Neighborhood Health Plan RI HBTS PASS ABA Coverage

Coverage Criteria and Limitations

inv-01: HBTS Initial Eligibility

Covered when ALL of the following are met for HBTS initial eligibility:

HBTS Initial 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 level of functioning is significantly compromised and requires services beyond typically developing peers; demonstrates impairments in one or more domains (cognitive functioning, problem solving, adaptive skills, mood regulation, or medical/neurological conditions).age <=20; condition duration >=12 months

Based on HBTS admission criteria; requires documented functional impairment and formal diagnosis within 3 years

Diagnostic and clinical documentation: A formal behavioral health or medical diagnosis (including a clinical diagnostic interview) made within 3 years by a qualified licensed health care professional, with clinical information demonstrating disability and evidence of functional impairment.

Clinical presentation and treatment need: Symptoms and behavior are consistent with the diagnosis and, based on best available clinical and evidence-based practice standards, are expected to respond to HBTS; the child presents with conditions requiring intensive therapeutic intervention and outpatient intensified services have been insufficient.

Program necessity and goals: There is evidence the child requires a comprehensive, integrated program of medical and psychosocial services to support improved functioning at the least restrictive level; individualized, measurable Treatment Plan goals with frequency and duration are documented; a previous evaluation by a licensed mental health professional within 3 years is included or documented.

Treatment Plan goals must be person/family-centered and approved by a licensed healthcare professional.

Risk and setting: The child and family require support to remain stable outside an inpatient environment or to transition from a more restrictive setting; in some instances the child may be at risk for hospitalization or out-of-home placement without HBTS (HBTS is not intended as emergency care).

Family/caregiver participation: Child, parent(s), caregiver(s), or legal guardian(s) are willing to accept and cooperate with HBTS, including required caregiver participation outlined in the HBTS Treatment Plan; the child lives at home with family/legal guardians.

inv-02: HBTS Continuing Care

Covered when ALL of the following are met for HBTS continuing care/reauthorization:

HBTS Continuing Care: Severity of condition(s) and resulting impairment continue to require this level of treatment; individualized treatment planning is maintained with realistic, specific goals and objectives; active treatment is occurring and continued progress toward goals is expected.documented measurable progress or justification for continued care

Documentation of progress: Progress in relation to goals is clearly evident, measurable, and described in observable terms; if objectives have not been achieved, documentation supports continued interventions and treatment plan adjustments are evident.

Treatment plan oversight: Individualized, measurable goals and objectives are written and approved by a licensed healthcare professional; treatment plan updates and realistic objectives are documented.

inv-03: PASS Initial Eligibility

Covered when ALL of the following are met for PASS initial eligibility:

PASS Initial Eligibility: Member is 20 years old or younger; has a chronic, moderate to severe cognitive, physical, developmental, and/or psychiatric diagnosis assessed within the last 2 years by a licensed provider competent in child psychology/psychiatry/development; meets the Federal definition of disability (marked and severe functional limitations expected >=12 months or resulting in death).age <=20; diagnosis within 2 years; duration >=12 months per federal definition

Clinical need and functioning: The child demonstrates symptoms and behavior consistent with the diagnosis that require therapeutic intervention and clinical information demonstrates disability with evidence of functional impairment (standardized assessment tools such as the Vineland are expected for continuation).

Family participation and safety assessment: Family/guardian willing to 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.

inv-04: PASS Continuing Care

Covered when ALL of the following are met for PASS continuing care/reauthorization:

PASS Continuing Care: Severity of condition(s) and resulting impairment continue to require a PASS service plan to maintain and/or improve adaptive and functional skills; clinical information demonstrates disability with evidence of functional impairment as reflected by standardized assessment tools.documented progress and use of standardized assessment

Progress and adherence: Progress in relation to goals is clearly evident, measurable, and described in observable terms; the family is adhering to requirements set forth in the PASS treatment plan.

Treatment plan scope: Treatment plan contains individualized, measurable goals and objectives addressing activities of daily living, self-preserving decision-making, and participation in social roles/settings; members live at home with consenting legal guardian or are over 18 and consent to services.

inv-05: EBP Admission Criteria

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

EBP Admission: Member meets the age requirement of the applicable EBP program (per program-specific eligibility).age per program

Risk of out-of-home placement: Member is at risk of out-of-home placement or is transitioning back from an out-of-home setting.

