Medicaid Coverage of Applied Behavior Analysis for Children Under 21 with Autism Spectrum Disorder

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Date: Tue, Apr 10, 2012 at 6:57 PMSubject: FW: Medicaid Coverage of Applied Behavior Analysis for Children Under 21 with Autism Spectrum DisorderTo: Karp

Hi ,

Please post this if you deem it appropriate.Thank you,

  

We’ve had a number of inquiries about Medicaid funding of ABA services. Below is the “Alert” sent by AHCA to the Area Medicaid Offices last week. When I called the Area Offices, I was told that they had no additional information, but I am letting you know the little that I know.

 The only thing we know for sure is that in order to get services going you must obtain prior authorization.

 The request for services must be completed by a physician (pediatrician, neurologist) and documentation of the child’s diagnosis of autism spectrum disorder must be attached to the request. This a basic form but it puts your physician in the position of determining whether a behavioral assessment is needed (it always is), the expected frequency and duration of treatment (AMA guidelines suggest 24 hours of early intervention per week but most ABA providers provide 10 to 20 hours per week – or 2 – 4 hours per day, 5 days per week) and whether the primary focus is maladaptive (severe) behaviors or the development of social and communicative skills. I suggest you work closely with your physician when completing this form so that you don’t end up limiting your authorization (ensure that an assessment is always indicated and at least 10 hours per week are indicated for children up to 3 years old and 15-20 for children 3 and older).

 The request must be mailed to your local Medicaid Area Office, who in turn will mail it to the Tallahassee AHCA office. The approval or denial is then mailed back directly to you and the physician. It appears than then it’s up to you to find an ABA provider who is enrolled in Medicaid,  provide them with a copy of the authorization, and . . . What happens after that is yet to be outlined. Since the authorization process may take some time, I suggest that if you are interested in pursuing this avenue, you download the “Request for Medicaid State Plan coverage of Applied Behavior Analysis for a Child under the Age of 21” form (see highlighted link in the Alert below) and ask your child’s physician to complete it and submit it  ASAP. Note that AHCA clearly states their intent to appeal the ruling; in the meantime however, they must cover services as ordered.

 It appears that in order to provide some immediate guidelines AHCA decided that they would allow existing providers who were providing behavioral services (whether behavior analysis or behavioral health) to provide specialized  ABA to  children in the spectrum. These are:

1.       Certified Behavior Analysts enrolled in the DD Waiver Program

2.       Infant Toddler Developmental Specialists (ITDS) who have certification in behavior analysis and enrolled in Early Intervention Services

3.       Qualified treating practitioners of Therapeutic On-Site Services (TBOS) who are aligned with a Community Behavioral Health Services (mental health) Provider.

 The problem with this is that each provider group has vastly different guidelines and rate structures and NONE of them are specific to ABA.  We need standard guidelines and standard rates which are specific to autism. In the meantime, I suggest that once you receive your authorization from AHCA you search for providers who are experienced in delivering ABA services to children in the spectrum and have Board Certified Behavior Analysts directly supervising or delivering the services. As you know, ABA is not the same at ITDS or TBOS.

 A bigger problem is that BCBAs and BCaBAs enrolled in the DD Waiver Program are insufficient in number to meet the need. The directive does not allow Behavior Assistants to provide ABA services under the direction of a BCBA. Trained paraprofessionals working under the supervision of Board Certified Behavior Analysts need to be included and an appropriate rate set for that level of provider.

 Comments on the AHCA Alert (copied below) may be sent to Florida Legal Services attorney, Betsy Havens at betsy@....

 Silvia

 Silvia MarussichStarin, MSW

Director of Operations

Behavior Analysis, Inc. and The Florida Autism Treatment Centers

8001 S.W. 36th Street, Suite 9, Davie, FL 33328

Phone: , extension 23

Email: smstarin@...

Web Site: www.behavior-analysis.org

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 FLORIDA MEDICAID

A Division of the Agency for Health Care Administration

 

Health Care Alerts & Provider Alerts Messages

April 2012

Provider Type(s): 05, 07, 16, 25, 26, 67, 68, 70, 71, 72, 77, 81, and 91

Medicaid Coverage of Applied Behavior Analysis for

Children Under 21 with Autism Spectrum DisorderOn March 26, a federal judge ordered Florida Medicaid to cover Applied Behavior Analysis (ABA) for the treatment of autism spectrum disorders for children under the age of 21, effective April 2, 2012.  Please note that the Agency for Health Care Administration intends to appeal this ruling.  If the ruling is overturned, Medicaid will cease to cover these services for the treatment of autism spectrum disorders.  Any such action will be announced through Provider Alerts and/or posted on the Medicaid website.

