SECTION 354.5011. Providers of Applied Behavior Analysis (ABA) Services

(a) Providers of ABA services include:

(1) LBAs who:

(A) practice within the LBA's state scope of practice and licensure requirements, meet all relevant provider qualifications, and comply with all applicable law, rules, and requirements under this subchapter;

(B) are currently enrolled in Texas Medicaid through TMHP;

(C) for claims submission purposes, serve as the Medicaid enrolled rendering provider for all ABA evaluation, treatment, and supervision services, including those ABA services rendered under the LBA's supervision by an LaBA or a BT, as applicable, where the rendering provider for the specific service, which may be the LBA, LaBA, or BT, may or must, as applicable, be indicated on the claim with an appropriate Medicaid modifier; and

(D) may provide the following Medicaid reimbursable ABA services when authorized:

(i) ABA evaluation and treatment services to the child;

(ii) education and training services to the LAR, parent, or caregiver, as applicable;

(iii) supervision services for the LaBA or BT, as applicable, to whom the LBA has delegated service delivery; and

(iv) required participation in ABA-related interdisciplinary team meetings, if utilized.

(2) LaBAs who:

(A) practice within the LaBA's state scope of practice and licensure requirements, meet all relevant provider qualifications and comply with all applicable law, rules, and requirements under this subchapter; and

(B) are not Medicaid enrolled but rather render in-person ABA treatment services, parent or caregiver education and training services, or supervision services for a BT, under the supervision of the enrolled LBA.

(3) BTs who:

(A) are currently fully registered or certified as a BT under this subchapter and meet all other relevant provider qualifications;

(B) practice in accordance with their national certification or registration requirements and as directed by the supervising LBA or LaBA, to ensure compliance with all applicable law, rules, and requirements under this subchapter; and

(C) are not Medicaid enrolled but rather render in-person ABA treatment services under the supervision of the enrolled LBA or the LaBA.

(4) Licensed professionals who:

(A) are described in the Autism Section in the TMPPM as eligible licensed professionals for participation in ABA-related interdisciplinary team meetings, other than LBAs; and

(B) participate in Medicaid reimbursable ABA-related interdisciplinary team meetings to coordinate care for the child when eligible.

(b) Providers of ABA services must comply with:

(1) all applicable state and federal law or rule, such as:

(A) Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.) (relating to Grants to States for Medical Assistance Programs);

(B) 42 CFR §440.40(b) (relating to EPSDT) and §§441.50 - 441.62 (relating to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21);

(C) Texas Human Resources Code Chapter 32 (relating to Medical Assistance Program);

(D) Texas Government Code Chapter 531 (relating to Health and Human Services Commission);

(E) Chapter 352 of this title (relating to Medicaid and Children's Health Insurance Program Provider Enrollment);

(F) Chapter 353 of this title (relating to Medicaid Managed Care);

(G) Chapter 354 of this title (relating to Medicaid Health Services);

(H) Chapter 363 of this title (relating to Texas Health Steps Comprehensive Care Program); and

(I) 25 TAC Chapter 33 (relating to Early and Periodic Screening, Diagnosis, and Treatment);

(2) the Texas Medicaid Provider Agreement, as applicable;

(3) the NCCI;

(4) the current TMPPM, including:

(A) all published updates, including updates made available through bulletins, banners, or other means, and any revisions of published updates;

(B) all published handbooks, standards, and guidelines; and

(C) the specific ABA service requirements in this subchapter and the Autism Section in the TMPPM;

(5) Texas Family Code Chapter 261 (relating to Investigation of Report of Child Abuse or Neglect); and

(6) retrospective reviews, which include reviews of providers and provider locations, activities, and records to confirm compliance with all applicable law or rule, and other applicable requirements under this subchapter.

Source Note: The provisions of this §354.5011 adopted to be effective March 8, 2023, 48 TexReg 1281