N.M. Admin. Code § 8.321.2.13 - APPLIED BEHAVIOR ANALYSIS (ABA)
MAD pays for medically necessary, empirically supported, applied behavior analysis (ABA) services for eligible recipients who have a well-documented medical diagnosis of autism spectrum disorder (ASD), and for eligible recipients who have well-documented risk for the development of ASD. As part of a three-stage comprehensive approach consisting of evaluation, assessment, and treatment, ABA services may be provided in coordination with other medically necessary services including but not limited to family infant toddler program (FIT) services, occupational therapy, speech language therapy, medication management, and developmental disability waiver services. ABA services are part of the early periodic screening, diagnosis and treatment (EPSDT) program (CFR 42 section 441.57) for recipients under the age of 21. There is no age requirement to receive ABA services and ABA is a covered benefit for medicaid enrolled adults.
A.
Coverage Criteria:
(1) Confirmation of the presence or risk of
ASD must occur through an approved autism evaluation provider (AEP) through a
comprehensive diagnostic evaluation (CDE) used to determine the presence of and
a diagnosis of ASD. A targeted evaluation is used when the eligible recipient
who has a full diagnosis of ASD presents with behaviors that are changed from
the last CDE. An ASD risk evaluation is used when an eligible recipient meets
the at-risk criteria found in Subsection C of
8.321.2.13 NMAC.
(2) An integrated service plan (ISP) must be
developed by the AEP together with a referral to an approved ABA provider
agency (stage one).
(3) The ABA
provider agency completes a behavior or functional analytic assessment. The
assessment results determine if a focused or comprehensive model is selected
and a treatment plan is completed (stage two).
(4) ABA stage two and three services are
rendered by a behavior analyst certification board (BACB) approved behavior
analyst (BA), a board certified assistant behavior analyst (BCaBA) or a
behavior technician (BT), in accordance with the treatment plan (stage three).
A BCaBA is referred to 8.321.2 NMAC as a behavior analyst assistant
(BAA).
B.
Eligible
providers: ABA services are rendered by providers and practitioners who
meet the qualification requirements: an AEP; a behavior analyst (BA) and a
behavior technician (BT) through an ABA provider agency; and an ABA specialty
care provider. Each ABA provider and practitioner has corresponding enrollment
requirements and renders services according to their provider type and
specialty. All providers must successfully complete a criminal background
registry check. See Subsections A and B of
8.321.2.9 NMAC for MAD general
provider requirements.
(1)
Stage 1:
Autism evaluation provider (AEP): Completes the CDE, ASD risk evaluation
or targeted evaluation and develops the ISP for an eligible
recipient.
(2)
Behavior
analyst (BA): a BA who is a board certified behavior analyst (BCBA® or
BCBA-D®) by the behavior analyst certification board (BACB®) or a psychologist
who is certified by the American board of professional psychology in behavior
and cognitive psychology and who was tested in the ABA part of their
certification, may render ABA stage two-behavior analytic assessment, service
model determination and treatment plan development and stage three
services-implementation of an ABA treatment plan.
(3)
Stage two and three BAA: A
BAA who is a board certified assistant behavior analyst (BCaBA®) by the BACB®
may assist their supervising BA in rendering a ABA stage two-behavior or
functional analytic assessment, service model determination and ABA treatment
plans development and stage three services implementation of the ABA treatment
plans, when the BAA's supervising BA determines they have the skills and
knowledge to render such services. This is determined in the contract the BAA
has agreed to with their supervising BA.
(4)
Stage three behavioral technician
(BT): A BT, under supervision of a BA, may assist stage two and
implement stage three ABA treatment plan interventions and services.
(5)
Stage three ABA specialty care
provider eligibility requirements: practitioners who are enrolled as BAs
must provide additional documentation that demonstrates the practitioner has
the skills, training and clinical experience to oversee and render ABA services
to highly complex eligible recipients who require specialized ABA
services.
(6)
Additional
provider types: To avoid a delay in receiving stage two services and
three services, a recipient may be referred for ABA services with a presumptive
diagnosis of ASD by a licensed practitioner whose scope of practice allows them
to render a diagnosis of ASD. This diagnosis must have been received within
three years of referral to stage two or three services.
C.
Identified population: The
admission criteria are separated into two types: at-risk for ASD and diagnosed
with ASD.
(1)
At-risk for ASD: an
eligible recipient may be considered at risk for ASD if they do not meet full
criteria for ASD per the latest version of the diagnostic statistical manual
(DSM) or international classification of diseases (ICD). To be qualified for
the ABA criteria of at-risk, the eligible recipient must meet all the following
requirements:
(a) is between 12 and 36 months
of age;
(b) presents with
developmental differences and delays as measured by standardized
assessments;
(c) demonstrates some
characteristics of the disorder including but not limited to impairment in
social communication and early indicators for the development of restricted and
repetitive behavior; and
(d)
presents with at least one genetic risk factor such as having an older sibling
with a well-documented ASD diagnosis or eligible recipient has a diagnosis of
Fragile X syndrome.
(2)
Diagnosed with ASD: an eligible recipient who has a documented
medical diagnosis of ASD according to the latest version of the DSM or the ICD
is eligible for ABA services if they present with a CDE or targeted
evaluation.
D.
Covered services:
(1)
Stage
one: An eligible recipient is referred to an AEP after screening
positive for ASD. The AEP conducts a diagnostic evaluation (CDE or targeted
evaluation), develops the ISP, and recommends ABA stage two services. For an
eligible recipient who has an existing ASD diagnosis, diagnostic re-evaluation
is not necessary, but the development of an ISP and the determination of the
medical necessity for ABA services are required.
