| (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.
|
