicaid manual; and

C. Obtain certification as an Autism Waiver provider from Arkansas Department of Human Services, Division of Developmental Disabilities Services or its contracted vendor.

201.200 Group Service Provider Participation Requirements

Group providers of Autism Waiver services must meet the following requirements to be eligible to participate in Arkansas Medicaid:

A. Complete the provider participation and enrollment requirements contained within section 140.000 of this Medicaid manual;

B. Each individual performing Autism Waiver services on behalf of the group must complete the individual provider participation and enrollment requirements under section 201.100 of this Medicaid manual; and

C. Obtain certification as an Autism Waiver provider from the Arkansas Department of Human Services, Division of Developmental Disabilities Services or its contracted vendor.

201.300 Providers in Arkansas and Bordering States

Providers with a principal place of business in Arkansas and within fifty (50) miles of the state line in the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may enroll as Autism Waiver providers if they meet all Arkansas Medicaid participation requirements of this Arkansas Medicaid manual.

202.000 AUTISM WAIVER PROVIDER REQUIREMENTS

202.100 Intensive Intervention Providers

A. Intensive Intervention providers are those Autism Waiver service providers that are certified to provide one or more of the following Autism Waiver services:

1. Individual Assessment, Treatment Development, and Monitoring services;

2. Lead Therapy Intervention services;

3. Line Therapy Intervention services; and

4. Therapeutic Aides and Behavioral Reinforcers.

B. Each individual rendering Autism Waiver services on behalf of a group intensive intervention provider must meet the credentialing, experience, training, and other qualification requirements for the applicable service.

202.200 Consultative Clinical and Therapeutic Provider Participation Requirements

A. Consultative Clinical and Therapeutic providers must:

1. Be an Institution of Higher Education with the capacity to conduct research specific to autism spectrum disorders;

2. Have a central/home office located within the State of Arkansas; and

3. Have the capacity to provide services in all areas within the State of Arkansas.

B. A Consultative Clinical and Therapeutic provider and each Clinical Services Specialist employed or contracted to provide Consultative Clinical and Therapeutic services must be independent of the intensive intervention provider selected by the parent/guardian.

202.300 Interventionist Participation Requirements

An Interventionist performing Individual Assessment, Treatment Development, and Monitoring Services must:

A. Have a minimum of two (2) years' experience performing one (1) or more of the following for children with autism spectrum disorder:

1. Developing individualized treatment;

2. Providing intensive intervention services; or

3. Overseeing an intensive intervention program; and

B. Hold either:

1. A Master's (or more advanced) degree in psychology, speech-language pathology, occupational therapy, special education, or related field; or

2. A certificate as a board certified behavior analyst (BCBA) from the Behavior Analyst Certification Board.

202.400 Lead Therapist Participation Requirements

A. A Lead Therapist performing Lead Therapy Intervention services must:

1. Hold a Bachelor's (or more advanced) degree in education, special education, psychology, speech-language pathology, occupational therapy, or related field;

2. One of the following:

a. Have completed one hundred twenty (120) hours of autism spectrum dsorder training; or

b. Have both:

i. Received an Autism Certificate offered by the University of Arkansas; and

ii. A minimum of two (2) years of experience in intensive intervention services to children with autism spectrum disorder.

B. In a hardship situation, DDS or its contracted vendor may allow an individual to act as a Lead Therapist and perform Lead Therapist Intervention services prior to meeting all the requirements in section 202.400(A).

1. A hardship situation exists when a beneficiary needs Lead Therapy Intervention services and staff is not available who meet all training/experience requirements.

2. In a hardship situation, the individual or group performing Lead Therapy Intervention services must meet all training/experience requirements in section 202.400(A) within one (1) year.

202.500 Line Therapist Participation Requirements

A. A Line Therapist performing Line Therapy Intervention services must:

1. Be at least eighteen (18) years of age;

2. Hold at least a high school diploma or GED;

3. Have completed eighty (80) hours of autism spectrum disorder training; and

4. Have a minimum of two (2) years' experience working with children.

B. In a hardship situation, DDS or its contracted vendor may allow an individual to act as a Line Therapist and perform Line Therapist Intervention services prior to meeting all the requirements in section 202.500(A).