(2)
Stage two BA: For all
eligible recipients, stage two services include a behavior or functional
analytic assessment, ABA service model determination, and treatment plan
development. The family, eligible recipient (as appropriate for age and
developmental level), and the ABA provider's supervising BA work
collaboratively to make a final determination regarding the clinically
appropriate ABA service model, with consultative input from the AEP as needed.
A behavior or functional analytic assessment addressing needs associated with
both skill acquisition and behavior reduction is conducted, and an
individualized ABA treatment plan, as appropriate for the ABA service model, is
developed by the supervising BA. The BA is responsible for completing all of
the following services:
(a) the recipient's
assessment;
(b) selection and
measurement of goals; and
(c)
treatment plan formulation and documentation.
(3)
Stage three - treatment:
Most ABA stage three services require prior authorization and may vary in terms
of intensity, frequency and duration, the complexity and range of treatment
goals, and the extent of direct treatment provided.
(4)
Stage three - clinical management
and case supervision: All stage three services require clinical
management. If a BAA or a BT is implementing the treatment plan, the BAA or BT
requires case supervision from their BA or supervising BAA. The BH policy and
billing manual provides a detailed description of the requirements for
rendering clinical management and case supervision.
(5)
Stage three - ABA specialty care
services: Specialty care services require prior authorization. In cases
where the needs of the eligible recipient exceed the expertise of the ABA
provider and the logistical or practical ability of the ABA provider to fully
support the eligible recipient MAD covers the eligible recipient for a referral
to a MAD enrolled ABA specialty care practitioner (SCP).
(6) If the eligible recipient is in a
residential facility or institutional setting that either specializes in or has
as part of its treatment modalities ABA services, and the residential facility
is not an ABA provider for ABA stage two and three services, and the eligible
recipient has a CDE or targeted evaluation which recommends ABA stage two
services, the residential facility is responsible to locate a MAD enrolled ABA
stage two and three ABA provider and develop an agreement allowing the ABA
provider to render stage two and three services at the residential facility.
Reimbursement for ABA stage two and three services is made to the MAD enrolled
ABA provider, not the residential facility.
(7) For an eligible recipient who meets the
criteria for ABA services and who is in a treatment foster care (TFC)
placement, they are not considered to be in a residential facility and may
receive ABA services outside of the TFC agency. An eligible recipient who meets
the criteria for ABA services who is in a residential treatment center,
accredited residential treatment center, or a group home may receive ABA
services to the extent that the residential provider is able to provide the
services.
(8) See the BH policy and
billing manual for specific instructions concerning stages one through three
services.
E.
Prior
authorization - general information stage three services:
(1) Prior authorization to continue ABA stage
three services must be secured every six months. At each six month
authorization, a UR contractor will assess, with input from the family and ABA
provider's BA, whether changes are needed in the eligible recipient's ISP or
treatment plan. Additionally, the family or ABA provider may request ISP
modifications prior to the UR contractor's six month authorization if immediate
changes are warranted to preserve the health and wellbeing of the eligible
recipient.
(2) To secure the
initial and ongoing prior authorization for stage three services, the ABA
provider must submit the prior authorization request, specifically noting:
(a) the CDE or targeted evaluation and the
ISP from the AEP along with the ABA treatment plan;
(b) the requested treatment model (focused or
comprehensive), maximum hours of service requested per week;
(c) the number of hours of case supervision
requested per week, if more than two hours of supervision per 10 hours of
intervention is requested; the BH policy and billing manual provides detailed
requirements for case supervision;
(d) the number of hours of clinical
management requested per week, if more than two hours of clinical management
per 10 hours of intervention is requested; and
(e) the need for collaboration with an ABA
specialty care provider, if such a need has been identified through initial
assessment and treatment planning; after services have begun, the ABA provider
agency may refer the eligible recipient to a SCP for a focused behavior or
functional analytic assessment focusing on the specific care needs of the
eligible recipient. The SCP will then request a prior authorization for
specialty care services from the UR contractor.
(3) The request must document hours allocated
to other services including but not limited to early intervention through FIT,
physical therapy, speech and language therapy that are in the eligible
recipient's ISP in order for the UR contractor to determine if the requested
intensity is feasible and appropriate.
(4) When an eligible recipient's behavior
exceeds the expertise of the ABA provider and logistical or practical ability
of the ABA provider to fully support them, MAD allows the ABA provider to
request prior authorization for ABA specialty care services.
(5) Services may continue until the eligible
recipient no longer meets service criteria for ABA services as described in the
BH policy and billing manual.
(6)
See the BH policy and billing manual for specific instructions on prior
authorizations.
F.
Non-covered services:
(1) The
eligible recipient's comprehensive or targeted diagnostic evaluation or the ISP
and treatment plan updates recommend placement in a higher, more intensive, or
more restrictive level of care (LOC) and no longer recommends ABA
services.
(2) Activities that are
not designed to accomplish the objectives delineated in covered services and
that are not included in the ABA treatment plan.
(3) Activities that are not based on the
principles and application of applied behavior analysis.
(4) Activities that take place in school
settings and have the potential to supplant educational services.
(5) Activities that are better described as
another therapeutic service (e.g., speech language therapy, occupational
therapy, physical therapy, counseling, etc.), even if the practitioner has
expertise in the provision of ABA.
(6) Activities which are better characterized
as staff training certification or licensure or certification supervision
requirements, rather than ABA case supervision.
G.
Reimbursement: Billing
instructions for ABA services are detailed in the BH policy and billing
manual.
Notes
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