Neighborhood Health Plan RI HBTS/ABA/PASS Coverage

Coverage & Medical Necessity Criteria

Initial HBTS Eligibility

Covered when ALL of the following are met:

Initial HBTS eligibility: Member is 20 years old or younger; has a chronic (>=12 months) moderate or severe cognitive, developmental, medical/neurological, and/or psychiatric condition whose functioning is significantly compromised requiring services beyond typically developing peers; demonstrates impairments in one or more domains (cognitive functioning, problem-solving, adaptive skills, mood regulation, or medical/neurological conditions); a formal behavioral health or medical diagnosis documented within 3 years by a qualified licensed clinician; symptoms consistent with diagnosis and expected to respond to HBTS intervention; intensified outpatient services have been insufficient; evidence the child requires a comprehensive, integrated program to support functioning in the least restrictive setting; child/family require support to remain stable outside inpatient or to transition from a more restrictive setting; and parent(s)/caregiver(s)/legal guardian accept and cooperate with HBTS including required degree of caregiver participation.age <=20; chronicity >=12 months

Sourced from HBTS initial eligibility criteria (chunks 6, 8, 2).

Continuing HBTS Eligibility

Covered when ALL of the following are met:

Continuing HBTS eligibility: Severity of the condition and resulting impairment continue to require this level of treatment; the mode, intensity, and frequency of services are consistent with evidence-based goals; active treatment is occurring with measurable, observable progress; if objectives have not yet been achieved, documentation supports continued interventions; individualized, measurable objectives are in place and approved by a licensed healthcare professional; prior evaluations have occurred within required timeframes.ongoing measurable progress

Continuation/reauthorization requirements from chunk 9.

Initial PASS Eligibility

Covered when ALL of the following are met:

Initial PASS eligibility: Member is 20 years old or younger; meets the Federal definition of disability with marked and severe functional limitations expected to persist >= 12 months or to result in death; has a chronic moderate-to-severe cognitive, physical, developmental, and/or psychiatric diagnosis documented within the last two years by a licensed clinician with competence in child psychology/psychiatry or child development; demonstrates symptoms requiring therapeutic intervention; child and caregivers accept and cooperate with PASS including required parental participation; a minimum of one home visit to assess health and safety must occur before plan submission/authorization; severity and functional impairment are documented using a standardized assessment tool (e.g., Vineland) as applicable.age <=20; diagnosis within 2 years; disability expected >=12 months

PASS initial criteria from chunk 14.

Continuing PASS Eligibility

Covered when ALL of the following are met:

Continuing PASS eligibility: Progress is clearly evident, measurable, and described in observable terms; family adheres to PASS treatment plan requirements; individualized, measurable objectives addressing activities of daily living, participation in social roles/settings, and decision-making are in place; member lives at home with consenting legal guardian or is over 18 and consents to treatment; ongoing documentation supports continued need for PASS services.observable progress and adherence

PASS continuation criteria from chunk 15.

Discharge Criteria

Discharge is appropriate when ANY of the following are met:

HBTS discharge: The child's documented Treatment Plan objectives have been successfully met; or the child no longer meets service initiation or continuing care criteria (or meets criteria for a less or more intensive level of care); or consent for treatment has been withdrawn by a youth 18+ or their parent/legal guardian; or parent/guardian is not engaged to a degree that the service is effective or safe despite multiple documented attempts; or there is no reasonable expectation of progress with the current treatment plan.N/A

HBTS discharge conditions from chunk 10.

PASS discharge: The child's documented Service Plan objectives have been successfully met; or the child meets criteria for a different level of care; or the recipient (age 18) or parent/legal guardian withdraws consent for treatment; or loss of Medicaid eligibility occurs.N/A

PASS discharge conditions from chunk 16.

EBP Initial Admission

Admission Criteria: The member meets all of the following eligibility criteria:

Admission Criteria (EBP): Member meets the age requirement of the applicable EBP program; presents externalizing behavior symptomatology resulting in a DSM-5 diagnosis consistent with conduct disorder/ODD/behavior disorder; is at risk of out-of-home placement or transitioning back from an out-of-home setting; exhibits ongoing multiple-system involvement due to high-risk behaviors and/or risk of failure in mainstream school settings; less intensive treatment has been ineffective or inappropriate; there is an expectation for improvement with EBP services; member currently does not have any other therapeutic behavioral health home-based treatment service in place; treatment will occur in a safe and stable home residence (not in residential treatment facilities); parent/guardian agrees to actively participate in the jointly developed treatment plan; and ONE of the following is met: discharged from a more restrictive LOC within past 30 days, recent admission within 6 months to a more restrictive LOC, evaluated and determined to need diversionary services to avoid a more restrictive LOC, or an EBP intervention was recently successful and continued involvement is likely to stabilize the family.all met

EBP admission criteria and required OR condition from chunks 23-25.