1. A hardship situation exists when a beneficiary needs Line Therapy Intervention services and staff is not available who meet all training/experience requirements.

2. In a hardship situation, the individual or group performing Line Therapy Intervention services must meet all training/experience requirements in section 202.500(A) within one (1) year.

202.600 Clinical Services Specialist (CSS) Participation Requirements

Each Clinical Services Specialist employed or contracted by a Consultative Clinical and Therapeutic provider to perform Consultative Clinical and Therapeutic services must hold a certificate in good-standing as a board-certified behavioral analyst (BCBA) from the Behavior Analyst Certification Board.

203.000 Supervision

A. The Clinical Services Specialist providing consultative clinical and therapeutic services to a beneficiary must perform quality reviews to ensure appropriate implementation of the intensive intervention services included in the plan of care:

1. Quality reviews are initially conducted monthly.

2. If the beneficiary is progressing as expected through the first quarter of Autism Waiver services, quarterly quality reviews are permitted as long as the beneficiary continues to progress as expected.

B. The Interventionist must perform monthly on-site monitoring of intensive intervention service(s) delivery by the parent/guardian, Lead Therapist, and Line Therapist.

C. The Lead Therapist must perform weekly or more frequent in-person monitoring of intensive intervention service(s) delivery by the Line Therapist.

204.000 Documentation Requirements

204.100 Documentation Requirements for all Medicaid Providers

See section 140.000 of this Arkansas Medicaid manual for the documentation that is required for all Arkansas Medicaid providers.

204.200 Autism Waiver Service Documentation Requirements

Autism Waiver providers must maintain in each beneficiary's service record in the Autism Waiver Database maintained by Arkansas Department of Human Services, Division of Developmental Disabilities Services (DDS) or its contracted vendor:

A. The beneficiary's autism spectrum disorder diagnosis;

B. The beneficiary's applicable medical records;

C. The beneficiary's plan of care;

D. The beneficiary's individualized treatment plan (ITP);

E. The evaluations conducted as part of any level of care determination or in the development of the beneficiary's comprehensive clinical profile;

F. The beneficiary's form DHS-3330;

G. All clinical progress assessments of the beneficiary;

H. The parent/guardian's signed election to receive Autism Waiver services;

I. The parent/guardian's signed choice of provider form;

J. The quarterly reviews conducted by the clinical services specialist;

K. Each session of intensive intervention service delivery must include the following documentation:

1. Beneficiary name;

2. The date and beginning and ending time of intensive intervention service delivery;

3. A description of specific intensive intervention techniques or activities that were utilized during the session;

4. The location and type of setting where the intensive intervention services were provided;

5. Name(s), credential(s), and signature(s) of the personnel who performed the intensive intervention services;

6. Which of the beneficiary's ITP goals and objectives the session's intensive intervention services were intended to address;

7. Weekly or more frequent progress notes signed or initialed by the Lead Therapist describing the beneficiary's status with respect to their ITP goals and objectives; and

8. Any other documentation and information required by the Arkansas Department of Human Services, Division of Developmental Disabilities Services (DDS) or its contracted vendor.

204.300 Electronic Signatures

Arkansas Medicaid will accept electronic signatures, in compliance with Arkansas Code § 25-31103, et seq.

210.000 PROGRAM ELIGIBILITY

211.000 Scope

The purpose of the Autism Waiver is to provide one-on-one, intensive early intervention treatment in a natural environment setting to beneficiaries between eighteen (18) months and eight (8) years of age with a diagnosis of autism spectrum disorder.

212.000 Beneficiary Eligibility Requirements

212.100 Age Requirement

A. A beneficiary must be between eighteen (18) months and eight (8) years of age to receive Autism Waiver services.

B. A beneficiary must enroll in the Autism Waiver on or before their fifth (5th) birthday to allow for the maximum three (3) consecutive years of Autism Waiver services prior to turning eight (8) years old. See section 221.000(C) of this Arkansas Medicaid manual.

