SECTION 354.5003. Definitions

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.

(1) ABA--Applied behavior analysis. The practice of applying the principles of learning and behavior, specifically about how behavior affects, and is affected by, past and current environmental events in conjunction with biological variables to improve the human condition through behavior change that is based on current, evidence-based, specialized principles, and delivered by a qualified professional under this subchapter.

(2) APRN--Advanced practice registered nurse. A person who:

(A) is currently licensed without restriction as an advanced practice registered nurse by the Texas Board of Nursing under Texas Occupations Code (TOC), Chapter 301 (relating to Nurses); and

(B) practices under a current, executed prescriptive authority agreement with a qualified physician in accordance with TOC, Chapter 157, Subchapter B (relating to Delegation to Advanced Practice Registered Nurses and Physician Assistants).

(3) ASD--Autism spectrum disorder. Is a condition included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is characterized by restricted, repetitive patterns of behavior, interests, or activities and deficits in social communication and social interaction, with onset of symptoms occurring in early childhood.

(4) Authorized primary care provider--Includes a qualified physician, acting as the primary care physician (PCP), or a qualified physician assistant (PA) or APRN, acting as the primary care provider.

(5) Autism--Autism spectrum disorder.

(6) Autism Section--Medicaid Autism Services section. The section in the Children's Services Handbook in the TMPPM that:

(A) addresses authorization to provide ABA to treat ASD and coverage of ABA services;

(B) covers ABA services to the extent required by EPSDT; and

(C) covers coordination of a comprehensive array of services to treat ASD.

(7) BT--Behavior technician. A person who is currently fully registered or certified without restriction as one of the following:

(A) Registered Behavior Technician (RBT);

(B) Board Certified Autism Technician (BCAT); or

(C) Applied Behavior Analysis Technician (ABAT).

(8) CFR--Code of Federal Regulations.

(9) Child--A child is an individual who is under 21 years of age who is Medicaid enrolled and who is eligible for ABA services under this subchapter and the Autism Section in the Children's Handbook in the Texas Medicaid Provider Procedures Manual (TMPPM).

(10) Children's Handbook--The Children's Services Handbook in the TMPPM.

(11) Co-morbid condition--A child who has a co-morbid condition with ASD has a physical, mental, or behavioral health condition, which may include a history of trauma, where diagnosis, symptoms, or treatment of the co-morbid condition occur at the same time as ASD.

(12) Comprehensive diagnostic evaluation--The medical standard of practice for the evaluation process and elements used by a qualified medical or health care professional to make an ASD diagnosis. The qualified medical or health care professional must either meet minimum requirements in the Autism Section in the Children's Handbook in the TMPPM to make a diagnosis of ASD, or be a PCP or other physician, working in consultation with an interdisciplinary diagnostic team that meets minimum requirements in the Autism Section in the TMPPM, to decide whether an ASD diagnosis is clinically appropriate for a child.

(13) DSM--Diagnostic and Statistical Manual for Mental Disorders. The current edition of the publication of the American Psychiatric Association, which is used by a qualified medical or health care provider in the evaluation and diagnosis of mental and behavioral health illnesses and conditions.

(14) Durable--Able to exist for a long time without significant deterioration in quality or value; not occurring only during ABA services or a temporary period thereafter.

(15) EPSDT--Early and Periodic Screening, Diagnosis, and Treatment. The federally mandated Early and Periodic Screening, Diagnosis, and Treatment program defined in Texas Administrative Code (TAC) Title 25, Chapter 33 (relating to Early and Periodic Screening, Diagnosis, and Treatment). The State of Texas has adopted the name Texas Health Steps (THSteps) for its EPSDT program.

(16) EPSDT-CCP--Early and Periodic Screening, Diagnosis, and Treatment-Comprehensive Care Program. A program described in Chapter 363 of this title (relating to Texas Health Steps Comprehensive Care Program).

(17) Evidence-based ABA services--ABA services for ASD which are consistently delivered based on rigorous and reliable clinical research outcomes that are widely recognized as effective by medical professionals.

(18) Family-centered--An approach to service delivery that uses a set of values, attitudes, and practices for working with children, which assures the health and well-being of the child and the people closest to the child, including the legally authorized representative (LAR), parent, caregiver, or other appropriate person, as applicable, through a respectful family-professional partnership, which honors the strengths, cultures, traditions, and expertise that everyone brings to this relationship.