This alert describes provider qualifications, recipient eligibility criteria, the prior authorization request process, service codes and reimbursement rates, the billing process, and instructions for managed care plans. These services require prior authorization.

Provider Qualifications:ABA services must be rendered by the following provider types who are enrolled in the Medicaid program and have received prior authorization from Medicaid for the service:

Certified behavior analysts enrolled under the Developmental Disabilities waiver program (see page 1-16 of the Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook for provider qualifications);

 Infant Toddler Developmental Specialists who have certification in behavior analysis and are enrolled as Early Intervention Service Providers (see page 1-4 of the Early Intervention Services Coverage and Limitations Handbook for ITDS enrollment criteria); or

 ·         Qualified treating practitioners of Therapeutic Behavioral On-Site Service – Behavior Management Services and behavioral health technicians providing Therapeutic Behavioral On-Site – Therapeutic Support Services working under a Medicaid-enrolled provider type 05 – Community Behavioral Health Services Provider (see pages 2-1-39 and 2-1-41 of the Medicaid Community Behavioral Health Services Coverage and Limitations Handbook for provider qualifications).  Therapeutic behavioral on-site behavior management services must be provided by a certified behavior analyst or certified associate behavioral analyst.  Therapeutic behavioral on-site therapeutic support services must be provided, at a minimum, by a behavioral health technician supervised by a master’s level practitioner. 

Recipient Eligibility Criteria:Qualified treating practitioners may render medically necessary ABA to a child having any of the following ICD-9 diagnosis codes:  299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91. 

Prior Authorization Request Process:ABA services must be prior approved by Medicaid.  If a physician determines that a Medicaid eligible child diagnosed with an autism spectrum disorder needs Applied Behavior Analysis (ABA), the provider must submit a request to the Medicaid area office. The following information must be included:

Recipient name, date of birth, Medicaid ID, and current mailing address.

Requesting provider name, national provider identifier, address, and telephone and fax numbers.Diagnosis of recipient and diagnosis code.

If already assessed, expected duration of ABA treatment.The primary focus of ABA treatment.

Medical records that document the diagnosis of autism spectrum disorder.An optional form for this purpose is available online at www.ahca.myflorida.com/chcup. Prior authorization documentation as described above must be submitted to the recipient’s Medicaid area office.  Contact information for the area offices can be found at www.mymedicaid-florida.com under " Area Offices. " If Medicaid approves the service, an authorization will be sent to the physician and the recipient or the recipient’s parent or guardian.  If services are not approved, the physician and recipient or the recipient’s parent or guardian will receive notification of the denial and instructions on how to request a Medicaid Fair Hearing.

Service Codes and Reimbursement Rates:

Instructions for Developmental Disability Waiver Providersto Bill Fee-For-Service for Non-Waiver Recipients ABA services must be prior approved by Medicaid. Please consult the Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook for complete service requirements.  A total of up to 160 quarter-hour units per week of combined service may be authorized.  Eligible service codes and rates of reimbursement for Applied Behavior Analysis services are:

Description ofServiceProcedureCode

Modifier1

Modifier2Rate

Limits

Assessment ServicesBehavior Analysis Assessment for Autism

H2020UD

--$299.85 per assessment

One assessment per state fiscal year

Treatment ServicesBehavior Analysis Level 1 for Autism

H2019UD

HP$19.05 per quarter hour

Maximum combined daily limit of up to 16 quarter-hour units

Maximum combined weekly limit up to 160 quarter-hour units of all treatment servicesBehavior Analysis Level 2 for Autism

H2019

UDHO

$16.64 per quarter hourBehavior Analysis Level 3 for Autism

H2019

UDHN

$10.35 per quarter hour 

Instructions for Early Intervention Services ProvidersABA services must be prior approved by Medicaid. Please consult the Medicaid Early Intervention Services Coverage and Limitations Handbook for complete service requirements.  When billing for services for treatment of autism spectrum disorders, the claim must include one of the following as a primary diagnosis:  299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91.  Eligible service codes and rates of reimbursement for Applied Behavior Analysis services are:

Description ofServiceProcedureCode

Modifier 1

Modifier2Modifier

3Rate

LimitsAssessment Services

Screening

T1023UD

----

$50.00 per assessmentThree screenings per calendar year

Evaluation

T1024UD

HNUK

$27.75 per half-hour unitMaximum of four units per event, one event per lifetime

Follow-up Evaluation

T1024UD

TS--

$27.75 per half-hour unitMaximum of four units per event; maximum of three events per calendar year