212.200 Qualifying Diagnosis

A. A beneficiary must have an autism spectrum disorder (ASD) diagnosis as defined in Ark. Code Ann. § 20-77-124.

B. The beneficiary's ASD diagnosis must be the primary contributing factor to their developmental or functional delays, deficits, or maladaptive behaviors to receive Autism Waiver services.

212.300 Institutional Level of Care

A. A beneficiary must require an institutional level of care (LOC) to enroll in the Autism Waiver and receive Autism Waiver services. A beneficiary is deemed to require an institutional LOC for Autism Waiver eligibility purposes if they meet one of the following:

1. A beneficiary scores seventy (70) or less in any two (2) of the Vineland Adaptive Behavior Scales (Vineland) domains.

2. A beneficiary three (3) years of age or older:

a. Scores eighty-five (85) or less in any two (2) Vineland domains; and

b. Has a Vineland Maladaptive Behavior Index Score between twenty-one (21) and twenty-four (24).

3. A beneficiary under the age of three (3):

a. Scores eighty-five (85) or less in any two (2) Vineland domains; and

b. Has a Temperament Atypical Behavior Scale score of at least eight (8).

i. Vineland scores falling within a domain's confidence interval for the beneficiary's developmental age will not preclude a beneficiary from Autism Waiver eligibility. For example, a beneficiary with a Vineland Communication domain score of seventy-four (74) where the beneficiary's developmental age confidence interval for the domain is four (4) points would be treated as a score of seventy (70) for purposes of this section 212.300.

B. A beneficiary must receive an annual LOC evaluation to demonstrate continued eligibility for the Autism Waiver.

220.000 PROGRAM SERVICES

221.000 Non-covered Services

A. Arkansas Medicaid will only reimburse for those services listed in sections 220.000 through 222.600, subject to all applicable limits.

B. Autism Waiver services are reimbursable if, and only to the extent, authorized in the beneficiary's plan of care. See section 223.000.

C. A beneficiary can receive a maximum of three (3) years of Autism Waiver services. Autism Waiver services are not covered beyond the three (3) year maximum limit.

222.000 Covered Services

222.100 Individual Assessment, Treatment Development, and Monitoring Services

A. Individual Assessment, Treatment Development, and Monitoring services include the following components:

1. Administering the evaluation instrument(s) and conducting the clinical observations necessary to create a comprehensive clinical profile of the beneficiary's skill deficits across multiple domains, including without limitation language/communication, cognition, socialization, self-care, and behavior.

a. The administration of the Assessment of Basic Language and Learning Skills-Revised instrument (ABLLS-R) is a required part of the comprehensive clinical profile.

b. Other evaluation instruments and clinical judgment may also be utilized so long as it supports the development of the beneficiary's comprehensive clinical profile.

2. Developing the individualized treatment plan (ITP) that guides the day-to-day delivery of intensive intervention services and includes without limitation the:

a. Intensive intervention service(s) delivery schedule;

b. Short and long-term goals and objectives; and

c. Data collection that will be implemented to assess progress towards those short and long-term goals and objectives.

3. Training and educating the parent/guardian, Lead Therapist, and Line Therapist on how to:

a. Implement and perform the intensive intervention service(s) included on the ITP;

b. Collect the required data; and

c. Record the service session notes necessary to assess the beneficiary's progress towards ITP goals and objectives.

4. Performing monthly monitoring of intensive intervention service delivery by the parent/guardian, Lead Therapist, and Line Therapist.

5. Completing beneficiary clinical progress assessments and adjusting the comprehensive clinical profile and ITP as required. Clinical progress assessments must be completed for each beneficiary at least every four (4) months and must always include:

a. The administration of an ABLLS-R; and

b. A written assessment of the beneficiary's progress based on an in-depth review of the data and session notes entered by the Lead Therapist and Line Therapist.

B. Individual Assessment, Treatment Development, and Monitoring services must be performed by a qualified Interventionist.

C. Individual Assessment, Treatment Development, and Monitoring services may be completed through telemedicine if in compliance with section 222.600 of this Medicaid manual, except for a beneficiary's initial evaluation, which must be conducted in-person in the beneficiary's natural environment setting.

