Habilitative Services (MD and DC Mandates)
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Governs coverage requirements for habilitative services (physical, occupational, speech therapy, and applied behavioral analysis) under CareFirst contracts as mandated by Maryland and District of Columbia law; affects members and providers in those jurisdictions and applies where member contracts follow state mandates.
No material clinical or coverage changes in this revision.
Mandated Coverage & Limitations
Mandated Coverage Criteria
Coverage required per state mandates when member contract follows applicable state law
Does not apply toward therapy maximums; applies to policies/contracts issued, delivered, or renewed on/after Jan 1, 2017.
Benefits may not be provided under an individualized education program (IEP) or any program imposed by the Individuals With Disabilities Education Act.
Benefits may not be provided to a child who is receiving services under an Individualized Education Program (IEP) or any program imposed on a public school by the Individuals With Disabilities Education Act (IDEA). This exclusion applies even when habilitative services (including ABA) otherwise would be covered under applicable mandates.
Coding and Reporting Requirements
| modifier 96 | CPT modifier 96 for habilitative services reporting |
Authorization, Documentation, and Billing Actions for Providers
Prior Authorization Required
Prior authorization is required for Applied Behavioral Analysis (ABA) and other habilitative services for Maryland members. Providers must submit preauthorization requests online at www.provider.carefirst.com or call 1-866-773-2884 (1-866-PRE-AUTH).
- ABA and habilitative diagnoses must be preauthorized.
- Preauthorization submissions: www.provider.carefirst.com or 1-866-773-2884 (1-866-PRE-AUTH).
Annual Documentation and Coding
If requested by the Plan, providers must make available annual documentation for habilitative services, including a brief medical history, a written evaluation establishing baseline data, and a treatment plan with diagnosis, short- and long-term goals, frequency and estimated duration, date of last certification by referring physician, and progress notes documenting improvement or plan changes. Habilitative services should be reported using the appropriate Category I CPT code with modifier 96 (habilitative services), effective 01/01/2018.
- Required documentation (if requested): brief medical history; written evaluation with objective tests/measurements where possible; treatment plan (diagnosis, goals, procedures, frequency per week, estimated duration); date of last certification by referring physician; progress notes.
- Billing: report habilitative services with Category I CPT code + modifier 96 (habilitative services).
Provider Responsibilities and Denial Risk
Providers must verify the member's contract for benefits before delivering services. Specific contract provisions, restrictions, and exclusions take precedence over these clinical criteria; the member contract supersedes clinical criteria adopted by CareFirst. Failure to verify the member's contract or to obtain required prior authorization may result in denial of coverage or claim payment.
- Always check the member's contract for benefits; some services, devices, drugs, and places of service require prior authorization.
- Failure to check member contract or obtain required prior authorization may lead to denial of coverage or claim payment.
Maryland Habilitative Services Mandate
Maryland mandate: habilitative services for children through the end of the month they turn 19 are covered per state requirements (minimum weekly hours specified). Prior authorization is required for ABA and habilitative services under Maryland mandates; providers should follow the Plan's provider guidelines when requesting authorizations and submitting documentation.
- Coverage minimums under Maryland mandate: 18 months–6 years: minimum 25 hours/week; 6 years–up to 19 years: minimum 10 hours/week.
- Prior authorization required for ABA and habilitative services for Maryland members.
Policy Background
Habilitative services are therapies and related services—such as physical therapy (PT), occupational therapy (OT), speech therapy (ST), and applied behavioral analysis (ABA)—that help an individual acquire, keep, or improve skills and functioning needed for daily living. These services are distinguished from rehabilitative care by their focus on development or skill acquisition rather than restoration of previously held function.
Jurisdictional mandates define coverage scope and age applicability: the District of Columbia requires coverage of habilitative services, including ABA for treatment of autism spectrum disorders, for all ages in non-grandfathered direct bill plans and applicable small-group products; Maryland’s mandate covers children through the month in which the enrollee turns 19 and specifies minimum weekly hours for intensive ABA/habilitative programs. Providers should confirm member contract applicability and prior authorization requirements before delivering services.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.