Diagnosis with externalizing symptoms: Member exhibits externalizing behavior symptomatology resulting in a DSM-5 diagnosis consistent with Conduct Disorder, ODD, or similar disorders requiring EBP intervention.

Multiple system involvement: Member exhibits ongoing multiple system involvement due to high-risk behaviors and/or risk of failure in mainstream school settings (e.g., complex/persistent behavioral health conditions, trauma, delinquency/truancy/running away).

inv-06: EBP Continuation Criteria

Continuation Coverage Criteria:

Continues to meet admission or need for LOC: Member continues to meet admission criteria and another level of care (more or less restrictive) is not appropriate.

Treatment plan updated: Treatment plan developed, implemented, and updated with realistic goals and objectives based on the member's condition and response to treatment.

Objective progress: Progress is clearly evident in objective terms, but goals are not yet achieved or treatment plan adjustments are documented to address lack of progress.

Family involvement: Family/caregivers are actively involved in treatment, or active persistent efforts to engage are documented and expected to lead to engagement.

inv-07: EBP Discharge Criteria

Discharge Coverage Criteria:

Discharge: ONE of: Member's documented treatment plan goals have been substantially met (including discharge plan); or member/family no longer meet admission criteria or meet criteria for a different level of care; or member/family have not benefited despite documented engagement efforts and there is no reasonable expectation of progress at this level, or member/guardian withdraws consent; or member is clinically appropriate for routine outpatient treatment.

inv-08: ABA Criteria

ABA Admission, Continuation, and Discharge Criteria:

ABA Admission: ALL: comprehensive diagnostic and/or functional assessment completed (examples: ABLLSR, Vineland-II, ADI-R, ADOS-G, CARS2, VB-MAPP, Autism Behavior Checklist); member exhibits atypical or disruptive behavior that significantly interferes with functioning or poses risk (aggression, self-injury, property destruction); initial evaluation from a Licensed Applied Behavior Analyst supports ABA; diagnostic report clearly states diagnosis and evidence; if member <3 years, valid PCP referral to early intervention and acceptance by early intervention for intensive services is required.

ABA Continuation: ALL: member continues to meet admission criteria; reasonable expectation of benefit exists; individualized treatment planning is updated based on progress; initial assessment from a Licensed Behavior Analyst supports continued services; progress is monitored with behavioral graphs, progress notes, and daily session notes; documented skills transfer and transition planning; documented attempts at coordination of care; parent/guardian training involvement documented; services are not duplicative of IEP/ISP supports.

ABA Discharge: ONE of: treatment plan goals met; adequate stabilization of challenging behavior and less-intensive modes appropriate; member no longer meets admission criteria or meets criteria for different LOC; treatment worsens symptoms; no progress despite efforts; home safety risks to staff; parent/guardian not following program rules.

inv-09: Coverage criteria for HBTS/PASS/Respite

Covered when ALL of the following are met for children under 21:

Eligibility and clinical need: Member is under 21 years old and lives at home; requires an institutional level of care at home (typically provided in a hospital, nursing facility, or ICF-IID) but does not require 24-hour medical/nursing monitoring that would necessitate inpatient care.

Regulatory and provider standards: Services must comply with Rhode Island EOHHS certification or practice standards applicable to HBTS, ABA, and PASS; ABA services must be overseen by a BCBA or appropriately licensed/trained professional; services must be ordered by an authorized practitioner.

Services are noncovered for members 21 years and older. HBTS is not intended to replace clinically necessary therapies such as emergency psychiatric care, psychiatric hospitalization/treatment, or licensed therapeutic services including speech/language therapy, occupational therapy, and physical therapy. HBTS must represent an integrated, measurable Treatment Plan approved by a licensed health care professional and is not a substitute for higher-intensity or emergency services.

HBTS may not be provided concurrently with other specified intensive programs such as Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS). Members whose level of required structure or supervision exceeds the scope of HBTS, or whose medical conditions prevent beneficial utilization of HBTS, are excluded from coverage.

Coverage varies by line of business. For Medicaid lines (for example RIte Care and related Medicaid LOBs) HBTS/PASS/Respite/EBP/ABA are limited to pediatric members and are noncovered for members 21 years and older. For commercial members (Health Benefits Exchange / HBE), these services are non-covered for members age 20 and older and, more broadly, HBTS, EBP, PASS, and Respite are listed as non-covered for Commercial members.