EBP Continuation

Continuation of Evidence Based Practices are appropriate when ALL of the following are met:

Continuation Criteria (EBP): Member continues to meet admission criteria and another level of care is not appropriate; a treatment plan has been developed, implemented, and updated with realistic goals and objectives; progress is clearly evident in objective terms though goals are not yet achieved or treatment adjustments are evident; family/caregivers are actively involved or persistent efforts to engage are occurring; medication assessment has been completed when appropriate; coordination of care and active discharge planning toward a less intensive setting are occurring; and member continues not to have any other therapeutic behavioral health home-based treatment service in place.all met

EBP continuation criteria from chunks 26-27.

EBP Discharge

Discharge is appropriate when ONE of the following is met:

Discharge Criteria (EBP): Member's documented treatment plan goals have been substantially met (including discharge planning); or the member/family no longer meet admission criteria or meet criteria for a different level of care; or the member/family have not benefited despite documented engagement efforts and there is no reasonable expectation of progress at this level; or the member/parent/guardian withdraws consent for treatment; or the member is clinically appropriate for routine outpatient treatment in an office or community-based setting.one met

EBP discharge criteria from chunk 28.

ABA Initial Admission

Admission Criteria: Admission for ABA Therapy is appropriate when ALL of the following criteria are met:

ABA Admission: Member has received a comprehensive diagnostic and/or functional assessment (examples: ABLLS-R, Vineland-II, ADI-R, ADOS, CARS-2, VB-MAPP, Autism Behavior Checklist); member exhibits atypical or disruptive behavior that significantly interferes with daily functioning or poses risk (aggression, self-injury, property destruction); an initial evaluation from a Licensed Applied Behavior Analyst supports the request for ABA services; the diagnostic report clearly states the diagnosis and the evidence used to make that diagnosis; and if the member is <3 years old and early intervention applies, there is a valid PCP referral and acceptance into early intervention for intensive services.all met

ABA admission criteria from chunks 33-34.

ABA Continuation

Continuation Coverage Criteria: Continuation of ABA Therapy is appropriate for ASD when ALL of the following are met:

ABA Continuation: Member's condition continues to meet admission criteria; there is a reasonable expectation of benefit from continued ABA services; treatment planning is individualized and updated based on progress with realistic goals; initial assessment from a Licensed Behavior Analyst supports continued services; member's progress is monitored regularly (behavioral graphs, progress notes, session notes) and the plan is modified if there is no measurable progress; documented skills transfer and transition planning are present from the start of treatment; parent(s)/guardian(s) involvement in behavioral techniques is documented; and services are not duplicative of services provided under an IEP or ISP when applicable.all met

ABA continuation criteria from chunk 35.

ABA Discharge

Discharge from ABA Therapy is appropriate when ONE of the following is met:

ABA Discharge: Member's individual treatment plan goals have been met; or the member has achieved adequate stabilization allowing transition to less-intensive treatment; or the member no longer meets admission criteria or meets criteria for a different level of care; or treatment is making symptoms persistently worse; or the home environment presents safety risks to staff; or the member is not making progress as demonstrated by absence of meaningful, durable, generalized measurable improvement with no reasonable expectation of progress; or parent/guardian is not successfully following program rules.one met

ABA discharge criteria from chunks 36-37.

Discharge Criteria

Coverage and discharge criteria and eligibility highlights for ABA/HBTS/Respite services

Discharge conditions for ABA: Discharge from ABA Therapy is appropriate when ONE of the following is met: individual treatment plan goals have been met; member has achieved adequate stabilization such that less-intensive treatment is appropriate; member no longer meets admission criteria or meets criteria for a different level of care; treatment is making symptoms persistently worse; the home environment presents safety risks to staff; member is not making progress toward treatment goals with no reasonable expectation of progress; or parent/guardian is not following program rules.

ABA discharge summary from chunks 36-37.

HBTS discharge summary: Discharge from HBTS is appropriate when treatment plan objectives have been achieved; member no longer meets initiation or continuing care criteria or requires a different level of care; consent withdrawn by eligible youth or guardian; parent/guardian non-engagement despite documented attempts; or no reasonable expectation of progress with current plan.

HBTS discharge highlights from chunk 10.

Respite eligibility highlights: Children under age 21 who live at home and require an institutional level of care at home (care typically provided in hospital, nursing facility, or ICF-IID) are eligible for Respite services.

