SECTION 354.5023. Additional Medicaid Reimbursement Limitations and Exclusions Specific to Applied Behavior Analysis (ABA) Services

(a) Texas Medicaid will not reimburse ABA services when ABA services:

(1) address academic goals;

(2) address goals only related to performative social norms that do not significantly impact health, safety, or independence;

(3) are not expected to result in improvements in the child's level of functioning, other than medically necessary services at the maintenance or consultative level;

(4) do not require the specific skills and judgment of an LBA to perform or supervise;

(5) do not meet evidence-based standards of practice for ABA for effective treatment of ASD;

(6) use any experimental or investigational treatment methods even with legally effective consent;

(7) are not generally accepted as clinically effective or appropriate, or not within the normal course and duration of treatment for medically necessary ABA services;

(8) are for the convenience of those who are closest to the child or the provider (e.g., as respite care, or limiting treatment to a setting chosen by provider for convenience);

(9) do not include the child age- and developmentally-appropriately engaging in a clinical ABA therapeutic relationship;

(10) are provided by a clinic or agency owned or partially owned by the child (if the child is legally authorized to represent his/herself)) or the child's LAR;

(11) are provided directly by the child's LAR;

(12) are delivered by a BT in the school setting as a shadow or an aide or to provide general support to the child; and

(13) include separate billing for:

(A) indirect ABA service time related to ABA treatment; parent or caregiver education and training; ABA-related interdisciplinary team meetings; or supervision of an LaBA or BT; for example, pre- and post-work for a session are not reimbursed separately, other than the pre- and post-work that is allowable for ABA evaluation services; or

(B) any indirect supervision, or direct supervision which does not otherwise meet all requirements in this subchapter, the Autism Section of the TMPPM, and the relevant Current Procedural Terminology code.

(b) Medicaid enrolled LBAs, as individual or performing providers, and ABA groups will not be reimbursed for:

(1) equipment and supplies used during ABA services as they are considered part of the Medicaid services provided;

(2) the services of more than one ABA provider (LBA, LaBA, or BT) during one ABA session with a child, when more than one ABA provider is present (concurrent billing);

(3) concurrent billing for ABA services except where the LAR, parent, or caregiver and the child are receiving separate services, specifically when the LAR, the parent, or caregiver, as appropriate, participates in parent or caregiver education and training, and the child participates in any ABA service for the child in the treatment plan where the child is not present in the parent or caregiver education and training session; or

(4) services billed that do not meet minimum requirements, exceed the limitations outlined in relevant law, rule, and other requirements under this subchapter, the Autism Section in the TMPPM, and the NCCI, or are excluded.

Source Note: The provisions of this §354.5023 adopted to be effective March 8, 2023, 48 TexReg 1281