D. Individual Assessment, Treatment Development, and Monitoring services are reimbursed on a per unit basis. The unit of service calculation should only include time spent administering beneficiary evaluations, conducting clinical observation, monitoring Lead and Line Therapist service delivery, or providing face-to-face training to the parent/guardian and Lead and Line Therapists. The unit of service calculation does not include time spent in transit to and from a service setting. View or print the billable Individual Assessment, Treatment Development, and Monitoring procedure codes and descriptions.

222.200 Consultative Clinical and Therapeutic Services

A. Consultative Clinical and Therapeutic services provide high level, independent clinical oversight of the implementation of the beneficiary's plan of care and individualized treatment plan, and include the following components:

1. Conducting quality reviews to ensure appropriate implementation of the intensive intervention services included in the plan of care.

a. Quality reviews are initially conducted monthly.

b. If the beneficiary is progressing as expected through the first quarter of Autism Waiver services, quarterly quality reviews are permitted as long as the beneficiary continues to progress as expected.

2. Providing technical assistance to the parent/guardian, Lead Therapist, and Line Therapist when the beneficiary is not progressing as expected.

3. Notifying DDS or its contracted vendor if any issues related to Autism Waiver compliance are discovered.

B. Consultative Clinical and Therapeutic services must be performed by a qualified Clinical Services Specialist.

C. Consultative Clinical and Therapeutic services may be conducted through telemedicine in accordance with section 222.600 of this Medicaid manual, unless:

1. The beneficiary, parent/guardian, Lead Therapist, or Line Therapist needs dictate that Consultative Clinical and Therapeutic services should be performed by the Clinical Services Specialist in-person; or

2. The beneficiary is not progressing as expected.

D. Consultative Clinical and Therapeutic services are reimbursed on a per unit basis. The unit of service calculation does not include time spent in transit to and from a service setting. View or print the billable Consultative Clinical and Therapeutic procedure codes and descriptions.

222.300 Lead Therapy Intervention Services

A. Lead Therapy Intervention services include the following components:

1. Providing intensive intervention service(s) in accordance with the individualized treatment plan (ITP);

2. Weekly or more frequent in-person monitoring of the intensive intervention service(s) delivery by the Line Therapist;

3. Reviewing all data collected and service session notes recorded by the Line Therapist and parent/guardian;

4. Training, assisting, and supporting the parent/guardian and Line Therapist;

5. Receiving parent/guardian feedback and responding to parent/guardian concerns or forwarding them to the appropriate person; and

6. Notifying the Interventionist when issues arise.

B. Lead Therapy Intervention services must be performed by a qualified Lead Therapist.

C. Lead Therapy Intervention services involving the beneficiary must:

1. Be conducted in a typical home or community setting for a similarly aged child without a disability or delay that the beneficiary and their family frequent, such as the beneficiary's home, neighborhood playground or park, church, or restaurant; and

2. Include the participation of a parent/guardian.

D. Lead Therapy Intervention services are reimbursed on a per unit basis. The unit of service calculation should only include time spent delivering face-to-face services to the beneficiary and parent/guardian, monitoring Line Therapist service delivery, or providing face-to-face training to a Line Therapist. The unit of service calculation does not include time spent in transit to and from a service setting. View or print the billable Lead Therapy Intervention procedure codes and descriptions.

222.400 Line Therapy Intervention Services

A. Line Therapy Intervention services include the following components:

1. Providing intensive intervention service(s) in accordance with the individualized treatment plan (ITP);

2. Collecting data and recording session notes in accordance with the ITP; and

3. Reporting progress and concerns to the Lead Therapist or Interventionist, as needed.

B. Line Therapy Intervention services must be performed by a qualified Line Therapist.

C. Line Therapy Intervention services involving the beneficiary must:

1. Be conducted face-to-face in a typical home or community setting for a similarly aged child without a disability or delay that the beneficiary and their family frequent, such as the beneficiary's home, neighborhood playground or park, church, or restaurant; and

2. Include the participation of a parent/guardian.

D. Line Therapy Intervention services are reimbursed on a per unit basis. The unit of service calculation should only include time spent delivering face-to-face services to the beneficiary and parent/guardian, and does not include time spent in transit to and from a service setting. View or print the billable Line Therapy Intervention procedure codes and descriptions.