Treatment Services

Early Intervention Individual SessionT1027

UDSC

--$12.50 per quarter-hour unit

Maximum of four units per day

Early Intervention Group SessionT1027

UDTT

SC$6.25 per quarter-hour unit

Maximum of four units per day

 Instructions for Community Behavioral Health ProvidersABA services must be prior approved by Medicaid. For children with an autism spectrum disorder diagnosis who have prior authorization, an assessment code may be used to assess the recipient, the treatment planning code may be utilized to develop a plan of care, and up to two service codes may be used to render treatment.  Please consult the Community Behavioral Health Services Coverage and Limitations Handbook for complete service requirements and the fee schedule.  When billing for services for treatment of autism spectrum disorders, the claim must include one of the following primary diagnoses:  299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91.      

For recipients under the age of 21, Medicaid will no longer enforce the service exclusion language located on page 2-1-4 of the Medicaid Community Behavioral Health Services Coverage and Limitations Handbook as it relates to the provision of ABA for treatment of autism spectrum disorders for the following services:

Description ofServiceProcedureCode

Modifier1

RateLimits

Assessment Services

Psychiatric Evaluation by PhysicianH2000

HP$210 per event

Two events per state fiscal year

Psychiatric Evaluation by Non-PhysicianH2000

HO$150 per event

Brief Behavioral Health Status Exam

H2010HO

$14.66 per quarter hourTen quarter-hour units per state fiscal year

In-Depth Assessment, New Patient, Mental Health

H0031HO

$125.00 per eventOne event per state fiscal year

In-Depth Assessment, Established Patient, Mental Health

H0031TS

$100.00 per eventPsychiatric Review of Records

H2000

--$26.00 per event

Two events per state fiscal yearBio-Psychosocial Evaluation, Mental Health

H0031

HN$48.00 per event

One event per state fiscal year

Psychological TestingH2019

--$15.00 per quarter hour

40 quarter-hour units per state fiscal year

Limited Functional Assessment, Mental HealthH0031

--$15.00 per event

Three event per state fiscal year

Treatment Plan Development, New and Established Patient, Mental HealthH0032

--

$97.00 per eventOne event per provider per state fiscal year

Treatment Plan Review, Mental Health

H0032TS

$48.50 per eventFour events per state fiscal year

Therapeutic Behavioral On-Site Services, Behavior Management

H2019HN

$10.00 per quarter hour36 quarter-hour units per month

Therapeutic Behavioral On-Site Services, Therapeutic Support

H2019HM

$ 4.00 per quarter hour128 quarter-hour units per month

Billing Process:To bill for the services, providers should submit claims in accordance with the Provider Reimbursement Handbook, CMS-1500 located at www.mymedicaid-florida.com. Click on " Public Information for Providers, " " Provider Support, " and then " Provider Handbooks. " All claims for ABA services for children with autism spectrum disorders must be billed fee-for-service, even for those recipients enrolled in a Medicaid managed care plan.  When billing for services for treatment of autism spectrum disorders, the claim must include one of the following primary diagnoses:  299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91.

Billing will be allowed for dates of service beginning with the date of prior authorization.  The Florida Medicaid Management Information System is not yet ready to accept claims for these services, but we expect the system to be ready by May 2012.  A notice will be posted when the system is ready to pay claims for these services. 

DO NOT SEND any attachments or medical records to the Medicaid fiscal agent with the CMS-1500 claim form.  Regardless of place or dates of service, attachments for Applied Behavior Analysis are not required.  All CMS-1500 claims for Applied Behavior Analysis services for children with autism spectrum disorders will be processed per these instructions. 

Instructions for Managed Care Plans:Managed care plans are not currently required to authorize or cover Applied Behavior Analysis Services for the treatment of autism spectrum disorders.  If a child enrolled in a Medicaid managed care plan requires ABA services, the plan may refer the recipient to any of the identified qualifying providers to receive the service under Medicaid fee-for-service.  Alternatively, the managed care plan may refer the recipient to the Medicaid area office for assistance with finding a qualified provider.  Managed care plans must share information on how to access ABA services with their contracted community behavioral health and physician providers.

Other Key Information:For questions, please contact your local Medicaid area office.  Contact information for the area offices can be found at www.mymedicaid-florida.com under " Area Offices. "  

 

LINKSFlorida Medicaid Web Portal | Florida Medicaid Health Information Network | Florida Medicaid HIPAA Information | HIPAA Transactions & Code Sets Standard | National Provider Identifier Standard (NPI) | Florida Medicaid EHR Incentive Program | FloridaHealthFinder.gov

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