Applied Behavior Analysis (ABA) coverage criteria — Section A. Coverage Criteria
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Comments and recommendations to New Mexico Health Care Authority about Section A Coverage Criteria for Specialized Behavioral Health Services, focusing on ABA benefit eligibility, provider roles, prior authorization, age limits, and diagnosis-specific restrictions. Affects state Medicaid behavioral health policy and providers delivering ABA services in New Mexico.
Request removal of 'age out' criterion from coverage language.
Recommend removing diagnosis-specific coverage criteria for ABA and adopting diagnosis-neutral, medical-necessity-based criteria.
Clarify residential access so Stage 2/3 ABA services are available based on an approved medical provider diagnosis even if a CDE/evaluation is pending.
Add BCBA involvement on UR review teams and include 'Behavior Analyst Candidate' as an eligible provider category.
Establish referral pathway to UR contractor for prior authorization to ABA specialty providers for targeted assessment and intervention.
Requested Coverage Criteria & Age-Based Decisions
Requested Coverage Criteria Changes
Submitter recommendations regarding coverage criteria
Cites multiple sources and practice guidelines arguing ABA procedures are effective across diagnoses and populations.
References BACB Practice Guidelines and submitter request to remove age-based termination language.
Intended to protect adults in residential care from diagnostic bottlenecks and provider shortages.
Recommendation cites BACB guidance that reviewing bodies include an experienced Behavior Analyst for appeals and complex determinations.
The commenter requests removal of the policy provision that permits an “age out of comprehensive ABA services” as a basis for denying or terminating Applied Behavior Analysis (ABA) services. They argue that age-based exclusions are not consistent with standards of care or the Behavior Analyst Certification Board (BACB) Practice Guidelines, and therefore ask NMHSD to eliminate any criterion that discontinues comprehensive ABA solely because a recipient reaches a certain age.
The letter challenges use of chronological age as a determinant of medical necessity for ABA, asserting that treatment intensity and eligibility should be driven by individual clinical need rather than an arbitrary age threshold. The submitter specifically asks NMHSD to delete or not apply any “age out” language that would end comprehensive ABA services when a recipient reaches a designated age, citing alignment with BACB guidance.
Referrals, Prior Authorization, and UR Involvement
Refer to UR contractor for ABA specialty prior authorization
When the AP cannot fully support a recipient because the recipient's behavior exceeds the AP's expertise or the AP's logistical/practical ability to fully support them, the AP may refer the recipient to the recipient's UR contractor for prior authorization to permit an ABA specialty care provider to complete a targeted assessment (including a functional assessment) and to provide or implement individualized interventions.
Add BCBA to UR review team for ABA prior authorization decisions
Include a Board Certified Behavior Analyst (BCBA) on the UR review team so that decisions about the appropriateness of ABA interventions and the design and dosage of ABA treatment are informed by a clinician with specialized training in behavior analysis.
- Recommendation cites BACB guidance that reviewers include a Behavior Analyst with experience in ABA when there are questions about appropriateness or efficacy, including appeals.
Allow Stage 2/3 ABA access for residential residents while awaiting MAD CDE/evaluation
Clarify that residents of residential facilities may access Stage 2 and Stage 3 ABA services when they have a diagnosis from an approved medical provider while they await a MAD-recognized CDE or targeted evaluation, to avoid delayed care for adults in residential settings.
- Current Section B(6) assigns responsibility to residential facilities to locate a MAD-enrolled AP if the facility is not an AP for Stage 2/3 services.
- Submitter requests explicit allowance to begin Stage 2/3 services based on an approved medical provider diagnosis pending MAD-recognized evaluation.
Prior authorization may be required before specialty ABA referral
Prior authorization may be required when the AP's expertise or logistical ability is exceeded before a referral to an ABA specialty care provider is authorized by the UR contractor; the UR contractor will approve prior authorization to permit specialty provider assessment or intervention.
- The AP may refer the eligible recipient to the UR contractor for prior authorization when behavior exceeds AP expertise or logistical capacity.
Residential Care and ABA Service Stages
Clinical Evidence and Eligibility Justification
Evidence supporting diagnosis- and age-neutral ABA
Clinical justification for broadening ABA access
Cites BACB Practice Guidelines and multiple research examples supporting diagnosis- and age-neutral application of ABA.
Specialty ABA Assessment and Targeted Care
ABA specialty care / targeted assessment
Reflects recommendation that the UR contractor include a BCBA for complex cases and prior authorization reviews; aligns with Section E referral language for specialty ABA prior authorization.
Applied Behavior Analysis (ABA) Overview
Applied Behavior Analysis (ABA) is characterized in the submission as the science of socially significant human behavior used to increase adaptive skills and decrease inappropriate behaviors. The commenter cites professional practice guidelines to support the position that ABA effectiveness is not bound by chronological age, and therefore policy should allow services to continue based on clinical need rather than an age-based exclusion.
Key Terms and Service Stages
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