405 IAC 5-22-12 - Applied behavioral analysis therapy services
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 12.
(a) ABA
therapy services shall be available to an individual who:
(1) is eligible for Medicaid
services;
(2) has been diagnosed as
having autism spectrum disorder by a qualified provider; and
(3) has a completed diagnostic evaluation.
A qualified provider, when completing such evaluation, shall utilize the most recent version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) at the time of the evaluation and include a recommended treatment referral for ABA therapy services.
(b)
Services shall be available from the time of initial diagnosis through twenty
(20) years of age.
(c) The
following providers may provide ABA therapy services:
(1) A health services provider in psychology
(HSPP).
(2) A licensed or board
certified behavior analyst.
(3) A
credentialed registered behavior technician (RBT).
(d) Services shall be reimbursed subject to
the following restrictions:
(1) Services
performed by a bachelor-level board certified behavior analyst (BCaBA) or a
credentialed RBT shall be supervised by a master's (BCBA) or doctoral level
board certified behavior analyst (BCBA-D), or an HSPP.
(2) Services provided by a credentialed RBT
shall be reimbursed at seventy-five percent (75%) of the rate on
file.
(e) A provider
described in subsection (c) shall develop a treatment plan for each recipient
eligible for services under this section. Treatment plans shall be focused on
addressing specific behavioral issues and community integration. All treatment
plans shall include a projected length of therapy. The treatment plan shall be
based on criteria such as the individual's:
(1) needs;
(2) age;
(3) school attendance, including any
homeschooling; and
(4) other daily
activities as documented in the treatment plan not otherwise excluded from
coverage under subsection (I) [sic, subsection (k)].
(f) All covered ABA therapy
services shall be subject to prior authorization. A provider shall abide by the
prior authorization requirements under
405 IAC 5-3, with the exception
that a BCBA may also submit a prior authorization request to the office for
review and approval. Each prior authorization request shall include, at a
minimum, the following:
(1) The individual's
treatment plan and supporting documentation.
(2) The number of therapy hours requested and
supporting documentation.
(3) Other
documentation as requested by the office.
(g) Prior approval for the initial course of
treatment may be approved for up to six (6) months. In order to continue
providing ABA therapy services, a provider shall submit a new prior
authorization request and receive approval. The prior authorization request
shall include an updated treatment plan along with the documentation specified
in subsection (f)(2) and (f)(3).
(h) ABA therapy services shall only be
available to a recipient for a period not to exceed forty (40) hours per week.
ABA therapy services extending beyond forty (40) hours per week of direct
therapy must be medically necessary and requires additional prior
authorization. The office shall not approve any prior authorization request
that provides ABA therapy services for a period longer than six (6) months at
one (1) time.
(i) Determinations
for hours and duration shall not be based upon any of the following:
(1) Other therapies that do not address the
specific behaviors being targeted.
(2) Any standardized formulas used to deduct
hours based upon daily living activities.
(j) Short term, adjunctive hours may be
requested outside of the standard therapy prior authorization if one (1) of the
following conditions occurs:
(1) Sudden
increase in self-injurious behaviors.
(2) Sudden increase in aggression or
aggressive behaviors.
(3) Increase
in elopement behaviors.
(4)
Regression in major self-care or language activities.
(5) A shift in family or home
dynamic.
(6) Development of a
non-mental health related comorbidity or health crisis with the patient.
(k) As follows, coverage
under this section shall not be available for services that:
(1) Focus solely on recreational
outcomes.
(2) Focus solely on
educational outcomes.
(3) Are
duplicative, such as services rendered under an individualized educational plan
that address the same behavioral goals using the same techniques as the
treatment plan.
Notes
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No prior version found.