Respite / HBTS Eligibility

Respite and institutional-level HBTS eligibility — Covered when ALL of the following are met:

Respite eligibility (children under 21): Child is under age 21; child lives at home; and the child requires an institutional level of care at home that is typically provided in a hospital, nursing facility, or an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID).age <21

Respite eligibility requirements from chunks 39-40.

HBTS institutional-level criteria: When HBTS is used to deliver an institutional level of care at home, documentation must demonstrate the level of care required and that services meet state certification standards; providers must follow RI EOHHS certification requirements for HBTS and Respite services.

Derived from respite and HBTS certification language in chunks 39-40 and 44.

Exclusions / Noncovered Services

Services are NOT covered when ANY of the following apply:

General exclusions: Services primarily for school/educational purposes (IEP-covered services) are not covered; physical/OT/PT/speech services are covered under the medical benefit and not by HBTS/PASS; administration of medication by HBTS/PASS staff is not permitted; services that are investigational or unproven (e.g., facilitated communication, Auditory Integration Therapy, Holding Therapy, Higashi) are not reimbursed; services provided for convenience or duplication of other covered services will not be covered; services for Medicaid members age 21 and older are noncovered.

General exclusions and noncoverage rules from chunks 43, 44, 38.

Service sequencing/duplication exclusion: HBTS may not be provided when Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS) are being used; duplication of same/similar services is not allowed.

Service sequencing and duplication restrictions from chunk 44.

Services are noncovered for members 21 years and older under Medicaid. HBTS may not be provided when Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS) are being used. Members living in specialized foster care through DCYF are excluded from HBTS coverage.

HBTS/EBP are not appropriate when the member requires a level of structure or 24-hour supervision beyond the scope of home- or community-based services. Coverage is excluded if the member is living independently without an identifiable primary caregiver despite extensive efforts, or when the member’s needs fall outside the intended scope of EBP (for example, when 24-hour medical/nursing monitoring is required).

Physical, occupational, and speech therapies are covered under the member’s medical benefit and are not reimbursed through HBTS/PASS. Services identified in a child’s IEP are the responsibility of the Local Education Agency (LEA). The administration of medication prescribed by a licensed practitioner cannot be performed by HBTS or PASS staff.

HBTS is not intended to replace clinically necessary therapies such as emergency behavioral health treatment, psychiatric care, speech/language therapy, occupational therapy, or physical therapy. HBTS is an integrated program of measurable objectives approved by a licensed healthcare professional and is meant to complement, not substitute for, these clinically necessary services.

For Medicaid members, services for members 21 years and older are noncovered. Services that are investigational or unproven (for example: facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, Higashi/Daily Life Therapy) are not reimbursed. Coverage may also be denied when services are primarily for school/educational purposes, duplicate services covered elsewhere, or when the member has medical conditions that prevent beneficial utilization of HBTS/PASS.

Billing Codes & Limits

Covered CPT/HCPCS Codes (referenced)mixed

See Authorization Quick Reference Guide

Covered Codes

HBTS weekly hours — summary

HBTS weekly treatment hoursUp to 20 hours per week (excluding ABA programs); must be documented with medical necessity, frequency, and duration

ABA exclusion from HBTS capABA programs are excluded from the 20 hours/week HBTS cap (ABA intensity is determined separately)

Documentation requirementEach HBTS service hour must be substantiated through the Treatment Plan with measurable frequency and duration

Authorization, Documentation & Operational Requirements

Prior Authorization

Authorization prerequisite requirements — Treatment Plan approval

Treatment Plan approval requires meeting initial eligibility criteria including age, documented diagnosis and functional impairment, evidence that intensified outpatient services were insufficient, medical/neurological conditions contributing to impairment, willingness of the family/caregiver to participate, and at least one home visit to assess health and safety prior to authorization. Continuing care/reauthorization requires ongoing severity of condition, individualized measurable objectives, documented progress toward goals, regular monitoring, and coordination with relevant providers.

Member must be 20 years old or younger for coverage (see age limitations for lines of business).
A formal behavioral health or medical diagnosis (clinical diagnostic interview) made within 3 years by a qualified licensed provider is required and must demonstrate functional impairment.
Outpatient services provided at an intensified level must have been insufficient to meet the child's needs prior to HBTS authorization.
At least one home visit to assess health and safety must occur before submission/authorization of the plan.
Family/caregiver acceptance and cooperation with the HBTS Treatment Plan (including required caregiver participation) must be documented.

