Medicaid Autism Behavioral Health Treatment/Applied Behavior Analysis Services
Coverage of Applied Behavior Analysis (ABA) services is provided for Medicaid eligible children under 21 years of age who are diagnosed with Autism Spectrum Disorder (ASD) and who meet medical necessity criteria. ABA is a Medicaid covered service under the Behavioral Health Treatment “umbrella” within the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit.
Applied Behavior Analysis (ABA) is a recommended service for children with Autism Spectrum Disorder. It has been researched for over 30 years and endorsed by the Surgeon General. ABA services can be used to address skills and behaviors relevant to children with Autism Spectrum Disorder. ABA services commonly address areas including, but not limited to, the following:
- Language skills
- Social skills
- Communication skills
- Following instructions
- Peer interactions
- Following daily routines
- Self-help and daily living skills
- Behavior challenges
The following are the necessary steps required to determine eligibility and appropriate intensity for ABA services:
Step 1: Screening
Screening for ASD typically occurs during an EPSDT well-child visit with the child’s primary care provider (PCP), but anyone can refer a child for concerns of the child showing early signs of ASD. The validated and standardized screening tool used may be completed by the parent and reviewed and verified by the practitioner. A full medical and physical examination must be performed before the child is referred for further evaluation.
Step 2: Referral
The PCP who screened the child for ASD and determined a referral for further evaluation was necessary will contact the Prepaid Inpatient Health Plan (PIHP) directly to arrange for a follow-up evaluation. The PIHP will contact the child's parent(s)/guardian(s) to arrange a follow-up appointment for a comprehensive diagnostic evaluation, behavioral assessment, ABA services, and for the related EPSDT medically necessary Mental Health Specialty Services.
Step 3: Comprehensive Diagnostic Evaluation and Determination of Medical Necessity
Accurate and early diagnosis of ASD is critical in ensuring appropriate intervention and positive outcomes. The comprehensive diagnostic evaluation must be performed before the child receives ABA services. The comprehensive diagnostic evaluation is a neurodevelopmental review of cognitive, behavioral, emotional, adaptive, and social functioning, and should include validated evaluation tools. Based on the evaluation, the practitioner determines the child's diagnosis, recommends general ASD treatment interventions, and refers the child for a behavior assessment.
The determination of a diagnosis by a qualified licensed practitioner is accomplished by utilizing the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) which includes direct observation of the child, and by administering a comprehensive clinical interview including a developmental symptom history (medical, behavioral, and social history) such as the Autism Diagnostic Interview-Revised (ADI-R) or clinical equivalent. In addition, a qualified licensed practitioner will rate symptom severity with the Developmental Disabilities - Children’s Global Assessment Scale.
Medical necessity and recommendation for ABA services is determined by a physician or other licensed practitioner working within their scope of practice under state law. The child must demonstrate substantial functional impairment in social communication and social interaction across multiple contexts, and must demonstrate substantial restricted, repetitive and stereotyped patterns of behavior, interests, and activities as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5).
Step 4: Develop the Plan of Care
Following a comprehensive diagnostic evaluation and determination of medical necessity, the child should then be referred for a behavioral assessment to evaluate the child’s current skill level in a variety of areas and determine goals for ABA services. This assessment should utilize a reliable and valid assessment tool and should be administered by a qualified provider. Service intensity will vary with each child and should reflect the goals of treatment, specific needs of the child, and response to treatment.
Step 5: Begin ABA Services
ABA services include a variety of behavioral interventions which have been identified as evidence-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence. Such interventions include, but are not limited to:
- adapting environments to promote appropriate behavior and learning while discouraging challenging behavior
- systematically collecting information regarding behavior and its relationship with the environment, teaching parents/guardians to implement strategies outlined in the Behavioral Plan of Care
Clinical oversight for ABA services are provided by a qualified provider who delivers face-to-face observation and direction regarding developmental and behavioral techniques, progress measurement, data collection, function of behaviors, and generalization of acquired skills for each child.
If there is concern that a child is showing signs of Autism Spectrum Disorder and he/she is covered by Medicaid, please contact your primary care provider or your local Community Mental Health Service Program (CMHSP) for assistance. See Map