(19) Generalizable--Able to be applied across the child's natural settings and not be limited to the specific locations where the ABA services are delivered.

(20) HHSC--The Texas Health and Human Services Commission. The single state agency charged with administration and oversight of the Texas Medicaid program, or its designee.

(21) In-person--Within the physical presence of another person. In-person does not include interacting with a member via a telemedicine or telehealth service.

(22) LaBA--Licensed assistant behavior analyst. A person who is currently licensed without restriction as a licensed assistant behavior analyst by the Texas Department of Licensing and Regulation (TDLR) under TOC, Chapter 506 (relating to Behavior Analysts), and 16 TAC Chapter 121 (relating to Behavior Analyst) and provides ABA services in accordance with state scope of practice and licensing requirements.

(23) LAR--Legally authorized representative. A person who is authorized by law to act on behalf of an individual regarding a matter described in this chapter, and may, depending on the circumstances, include a parent, caregiver, guardian, or managing conservator of a minor, or the guardian of an adult, or a representative designated pursuant to 42 CFR §435.923 (relating to Authorized Representatives).

(24) LBA--Licensed behavior analyst. A person who is currently licensed without restriction as a licensed behavior analyst by TDLR under TOC, Chapter 506, and 16 TAC Chapter 121, and provides ABA services in accordance with state scope of practice and licensing requirements.

(25) LD--Licensed dietitian. A person who is currently licensed without restriction as a licensed dietitian by TDLR under TOC, Chapter 701 (relating to Dietitians).

(26) Medicaid--The medical assistance program authorized and funded pursuant to Title XIX of the Social Security Act (Title 42, United States Code (U.S.C.), 1396 et seq.) (relating to Grants to States for Medical Assistance Programs) and administered in Texas by HHSC.

(27) Medically necessary--This term has the meaning set forth in §353.2 of this title (relating to Definitions).

(28) NCCI--National Correct Coding Initiative. The initiative of the Centers for Medicare & Medicaid Services for using the Current Procedural Terminology codes of the American Medical Association to promote national correct coding methodologies and to control improper coding.

(29) Nutrition services--Medicaid covered nutrition services provided by an LD.

(30) ORP--Ordering, referring, or prescribing physician. The ORP, including an authorized primary care provider, may request prior authorization, or authorization, as applicable, for a specific amount, duration, and scope of ABA services for a child, including Medicaid ABA evaluation, treatment, and ABA-related interdisciplinary team meeting services to treat ASD, and the ORP may receive formal authorization for a specific amount, duration, and scope of ABA services for a child.

(31) OT--Occupational therapy. OT is the discipline and services of occupational therapy, where the services are regulated by the Executive Council of Physical Therapy and Occupational Therapy Examiners, Texas Board of Occupational Therapy Examiners, under TOC, Chapter 454 (relating to Occupational Therapists).

(32) PA--Physician assistant. A person who:

(A) is currently licensed without restriction as a physician assistant by the Texas Medical Board-Physician Assistant Board, under TOC, Chapter 204 (relating to Physician Assistants); and

(B) practices under a current and executed prescriptive authority agreement with a qualified physician in accordance with TOC, Chapter 157, Subchapter B.

(33) PCP--Primary care physician. A person who is a qualified physician who:

(A) has agreed with a Medicaid health care managed care organization to provide a medical home to Medicaid enrolled members; and

(B) is responsible for providing on-going primary care services to Medicaid members, maintaining the continuity of patient care, and initiating referrals for care.

(34) Person-centered--An approach to health care services that:

(A) is based on the clinically assessed needs of the child, in collaboration with all relevant and available service providers, that focuses on the child as an individual and supports those who are closest to the child, as applicable;

(B) uses a documented service planning process that includes the child and those who are closest to the child, as applicable, that:

(i) is directed by the child to the greatest extent possible;

(ii) enables the child to make choices and decisions, including who provides the services and supports they receive;

(iii) reflects cultural considerations;

(iv) includes strategies for solving conflict or disagreement within the service provision process;

(v) provides services which are timely and occur at times and locations convenient to the child and those closest to the child; and

(vi) includes a method for them to require updates to the treatment plan; and

(C) involves a continual process by the provider of listening, testing new approaches, and changing routines and organizational approaches to individualize and de-institutionalize the care environment.

