DraftMontana Department of Public Health & Human ServicesPolicy N/A

Proposed Changes to Autism State Plan — ABA services (coverage criteria)

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Defines proposed changes to Montana's Autism Treatment State Plan governing eligibility, authorization, service scope, settings, and assessment tools for ABA services for Medicaid members (children and youth up to specified ages). Affects Medicaid-enrolled members, providers of ABA, and the Developmental Disabilities Program administration.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyProposed Changes to Autism State Plan — ABA services (coverage criteria)

Policy CodePolicy N/A

Change TypeEligibility expansionauthorization and unit-package revisionscoding and assessment updates

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit notification of intent to initiate ABA services to the Department before beginning services (prior authorization is not required for the initial unit package).

SourceLink

POLICY UPDATE CHANGES

Eligibility expanded from members with Autism Spectrum Disorder (ASD) to also include Medicaid members up to age 21 with Intellectual and/or Developmental Disability and members with Serious Emotional Disturbance (SED) up to age 17 (or up to 20 if attending accredited secondary school).

Prior authorization requirement removed; providers must submit notification of intent to initiate ABA services instead of obtaining prior approval.

Provisional qualifying diagnoses allowed from licensed mental health professionals, psychologists, nurse practitioners, or physicians to begin services for an initial 180-day period, with confirmation required by a diagnostic expert for continued services.

Introduces a 1,260-unit (15-minute units) package usable over 180 calendar days before authorization is required, and expands billable CPT codes from three (97151, 97153, 97155) to eight (97151–97518).

Removes requirement that parents/caregivers be present for all ABA sessions; caregiver presence required only for caregiver-targeted training, and services may be provided in settings the provider deems appropriate.

Functional impairment criteria broadened and providers may select assessment tools beyond the Vineland to measure and track progress.

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DraftMontana Department of Public Health & Human ServicesPolicy N/A

Proposed Changes to Autism State Plan — ABA services (coverage criteria)

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Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyProposed Changes to Autism State Plan — ABA services (coverage criteria)

Policy CodePolicy N/A

Change TypeEligibility expansionauthorization and unit-package revisionscoding and assessment updates

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit notification of intent to initiate ABA services to the Department before beginning services (prior authorization is not required for the initial unit package).

SourceLink

POLICY UPDATE CHANGES

Prior authorization requirement removed; providers must submit notification of intent to initiate ABA services instead of obtaining prior approval.

Functional impairment criteria broadened and providers may select assessment tools beyond the Vineland to measure and track progress.

Coverage and Eligibility Criteria

Diagnostic Eligibility

Covered when ANY of the following diagnostic eligibility paths are met

Diagnostic eligibility: Member has a qualifying primary diagnosis of (1) Autism Spectrum Disorder (ASD) up to age 21, OR (2) Intellectual and/or Developmental Disability up to age 21 (defined as eligibility for state developmental disabilities services), OR (3) Serious Emotional Disturbance (SED) up to age 17, or up to age 20 if attending an accredited secondary school.age limits apply per diagnosis

Provisional diagnoses allowed for initiation; confirmation required for continuation after initial 180 days

Initiation and Continuation

Service initiation and continuation rules

Initiation: Services may begin under a provisional qualifying diagnosis provided by a licensed mental health professional, psychologist, nurse practitioner, or physician; provider must notify the Department of intent to initiate services; no prior authorization is required to begin services for the initial unit package.180 calendar days or 1,260 units

Qualifying provisional diagnosis must be confirmed by a qualified diagnostic expert for continued ABA services after the initial 180 calendar days or when the initial unit package is exhausted.

Unit Package and Authorization

Volume and authorization before further authorization required

Unit-package: A package of 1,260 units (each unit = 15 minutes) usable over 180 calendar days is available before authorization is required; these units may be applied across the expanded CPT code set (97151–97518) as clinically appropriate; additional units may be authorized if the package is exhausted prior to 180 days.1,260 units over 180 days

Provider must submit notification of intent to initiate services to the Department; no prior authorization required for the initial package.

The proposal does not extend coverage to adults beyond the age limits explicitly stated. Coverage remains tied to diagnosis-specific age caps: Autism Spectrum Disorder and Intellectual and/or Developmental Disability coverage is limited to members up to age 21, and Serious Emotional Disturbance is limited to members up to age 17 (or up to age 20 when the member demonstrates attendance at an accredited secondary school). There is no expansion in this proposal to cover adult populations older than these specified age limits.

The document does not list a discrete set of conditions designated as Not Medically Necessary. Instead, determinations about medical necessity or non‑medical necessity for ABA services will follow the Department’s usual clinical and administrative rules. The proposal establishes that services may begin on a provisional qualifying diagnosis from specified licensed professionals, but continuation beyond the initial period requires confirmation by a qualified diagnostic expert; NMN determinations would be made under the Department’s standard clinical-review processes rather than by new, enumerated NMN exclusions in this proposal.