222.500 Therapeutic Aides and Behavioral Reinforcers

A. Therapeutic aides and behavioral reinforcers are tools, aides, or other items a beneficiary uses in their home when necessary to implement and carry out the beneficiary's individualized treatment plan (ITP) and substitute materials or devices are otherwise unavailable.

B. The Interventionist determines when therapeutic aides and behavioral reinforcers should be included in the ITP.

C. A beneficiary may keep any therapeutic aides and behavioral reinforcers after exiting the Autism Waiver as long as the requirements of the Parent/Guardian Participation Agreement are met.

D. Therapeutic aides and behavioral reinforcers are limited to a maximum reimbursement of one thousand dollars ($1,000.00) per beneficiary, per lifetime. View or print the billable Therapeutic Aides and Behavioral Reinforcers codes and descriptions.

222.600 Telemedicine Services

A. Consultative Clinical and Therapeutic services and Individual Assessment, Treatment Development, and Monitoring services may be delivered through telemedicine in accordance with this section 222.600.

1. A beneficiary's initial evaluation by the Interventionist may not be conducted through telemedicine and must be performed through traditional in-person methods.

2. Parental or guardian consent is required prior to telemedicine service delivery.

3. All telemedicine services must be delivered in accordance with the Arkansas Telemedicine Act, Ark. Code Ann. § 17-80-401 to -407, or any successor statutes, and section 105.190 of this Medicaid manual.

B. The Autism Waiver service provider is responsible for ensuring service delivery through telemedicine is equivalent to in-person, face-to-face service delivery.

1. The Autism Waiver service provider is responsible for ensuring the calibration of all clinical instruments and proper functioning of all telecommunications equipment.

2. All Autism Waiver services delivered through telemedicine must be delivered in a synchronous manner, meaning through real-time interaction between the practitioner and beneficiary, parent/guardian, or practitioner via a telecommunication link.

3. A store and forward telecommunication method of service delivery where either the beneficiary, parent/guardian, or practitioner records and stores data in advance for the other party to review at a later time is prohibited, although correspondence, faxes, emails, and other non-real time interactions may supplement synchronous telemedicine service delivery.

C. Autism Waiver services delivered through telemedicine delivered in compliance with this section 222.600 are reimbursed in the same manner and subject to the same benefit limits as in-person, face-to-face service delivery.

223.000 Plan of Care

A. The Division of Developmental Disabilities Services or its contracted vendor must develop an individualized plan of care for each beneficiary.

1. The plan of care must be developed by an individual who has either:

a. A Registered Nurse license; or

b. A Bachelor's (or more advanced) degree in psychology, nursing, speechlanguage pathology, education, or related field.

2. The plan of care must be developed in collaboration with:

a. The parent/guardian; and

b. Any other individuals requested by the parent/guardian.

B. Each beneficiary's plan of care must include the following:

1. The beneficiary's identification information, which includes without limitation the beneficiary's:

a. Full name;

b. Address;

c. Date of birth;

d. Medicaid number; and

2. The name and credentials of the individual responsible for plan of care development;

3. The beneficiary's needs and potential risks;

4. The intensive intervention service(s) that will be implemented to meet those needs;

5. The amount, frequency, and duration of each intensive intervention service; and

6. The parent/guardian's choice of intensive intervention service provider(s).

C. A beneficiary's plan of care must be updated at least annually and any time the beneficiary is not progressing as expected.

224.000 Individualized Treatment Plan

A. The Individual Assessment, Treatment Development, and Monitoring service provider selected by the beneficiary's parent/guardian must develop an individualized treatment plan (ITP) for the beneficiary.

1. The individual responsible for developing and updating the ITP must be a qualified Interventionist.

2. The Interventionist must develop and update the ITP in in collaboration with the:

a. Lead Therapist;

b. Line Therapist;

c. Parent/guardian; and

d. Any other individuals requested by the parent/guardian.

