Proposed Changes to Autism State Plan: ABA Services Coverage Criteria
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Proposed changes to Montana's Autism State Plan governing Medicaid-covered ABA services for members up to age 21, expanding eligible diagnoses, modifying prior authorization and service unit rules, and changing caregiver presence and assessment requirements.
Expand ABA services to include Medicaid members up to age 21 with a primary mental health condition or a diagnosis of intellectual disability.
Allow members to begin receiving ABA based on a diagnosis the ABA provider believes qualifies, with a required confirmation by a diagnostic expert for continued services after the initial 6 months or service package.
Remove requirement for prior authorization before a member can begin receiving ABA services.
Provide an initial package of 1,260 service units (15-minute units) over 6 months available before authorization is required, with additional 1,260-unit packages authorizable if all units are used.
Remove requirement that caregivers/parents must always be present and participating during ABA treatment.
Allow BCBAs to choose the assessment tool they deem most useful instead of requiring Vineland testing and scores.
Coverage Criteria for ABA Services
General ABA coverage
Covered when ALL of the following are met:
ABA providers may initiate services based on a diagnosis they believe qualifies; confirmation by a diagnostic expert is required for continued services after the initial 6‑month period or after the initial service‑unit package has been used.
Additional 1,260‑unit packages may be authorized if all units have been used and continued services are clinically indicated.
Vineland testing is no longer mandated; provider choice of assessment is allowed.
The proposed changes revise the Autism State Plan to expand who may receive Medicaid-covered Applied Behavioral Analysis (ABA) services and to adjust how services begin and continue. Key policy shifts include expanding eligibility to Medicaid members up to age 21 with a primary mental health condition or with an intellectual disability (as defined by Developmental Disabilities Program eligibility), permitting ABA providers to initiate services based on a diagnosis they believe qualifies, and removing the requirement for prior authorization before the initial service package. These changes are intended to improve access and reduce delays in starting ABA treatment while retaining requirements for diagnostic confirmation if services continue beyond the initial period.
The proposed revision does not list any explicit exclusions or conditions labeled as "not medically necessary." No specific services or diagnoses are identified in the provided text as being excluded from coverage under the revised Autism State Plan.
Applied Behavioral Analysis Specific Criteria
ABA-specific criteria
Proposed ABA service rules and provider practices
If services continue beyond the initial 6 months or after the initial 1,260‑unit package, the qualifying diagnosis must be confirmed by a professional with expertise in the diagnostic area.
Units apply across an expanded list of billable codes and may be used per provider clinical judgment.
Services may occur in home, community, or other settings the ABA provider deems appropriate.
The policy removes the prior requirement mandating Vineland testing and scoring for access to services.
Service Units and Coding
Visit Limits and Unit Packages
Provider Actions, Authorization, and Documentation
Prior authorization not required to start; required for additional packages
No prior authorization is required to begin ABA services; however, additional service packages beyond the initial 1,260 units (6 months) must be authorized by the Department if further services are needed.
Initial 1,260-unit package available before authorization
An initial package of 1,260 service units (each unit = 15 minutes) is available to the member to use over a 6-month period before any authorization is required. Additional packages of 1,260 units may be authorized if all units have been used and continued services are clinically indicated.
- Initial package: 1,260 units over 6 months (1 unit = 15 minutes).
- Additional 1,260-unit packages may be authorized before the 6-month period ends if all units have been used and continued services are needed.
Document initial diagnosis, confirmations, and unit-tracking
Document the initial qualifying diagnosis used to start ABA services and maintain records of subsequent diagnostic confirmation if services continue beyond the initial 6-month/1,260-unit package. Track use of the initial 1,260-unit packages and any requests for additional packages.
- Record the diagnosis relied upon by the ABA provider to initiate services.
- Retain documentation of confirmation by a diagnostic expert if services extend past the initial period or unit package.
- Track units used from each 1,260-unit package and document requests for authorization of additional packages.
Specialist confirmation required for continuation after initial period
Continued ABA services after the initial 6-month period and/or after the initial 1,260-unit package requires confirmation of the qualifying diagnosis by a professional with expertise in the diagnostic area.
- ABA providers may initiate services based on a diagnosis they believe qualifies, but continuation beyond the initial period is contingent on specialist confirmation.
Definitions
Background
Applied Behavioral Analysis (ABA) is described in the source as a therapy that can improve social, communication, and learning skills through positive reinforcement. The document states that many experts consider ABA to be the gold-standard treatment for children with Autism Spectrum Disorder (ASD) and other developmental conditions, and notes that ABA may also be used for other conditions.
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