Providers must confirm the member's applicable line of business and age-based eligibility prior to authorization submission because age cutoffs and LOB-specific exclusions differ between Medicaid and Commercial plans and will determine whether prior authorization can be considered.

Members who require 24-hour medical or nursing monitoring or procedures available only in a hospital are excluded from HBTS/PASS/Respite coverage. Coverage is also excluded when a member has medical conditions or impairments that would prevent beneficial utilization of the home/community-based services.

Additionally, members residing in specialized foster care through DCYF are identified as not appropriate for these services under this policy and should not be authorized for HBTS/PASS/Respite when that placement applies.

Physical, occupational, and speech therapy are covered under the member's medical benefit and are not to be billed as HBTS/PASS services. Services that are part of a child’s Individualized Education Program (IEP) necessary to provide a Free and Appropriate Public Education (FAPE) are the responsibility of the Local Education Agency (LEA)/school district and are not payable by Neighborhood.

HBTS and PASS are intended to complement, not replace, licensed clinical therapy or school-based educational services. Distinctions from other services (such as PASS, HBTS, and ABA) include scope limits: HBTS/ABA focus on therapeutic behavioral interventions in the home/community, PASS is consumer-directed personal assistance, and services documented in an IEP remain the LEA’s responsibility.

PASS is not intended for individuals exhibiting marked impairments in self-control (for example, significant aggression or conduct problems), nor for those with severe disturbances in thinking, perception, or mood, or for individuals whose primary needs are learning disabilities. PASS must comply with Rhode Island practice standards and is not an appropriate substitute for services requiring intensive clinical management or private duty nursing.

HBTS will not provide medication administration and must not be used to replace licensed clinical therapy or educational services provided under an IEP. HBTS staff are not authorized to perform private duty nursing functions or tasks reserved for licensed medical personnel.

HBTS/ABA are intended to deliver therapeutic behavioral interventions, supervise and train direct-care staff, and implement measurable Treatment Plan goals — not to assume roles such as medication administration or school-based instruction.

HBTS is not intended for emergency care and should not be used as a substitute for crisis or inpatient psychiatric treatment. Services are considered not medically necessary when the member requires a level of structure or supervision beyond the scope of HBTS (for example, 24-hour supervision or hospital-level care).

If a member’s clinical needs indicate that emergency intervention, inpatient admission, or other higher-intensity services are required, HBTS should not be initiated or continued in place of those services.

Continuation or initiation of HBTS, PASS, ABA, or other covered home/community-based services is not medically necessary when there is an absence of any documented meaningful (i.e., durable and generalized) measurable improvement or stabilization of challenging behavior and there is no reasonable expectation of progress despite documented engagement efforts.

Services may be discontinued if treatment is making symptoms persistently worse, the home environment presents safety risks to staff, or the parent/guardian is not following program rules despite documented attempts at remediation.

Authorization and Billing Codes

Covered Codes / Authorization coding referencemixed

affected codes

See Authorization Quick Reference Guide on payer website for specific covered procedure codes.

HBTS weekly hours

Weekly maximumUp to 20 hours per week (excluding ABA programs)

Documentation requiredHours must be substantiated through documented medical necessity and measurable Treatment Plan goals with frequency and duration

Scope noteLimit applies to HBTS treatment hours; ABA hours are excluded from this weekly cap

HBTS treatment hours (excluding ABA)

Treatment hours (non-ABA)Up to 20 hours per week

RequirementMust be supported by medical necessity and measurable goals in the Treatment Plan

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for admission to Home Based Therapeutic Services (HBTS) and for ABA programs. Use Neighborhood Health Plan of Rhode Island prior authorization request forms available on the provider website and follow the Authorization Quick Reference Guide. Treatment Plan approval must document a formal behavioral health or medical diagnosis (within 2–3 years as applicable), measurable goals with frequency and duration, evidence of functional impairment, and that less intensive outpatient services were insufficient or inappropriate. Providers must submit comprehensive assessments and documentation to support medical necessity, including initial and ongoing progress documentation for continuation requests.

Providers must use Neighborhood prior authorization request forms (www.nhpri.org → Providers → Provider Resources → Forms).
Treatment Plan must include diagnosis, measurable goals with frequency/duration, caregiver participation, and documentation that outpatient services at intensified level were insufficient.
For ABA admission: documented comprehensive diagnostic/functional assessment (e.g., ABLLSR, Vineland-II, ADI-R, ADOS, CARS2, VB-MAPP).
For ABA continuation: regular monitoring with behavioral graphs, progress notes, daily session notes, documented skills transfer, updated treatment plan, and evidence a Licensed Behavior Analyst supports services.