B. Each ITP must include the following:

1. The beneficiary's identification information, which includes without limitation the beneficiary's:

a. Full name;

b. Address;

c. Date of birth; and

d. Medicaid number; and

2. The name and credentials of the Interventionist responsible for ITP development;

3. A written description of a minimum of three (3) goals and objectives, which must each be:

a. Written in the form of a regular function, task, or activity the beneficiary is working toward successfully performing;

b. Measurable; and

c. Specific to the individual beneficiary;

4. The intensive intervention service(s) delivery schedule;

5. Detailed instructions for implementation of intensive intervention services including the job title(s) or credential(s) of the personnel that will furnish the intensive intervention service(s);

6. The data collection that will be required to monitor and assess progress towards the beneficiary's goals and objectives; and

7. When appropriate, a positive behavior supports plan for maladaptive behavior.

C. A beneficiary's ITP must be updated every four (4) months after the administration of the Assessment of Basic Language and Learning Skills-Revised instrument, and anytime a beneficiary is not progressing as expected.

250.000 REIMBURSEMENT

251.000 Method of Reimbursement

Except as otherwise provided in this manual, covered Autism Waiver services use fee schedule reimbursement methodology. Under fee schedule methodology, reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service under Arkansas Medicaid. The maximum allowable reimbursement for a service is the same for all Autism Waiver providers.

A. A full unit of service must be rendered to bill a unit of service.

B. Partial units of service may not be rounded up and are not reimbursable.

C. Non-consecutive periods of service delivery over the course of a single day may be aggregated when computing a unit of service.

251.100 Fee Schedules

A. Arkansas Medicaid provides fee schedules on the DHS website. View or print the Autism Waiver fee schedule.

B. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.

C. Fee schedules and procedure codes do not guarantee payment, coverage, or the reimbursement amount. Fee schedule and procedure code information may be changed or updated at any time.

ATTACHMENT 3.1-A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM

STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

January 1, 2025

CATEGORICALLY NEEDY

4b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found.

25. Applied Behavioral Analysis (ABA) Therapy

(1) Applied Behavior Analysis (ABA) therapy is only one component of services to treat Autism Spectrum Disorder (ASD). ABA therapy services are provided in accordance with 42 CFR 440.130(c).

(2) ABA therapy services must be prescribed by the beneficiary's Arkansas Medicaid assigned primary care provider (PCP);

(3) ABA therapy services must be performed by a:

a. Board-certified behavior analyst (BCBA) who must have board-certified behavior analyst (or more advanced) certification in good-standing from the Behavior Analyst Certification Board;

b. Board-certified assistant behavior analyst (BCaBA) who must have board-certified assistant behavior analyst certification in good-standing from the Behavior Analyst Certification Board; or

c. Registered behavior technician (RBT) who must have registered behavior technician certification in good-standing from the Behavior Analyst Certification Board.

4. ABA therapy services include the following components:

a. Behavior identification assessment services, which include the following components:

i. Performing required comprehensive evaluations; and

ii. Developing the initial individualized treatment plan (ITP);

b. ABA therapy treatment services, which includes delivering ABA therapy treatment services directly to the beneficiary in accordance with the beneficiary's ITP;

c. Adaptive behavior treatment with protocol modification services, which includes the following components:

i. Actively training or assisting a BCaBA or RBT with the delivery of services to a beneficiary during an ABA therapy treatment session;

ii. Conducting clinical observation of and data collection on the beneficiary's progress towards ITP goals and objectives during an ABA therapy treatment session; and

iii. Adjusting and updating the ITP as required;

d. Family adaptive behavior treatment services, which are meetings between the beneficiary's parent(s)/guardian(s) or other appropriate caregiver and the supervising BCBA, where the supervising BCBA:

i. Discusses the beneficiary's progress;

ii. Provides any necessary technical or instructional assistance to the parent/guardian in connection with service delivery;

iii. Answers any parent/guardian or beneficiary questions and concerns; and

iv. Discusses any necessary changes to the beneficiary's individualized treatment plan.

ATTACHMENT 3.1-B

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM

STATE ARKANSAS

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

January 1, 2025

MEDICALLY NEEDY

(1) Applied Behavior Analysis (ABA) therapy is only one component of services to treat Autism Spectrum Disorder (ASD). ABA therapy services are provided in accordance with 42 CFR 440.130(c).

