Applied Behavior Analysis Services

PURPOSE: This rule establishes the regulatory basis for coverage and reimbursement for applied behavior analysis services under the Medicaid state plan. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumber some or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. (A) “Applied Behavior Analysis (ABA)” means the design, im plementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior. ABA does not include psychological testing, personality assess ment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, or counseling. (B) “ABA Assessment for Intervention Planning” means as sessment that is conducted according to best practice guide lines and considers the individual’s specific strengths and concerns to inform the intervention planning process. (C) “ABA intervention” means a type of intervention that involves directly and objectively measuring potential target behaviors and environmental events that influence them; con structing detailed, individualized behavior analytic treatment plans; using reinforcement and other scientifically validated procedures to build functional skills and reduce behaviors that jeopardize health, safety, and independent functioning; managing treatment environments to maximize client prog ress; implementing treatment protocols repeatedly, frequently, and consistently; measuring target behaviors directly and frequently; and adjusting treatment protocols based on data. (D) “Licensed Psychologist (LP)” means an individual who is currently licensed by the psychology board of the state in which the individual is practicing. (E) “Autism Spectrum Disorder (ASD)” as defined in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders. (F) “Best practice guidelines” means guidelines described in the Missouri Autism Guidelines Initiative’s publications enti tled Autism Spectrum Disorders: Missouri Best Practice Guidelines for Screening, Diagnosis, and Assessment as published by the Mis souri Department of Mental Health at their website at https:// www.autismguidelines.dmh.mo.gov/pdf/Guidelines.pdf, 2010, and Autism Spectrum Disorders: Guide to Evidence-Based Inter ventions as published by the Missouri Department of Mental Health at their website at https://www.autismguidelines.dmh. mo.gov/documents/Interventions.pdf, 2012. These guidelines are incorporated by reference and made a part of this rule and a copy of each is available for reference at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions. (G) “Diagnostic evaluation” means evaluation conducted according to best practice guidelines in order to determine if an ASD is present; (H) “Licensed Assistant Behavior Analyst (LABA)” means an individual who is currently licensed to practice applied behav ior analysis under the supervision of a licensed behavior ana lyst by the behavior analyst board under which the individual is practicing. (I) “Licensed Behavior Analyst (LBA)” means an individual who is currently licensed by the behavior analyst board of the state in which the individual is practicing. (J) “Technician” means an individual who is credentialed by the Behavior Analyst Certification Board (BACB) as a Registered Behavior Technician® (RBT®). (2) Administration. (A) The MO HealthNet ABA program shall be administered by the Department of Social Services, MO HealthNet Division. ABA services covered and not covered and the limitations under which services are covered shall be determined by the MO HealthNet Division and shall be included in the MO Health Net provider manual, which is incorporated by reference and made a part of this rule as published by the Department of So cial Services, MO HealthNet Division, 615 Howerton Court, Jef ferson City, MO 65109, at its website at http://manuals.momed. com/collections/collection_psy/print.pdf, August 25, 2022. This rule does not incorporate any subsequent amendments or additions. (3) Participant Criteria. (A) In order to qualify for and receive ABA services, a MO HealthNet participant must meet all of the following criteria: 1. Be under twenty-one (21) years of age; 2. Exhibit the presence of excesses and/or deficits of be haviors that significantly interfere with home or community activities (examples include but are not limited to aggression, self-injury, and elopement); and 3. Have a diagnostic evaluation performed by a licensed physician or licensed psychologist, resulting in a diagnosis of ASD, and recommending ABA services as medically necessary. (4) Provider Criteria. (A) To direct, supervise, and render ABA services, a profes sional shall meet the following specifications: 1. Be currently licensed as an LBA or LP; 2. In order to be reimbursed by the MO HealthNet Division for ABA services, an LP must have ABA in his/her education, training, and experience; 3. Be covered by professional liability insurance [to] with minimum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate; 4. Have no sanctions or disciplinary actions by the applica ble state licensing board or the BACB; 5. Have no current overpayment(s) due MO HealthNet and no Medicare or Medicaid sanctions or exclusions from partici pation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider. (B) Assistant behavior analysts who render or supervise ABA services shall meet the following qualifications: 1. Be currently licensed as an LABA; 2. Be currently supervised by an LBA. A. The supervisory relationship must be documented in writing; 3. Be covered by professional liability insurance with min imum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate; 4. Have no sanctions or disciplinary actions by the state licensing board or BACB; 5. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from partici pation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider. (C) Technicians who render ABA services shall— 1. Be credentialed by the BACB as an RBT®; 2. Work under the supervision of an LBA, LP (if officially granted supervisory privileges by the BACB), or LABA to the extent allowed for holders of the latter credential and at the discretion of the supervising LBA. RBT®s are required by the BACB to be supervised by LBAs who are also Board Certified Behavior Analysts, Board Certified Behavior Analysts-Doctoral, Board Certified Assistant Behavior Analysts, or members of a professional group officially granted supervisory privileges by the BACB. A. The supervisory relationship must be documented in writing; and 3. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from partici pation in federally funded programs. (5) Covered Services and Limitations. (A) MO HealthNet covered ABA services (ABA assessment for intervention planning and ABA intervention) must be— 1. Medically necessary; 2. Precertified by MO HealthNet or its designee; 3. Delivered in accordance with the participant’s treat ment plan; and 4. Overseen and delivered by providers who meet criteria specified herein. (B) Medical necessity for initial ABA assessment for interven tion planning shall be determined based on a diagnostic eval uation. Medical necessity for periodic reassessments shall be determined based on rationale for reassessment, to include but not limited to such considerations as readministration of tools, new behavior observed, new environment and participant responding differently, or lack of adequate progress. Medical necessity for ABA intervention shall be determined based on an ABA assessment for intervention planning for initial interven tion. Medical necessity for continued ABA intervention beyond the initial precertification period shall be determined based upon requested documentation including but not limited to updated treatment plan and progress graphs. If progress is not evident, identification of barriers to progress and strategies to improve effectiveness of interventions are required. (C) ABA intervention services may be precertified for a time period not to exceed one hundred eighty (180) days. Services provided without precertification shall not be considered for reimbursement, except in the case of retroactive MO HealthNet eligibility. (D) Service Limitations. 1. Services shall be based upon the individual needs of the child and must give consideration to the child’s age, school attendance requirements, and other daily activities as docu mented in the treatment plan. 2. Services must be delivered in a clinically appropriate setting for the behavior being treated. (6) Not Medically Necessary/Non-Covered Services. The follow ing services do not meet medical necessity criteria, nor qualify as MO HealthNet covered ABA services: (A) Intervention services rendered when measurable func tional improvement is not expected and services are not neces sary to maintain function or prevent deterioration; (B) Services that are solely educational are not covered. ABA treatment goals, objectives, and procedures that may be re lated in some way to educational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; (C) Services that are solely vocational or recreational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to vocational or recreational ac tivities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; and (D) Custodial care is not an ABA service and is not covered as part of this benefit. Developing, restoring, or maintaining selfhelp, daily living, or safety skills as part of an ABA treatment plan does not constitute custodial care and are covered. (7) ABA Treatment Plan. (A) ABA intervention services shall be rendered in accor dance with the individual’s treatment plan. The treatment plan shall— 1. Be person centered and individualized; 2. Be developed by an LBA or LP; 3. Be based on the ABA assessment for intervention plan ning; 4. Include assessment and treatment protocols for address ing each of the target behaviors; 5. Include training to enable LABAs and RBT®s to imple ment assessment and treatment protocols; 6. Include training and support to enable parents and other caregivers to participate in treatment planning and treat ment plan implementation; 7. Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and 8. Be consistent with applicable professional standards and guidelines relating to the practice of ABA as well as state Medicaid laws and regulations and applicable Missouri licen sure laws and regulations. (8) Reimbursement Methodology. (A) MO HealthNet shall provide reimbursement for ABA ser vices to enrolled LBAs or LPs who are currently licensed and in good standing with the state. Payment for services rendered by LABAs shall be made to the LBA supervising and employing these personnel. Payment for services rendered by technicians shall be made to the LBA or LP supervising and employing these personnel. If the LBA or LP operates through an agency or corporate entity, payment may be made to that agency or entity. Reimbursement for ABA services shall not be made to or for services rendered by a parent, a legal guardian, or other legally responsible person. (B) Reimbursement for ABA services is made on a fee-for-ser vices basis. The maximum allowable fee for a unit of service has been determined by the MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and cus tomary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services precertified by MO HealthNet or its designee. (C) The fee schedule and any annual/periodic adjustments to the fee schedule are published at https://dss.mo.gov/mhd/ providers/pages/cptagree.htm. The fee schedule is incorpo rated by reference and made a part of this rule as published by the Department of Social Services, Division of Legal Services, 221 West High Street, Jefferson City, MO 65101, at its website at https://apps.dss.mo.gov/fmsFeeSchedules/default.aspx, Au gust 25, 2022. This rule does not incorporate any subsequent amendments or additions. AUTHORITY: sections 208.201 and 660.017, RSMo 2016*. Original rule filed Dec. 14, 2015, effective July 30, 2016. Amended: Filed Aug. 25, 2022, effective March 30, 2023. *Original authority: 208.201, RSMo 1987, amended 2007; 660.017, RSMo 1993, amended 1995.