(35) Physician--A medical doctor or a doctor of osteopathy who is currently licensed without restriction by the Texas Medical Board under TOC, Chapter 155 (relating to License to Practice Medicine) to practice medicine or osteopathy.

(36) PT--Physical therapy. PT is the discipline and services of physical therapy, where the services are regulated by the Executive Council of Physical Therapy and Occupational Therapy Examiners, Texas Board of Physical Therapy Examiners, under TOC, Chapter 453 (relating to Physical Therapists).

(37) Rendering provider--For the purposes of Medicaid claim submission for ABA evaluation and treatment services for ASD, an LBA is the only Medicaid enrolled rendering provider as described in §354.5011 of this subchapter (relating to Providers of Applied Behavior Analysis (ABA) Services).

(38) Speech-language pathology--The discipline and services of speech-language pathology. In documents related to services under this subchapter and the Autism Section, these services are also called speech therapy, interchangeably. These services are regulated by TDLR under TOC, Chapter 401 (relating to Speech-Language Pathologists and Audiologists).

(39) ST--Speech therapy. The discipline and services of speech therapy or speech-language pathology. In documents related to services under this subchapter and the Autism Section, these services are also called speech-language pathology, interchangeably. These services are regulated by TDLR under TOC, Chapter 401.

(40) Supervision of ABA services rendered by an LaBA or BT--Means:

(A) the LBA must:

(i) provide direct and indirect supervision of the ABA services of the LaBA or BT, who is included in the formal ABA supervision documentation; and

(ii) deliver appropriate supervision in accordance with state licensing requirements, in TOC, Chapter 506 (relating to Behavior Analysts) and 16 TAC Chapter 121 (relating to Behavior Analyst), and the Autism Section in the TMPPM;

(B) the LaBA, if applicable, must:

(i) provide direct and indirect supervision of the ABA services of the BT, where both the LaBA and BT are identified in the formal ABA supervision documentation and in which the services delegated to each are specified; and

(ii) deliver appropriate supervision in accordance with state licensing requirements, in TOC, Chapter 506 (relating to Behavior Analysts) and 16 TAC Chapter 121 (relating to Behavior Analyst); and

(C) a Medicaid reimbursable direct supervision session by the LBA, or LaBA, as applicable, must occur when the LaBA or BT is currently and actively providing in-person ABA treatment services to a child, and requires the LBA, or LaBA, as applicable, to consider any necessary ABA service protocol modification, as described in the appropriate Current Procedural Terminology code.

(41) TAC--Texas Administrative Code.

(42) TDLR--Texas Department of Licensing and Regulation. The Texas licensing agency that regulates and issues licenses for LBAs, LaBAs, and certain other professionals.

(43) THSteps--Texas Health Steps. A Medicaid program defined in 25 TAC Chapter 33. The State of Texas has adopted the name Texas Health Steps for its EPSDT program.

(44) THSteps-CCP--Texas Health Steps-Comprehensive Care Program. The Texas Medicaid EPSDT-CCP, described in Chapter 363 of this title.

(45) TMHP--Texas Medicaid and Healthcare Partnership.

(46) TMPPM--Texas Medicaid Provider Procedures Manual. The current manual published by TMHP, that:

(A) is a comprehensive guide for Texas Medicaid providers for fee-for-service benefits, policies, and procedures; and

(B) is updated monthly to include all published updates, including those made available to providers through bulletins, banners, or other means, and any revisions of published updates which became effective in the month prior.

(47) TOC--Texas Occupations Code.

(48) Trauma-informed--A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and:

(A) understands potential paths for recovery from trauma;

(B) recognizes the signs and symptoms of trauma in members, families, staff, and others involved with the system; and

(C) responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist traumatization and re-traumatization.

(49) Treatment plan--A plan for ABA services for a child that:

(A) is tailored to the specific needs of the child, and those who are closest to the child, as applicable;

(B) meets all requirements under this subchapter and the Autism Section in the TMPPM; and

(C) must be authorized.

(50) U.S.C.--United States Code.

Source Note: The provisions of this §354.5003 adopted to be effective March 8, 2023, 48 TexReg 1281