Key Terms & Program Definitions

HBTS — definition and scope

DefinitionAn intensive home- or community-based service more intensive than outpatient and less restrictive than inpatient, providing one-on-one therapeutic services and supervision of direct care staff as part of an integrated HBTS Treatment Plan

Service componentsIncludes pre/post treatment consultation, treatment consultation, coordination, HBTS direct services, specialized treatments (including ABA subset), therapy consults, assessment and treatment planning

Setting and purposeDelivered in natural settings (home/community) to support child and family with documented progress toward Treatment Plan goals

PASS — definition and components

DefinitionPersonal Assistance Services and Supports (PASS) is a comprehensive, integrated, consumer-directed program of intermittent, limited, or extensive one-to-one personal assistance to support the child and family in natural community settings

Program-Level Eligibility & Care Intensity

Home/Community-Based (HBTS/PASS)

ABA as a subset of HBTS: ABA is a specialized subset of HBTS: ABA services are included within the HBTS phased system and must be delivered as part of an integrated HBTS Treatment Plan with measurable goals and appropriate supervision; HBTS weekly hour guidance (up to 20 hours/week) excludes ABA programs which may have separate intensity rules; ABA sessions are one-on-one and supervised by a Licensed Applied Behavior Analyst.refer to HBTS rules

From HBTS definition and HBTS weekly hours (chunks 2,5).

Home and Community Based EBP

EBP modalities: Evidence Based Practices (EBP) include community/home-based modalities such as Multisystemic Therapy (MST), Parenting with Love and Limits (PLL), Trauma Systems Therapy (TST), Functional Family Therapy, Teen Assertive Community Treatment (TACT), and Triple P Positive Parenting Program; these are examples of EBPs available in Rhode Island for children with complex needs.

EBP examples and modality ages from chunks 18,19,21.

Applied Behavior Analysis Requirements

ABA (subset of HBTS)

ABA is described in policy as a specialized subset of HBTS:

ABA subset summary: ABA is included as a specialized treatment within the HBTS phased system; ABA services must be part of an integrated Treatment Plan focused on measurable progress, overseen by a Licensed ABA provider, and the HBTS weekly hours guidance (up to 20 hours/week) excludes ABA which may follow separate intensity rules.

Derived from HBTS description and HBTS hours guidance (chunks 2,5).

ABA Criteria Summary

ABA program requirements and criteria:

ABA Program Admission and Continuation: ABA requires a comprehensive diagnostic/functional assessment (examples listed), initial evaluation and ongoing oversight by a Licensed Applied Behavior Analyst, documentation of significant disruptive behaviors interfering with functioning or posing safety risk, individualized treatment plan with measurable objectives, documented parent/caregiver involvement and skills transfer, regular outcome monitoring (behavioral graphs, progress notes), coordination of care, and services must not duplicate IEP/ISP services.

Evidence Based Practices & Program Types

Evidence Based Practices (MST, PLL, TST)

EBP inclusion: Evidence Based Practices (EBP) include Multisystemic Therapy (MST), Parenting with Love and Limits (PLL), and Trauma Systems Therapy (TST) among other community/home-based modalities designed for children with complex needs.

EBP examples from chunks 18-19.

EBP modalities

EBP modalities examples: Examples of EBP modalities include MST, PLL, TST, Functional Family Therapy, Teen Assertive Community Treatment (TACT), and Triple P Positive Parenting Program; applicable age ranges for programs vary by modality (examples cited: 5–20 or 12–20 years depending on program).

EBP modality details and ages from chunks 19 and 21 and ABA definition in chunk 30.

ABA

Service Frequency & Duration Limits

HBTS treatment hours (excluding ABA)

HBTS treatment hours (non-ABA)Up to 20 hours per week (excluding ABA programs); hours must be supported by Treatment Plan documentation of medical necessity

Documentation of frequency/durationTreatment Plan must specify measurable frequency and duration for each service delivered

ABA programs excludedThe 20-hour weekly limit does not apply to ABA programs (ABA intensity governed separately)

Program Purpose & Context

Home-Based Therapeutic Services (HBTS) are an intensive home- or community-based treatment delivered one-on-one and designed to be more intensive than standard outpatient care but less restrictive than inpatient or residential services. HBTS provides therapeutic interventions, supervision of direct care staff, and integrated Treatment Plans with measurable objectives to support functioning in natural settings and to avoid more restrictive levels of care when possible.

OpenPayer

Behavioral Health: Home and Community Based Services (HBTS, ABA, PASS)

Coverage & Medical Necessity Criteria

Billing Codes & Limits

Authorization, Documentation & Operational Requirements

Key Terms & Program Definitions

Program-Level Eligibility & Care Intensity

Applied Behavior Analysis Requirements

Evidence Based Practices & Program Types

Service Frequency & Duration Limits

Program Purpose & Context