Definitions and Service Descriptions

HBTS — Home-Based Therapeutic Services

DefinitionHome-Based Therapeutic Services (HBTS) is an intensive home or community-based service more intensive than outpatient but less restrictive than inpatient/residential care, delivered one-on-one to child and family with documented progress toward Treatment Plan goals.

ComponentsPhased, in-person, high-frequency specialized treatment that can include ABA, PASS, Respite, treatment coordination, direct services, and supervision of direct care staff.

IntegrationAn integrated HBTS Treatment Plan may include assessment, treatment consultation, coordination, specialized treatment, therapy consults, and child-specific orientation for home-based workers.

PASS — Personal Assistance Services and Supports

DefinitionPersonal Assistance Services and Supports (PASS) is a consumer-directed, comprehensive program of intermittent, limited, or extensive one-to-one personal assistance services to support functioning in natural community settings, with the family directing service delivery.

Level-of-Care Criteria for Programs

inv-40: Home-Based (HBTS)

Home-Based (HBTS) — Level-of-care criteria (top-level nodes):

Admission to HBTS (top-level): Child/adolescent meets HBTS Initial Eligibility criteria: age <=20, chronic condition >=12 months, documented functional impairment, formal diagnosis within 3 years, outpatient intensified services insufficient, requires comprehensive integrated program, family willing to participate.age <=20; condition duration >=12 months

Continued Stay (top-level): Severity and impairment continue to require HBTS level; individualized measurable treatment planning in place; active treatment with documented measurable progress or justification for continued care.

Discharge (top-level): ONE of: Treatment Plan goals substantially met; no longer meets admission/continuation criteria or meets criteria for different LOC; no benefit despite documented engagement efforts or withdrawal of consent; unsafe home environment or parent/guardian noncompliance.

Applied Behavior Analysis Specific Criteria and Oversight

inv-44: ABA Services (subset of HBTS)

ABA Services (subset of HBTS) — key point:

ABA within HBTS: ABA services are a reimbursable subset of HBTS and follow HBTS documentation and medical necessity requirements; HBTS hour limits exclude ABA programs and ABA must be integrated into the HBTS Treatment Plan with measurable goals and supervision of direct care staff.see HBTS thresholds

ABA-specific oversight and documentation requirements apply

inv-45: Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) — program overview and provider roles:

ABA definition: ABA is the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement; uses direct observation, measurement, and functional analysis; parental/caregiver involvement is critical.

Evidence-Based Practices and Treatment Modalities

inv-47: Evidence-Based Practices (MST, PLL, TST, Family Centered Treatment)

Evidence-Based Practices (MST, PLL, TST, Family Centered Treatment) — examples and criteria:

Evidence Based Practices: EBP services include Multisystemic Therapy (MST), Parenting with Love and Limits (PLL), Trauma Systems Therapy (TST), Family Centered Treatment and other intensive family/community-based programs; these are time-limited, intensive modalities with specific age eligibilities and program features.age-specific where noted

inv-48: Examples of EBPs and ABA

Examples of EBPs and ABA — illustrative programs and examples:

Named EBPs and features: Named programs described include MST (ages 12-17), PLL (6-week active phase plus aftercare), Functional Family Therapy, TACT (ages 12-20), TST (ages 5-20), Triple P, and others; ABA modalities and techniques (discrete trial, verbal behavior, pivotal response) are listed as examples of ABA types.

Service Frequency and Visit Limits

HBTS treatment hours (excluding ABA)

Weekly cap (non-ABA)Up to 20 hours per week

Documentation expectationHours must be substantiated by medical necessity and measurable Treatment Plan goals with frequency and duration specified.

ABA exclusionABA programs are excluded from this HBTS weekly hours limit.

Background and Context

Home-Based Therapeutic Services (HBTS) are an intensive home and community-based behavioral health service that is more intensive than routine outpatient care but less restrictive than inpatient or residential treatment. HBTS is delivered one-to-one to the child and family with an integrated Treatment Plan containing measurable goals and objectives approved by a licensed healthcare professional.

HBTS may include Applied Behavior Analysis (ABA) as a reimbursable subset and focuses on improving functioning to allow the child to remain at home or transition from a more restrictive setting; services are time-limited, closely monitored, and require documentation of progress toward individualized goals.

OpenPayer

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