Billing Codes, Units, and Limits

Proposed covered CPT Codes for ABA servicesCPTCovered

97151	Behavior identification assessment, by the physician or other qualified health care professional, with the caregiver and/or the patient
97152	Behavior identification supporting services by technician
97153	Adaptive behavior treatment by protocol delivered by technician
97154	Group adaptive behavior treatment by protocol
97155	Adaptive behavior treatment with protocol modification by physician or other qualified health care professional
97156	Family adaptive behavior treatment guidance, administered by the physician or other qualified health care professional
97157	Multiple-family group adaptive behavior treatment guidance
97518	Family training and counseling for disability and behavior management (example placeholder as included in proposed expansion)

inv-07: Unit-package — 1,260 fifteen-minute units over 180 calendar days

Unit-package total1,260 fifteen-minute units

Billing unit length15 minutes per unit

Authorized periodUsable over 180 calendar days before further authorization is required

Additional authorizationAdditional units may be authorized if the 1,260 units are exhausted before 180 days

inv-18: fifteen-minute ABA service units — 1,260

Total fifteen-minute ABA service units1,260 units

Unit duration

Provider Requirements and Administrative Actions

Prior Authorization

Prior authorization replaced by notification; unit-package available

No prior authorization is required before a member may begin receiving ABA services; instead, providers must submit documentation notifying the Department of the intent to initiate services. A package of 1,260 fifteen-minute units usable over 180 calendar days is available before authorization is required; additional units may be authorized if the package is exhausted prior to 180 days.

Providers must notify the Department of intent to initiate ABA services rather than obtain pre-service prior authorization.
A 1,260-unit (15-minute units) package over 180 calendar days is available prior to needing authorization.
If the 1,260-unit package is exhausted before 180 calendar days, additional units may be authorized.

Step Therapy

Unit-package then authorization

A defined package of 1,260 fifteen-minute units to be used over 180 calendar days is provided before any authorization is required; if all package units are used prior to the end of the 180-day period, providers may request authorization for additional units to continue services.

ABA Eligibility and Delivery Standards

ABA Eligibility and Delivery

Criteria for ABA service eligibility and delivery under proposed changes

Eligibility diagnoses: Member qualifies for ABA services if they meet ONE of: ASD up to age 21; Intellectual and/or Developmental Disability up to age 21 (i.e., eligible for state developmental disabilities services); or Serious Emotional Disturbance (SED) up to age 17, or up to age 20 if attending an accredited secondary school.age-specific

Provisional qualifying diagnoses permitted for initiation; confirmation by a diagnostic expert required for continuation after initial 180 days or when initial unit package is used.

Provider notification and authorization: Provider must submit documentation notifying the Department of the intent to initiate ABA services prior to starting; no prior authorization is required for the initial 1,260-unit package over 180 days. Additional authorization may be obtained if the package is exhausted before 180 days.

Service settings and caregiver involvement:

Service Modalities and Therapeutic Components

ABA (behavioral therapy)

Code use: Providers may use the expanded CPT code set (97151–97518) as appropriate to meet individual member needs within the unit-package and authorization rules.

Key Definitions

inv-14: Intellectual and/or Developmental Disability (ID/DD) — Definition as used in the proposal

DefinitionDefined as having been deemed eligible for receipt of state-sponsored developmental disabilities services

Coverage implicationProposed expansion includes Medicaid members up to age 21 with ID/DD

Source contextUsed to identify members eligible for ABA under the Autism State Plan expansion

inv-15: Serious Emotional Disturbance (SED) — Definition and age limits (up to 17, or up to 20 if attending accredited secondary school)

DefinitionSerious Emotional Disturbance (SED) proposed as a qualifying primary diagnosis for ABA

Age limitsUp to 17 years of age, or up to 20 years of age if the member demonstrates attendance at an accredited secondary school

Visit and Unit Limits

inv-18: fifteen-minute ABA service units — 1,260

Total fifteen-minute ABA service units1,260 units

Unit length15 minutes per unit

Usage periodUnits may be used over a 180 calendar day period before authorization is required

Codes applicabilityUnits apply across the expanded CPT code set as clinically appropriate

Background and Clinical Context

Applied Behavioral Analysis (ABA) is described in the proposal as a therapy that uses positive reinforcement to improve social, communication, and learning skills. The source characterizes ABA as widely regarded by many experts as the gold-standard treatment for children with Autism Spectrum Disorder and other developmental conditions, while noting it can also be applied to other clinical presentations.