(2) ABA therapy services must be prescribed by the beneficiary's Arkansas Medicaid assigned primary care provider (PCP);

(3) ABA therapy services must be performed by a:

a. Board-certified behavior analyst (BCBA) who must have board-certified behavior analyst (or more advanced) certification in good-standing from the Behavior Analyst Certification Board;

b. Board-certified assistant behavior analyst (BCaBA) who must have board-certified assistant behavior analyst certification in good-standing from the Behavior Analyst Certification Board; or

c. Registered behavior technician (RBT) who must have registered behavior technician certification in good-standing from the Behavior Analyst Certification Board.

4. ABA therapy services include the following components:

a. Behavior identification assessment services, which include the following components:

i. Performing required comprehensive evaluations; and

ii. Developing the initial individualized treatment plan (ITP);

b. ABA therapy treatment services, which includes delivering ABA therapy treatment services directly to the beneficiary in accordance with the beneficiary's ITP;

c. Adaptive behavior treatment with protocol modification services, which includes the following components:

i. Actively training or assisting a BCaBA or RBT with the delivery of services to a beneficiary during an ABA therapy treatment session;

ii. Conducting clinical observation of and data collection on the beneficiary's progress towards ITP goals and objectives during an ABA therapy treatment session; and

iii. Adjusting and updating the ITP as required;

d. Family adaptive behavior treatment services, which are meetings between the beneficiary's parent(s)/guardian(s) or other appropriate caregiver and the supervising BCBA, where the supervising BCBA:

i. Discusses the beneficiary's progress;

ii. Provides any necessary technical or instructional assistance to the parent/guardian in connection with service delivery;

iii. Answers any parent/guardian or beneficiary questions and concerns; and

iv. Discusses any necessary changes to the beneficiary's individualized treatment plan.

ATTACHMENT 4.19-B

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM

STATE ARKANSAS

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES-OTHER TYPES OF CARE

Revised: January 1, 2025

4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age and Treatment of Conditions Found

(19) Physical Therapy and Related Services

3. Speech-Language Therapy

At the beginning of each calendar year, Medicaid officials and the Arkansas SpeechLanguage Therapy Association or its successor will arrive at mutually agreeable increase or decrease in reimbursement rates based on the market forces as they impact on access. Any agreed upon increase or decrease will be implemented at the beginning of the following state fiscal year, July 1 with any appropriate State Plan changes.

(19a) Applied Behavior Analysis (ABA) Therapy

Applied Behavior Analysis (ABA) therapy services are reimbursed on a per unit basis using fee schedule reimbursement methodology, where reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service under Arkansas Medicaid. DHS engaged an independent actuary to conduct a rate study on ABA therapy services during the summer of 2023 to determine appropriate service rates. The rate study considered direct wages (using Arkansas-specific May 2021 Bureau of Labor Statistics data), indirect and transportation costs, employee related expenses, and supervisor time, and used an independent rate model approach that captured the average expected costs a reasonably efficient Arkansas provider would incur while delivering ABA therapy services. The applicable fee schedule of ABA therapy service rates is published on the agency's website.

(20) Rehabilitative Services for Persons with Physical Disabilities (RSPD)

1. Residential Rehabilitation Centers

The per diem reimbursement for RSPD services provided by a Residential Rehabilitation enter will be based on the provider's fiscal year end 1994 audited cost report as submitted by an independent auditor plus a percentage increase equal to the HCFA Market Basket Index published for the quarter ending in March. A cap has been established at $395.00. This is a prospective rate with no cost settlement. Room and board is not an allowable program cost. The criteria utilized to exclude room and board is as follows: The total Medicaid ancillary cost was divided by total Medicaid inpatient days which equals the RSPD prospective per diem. The ancillary cost was determined based upon Medicare Principles of Reimbursement. There is no routine cost included.

Click here to view image

Notes

016.05.24 Ark. Code R. 004

Adopted by Arkansas Register Volume 50, Number 01, Effective 12/30/2024