CurrentNew Mexico Health Care AuthorityPolicy N/A

Applied Behavior Analysis (ABA) services — Coverage Criteria and Prior Authorization

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Public comments and recommendations regarding New Mexico Administrative Code 8.321.2 Specialized Behavioral Health Services focused on coverage, eligible providers, prior authorization, and age/diagnosis limits for ABA services; affects state behavioral health policy and provider reimbursement in New Mexico.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyApplied Behavior Analysis (ABA) services — Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypePublic comment recommendations

Effective DateN/A

Next Review DateN/A

Key ActionRefer recipients to the UR contractor for prior authorization when behavior exceeds the primary AP's expertise to allow targeted assessment and ABA specialty care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Remove age/diagnosis limitsprimary coverage recommendation

Section A–Edocument sections discussed

Behavior Analyst Candidaterecommended provider type to add

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Applied Behavior Analysis (ABA) services — Coverage Criteria and Prior Authorization

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Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyApplied Behavior Analysis (ABA) services — Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypePublic comment recommendations

Effective DateN/A

Next Review DateN/A

Key ActionRefer recipients to the UR contractor for prior authorization when behavior exceeds the primary AP's expertise to allow targeted assessment and ABA specialty care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Remove age/diagnosis limitsprimary coverage recommendation

Section A–Edocument sections discussed

Behavior Analyst Candidaterecommended provider type to add

Coverage and Medical Necessity

Recommendation: Coverage based on medical necessity, not diagnosis/age

Recommended coverage stance from commenter:

Coverage eligibility: ABA treatment eligibility should be based on medical necessity rather than limited to specific diagnoses or ages; multiple behavior-change procedures are effective across populations and ages.

Supported by citations to BACB guidelines and literature.

The commenter requests removal of the policy language that causes an "age out of comprehensive ABA services". They state that terminating comprehensive Applied Behavior Analysis (ABA) solely on the basis of chronological age is inappropriate and ask that the age-based termination criterion be deleted so that continuation of comprehensive ABA is determined by clinical need rather than age.

The commenter asserts that criteria that cause an "age out" of comprehensive ABA services are not aligned with standards of care, referencing the Behavior Analyst Certification Board (BACB) Practice Guidelines. They recommend that determinations of medical necessity for ABA not be based on age or diagnosis but on individualized clinical assessment and the recipient’s ongoing treatment needs.

Medical necessity-driven ABA criteria (commenter recommendation) — references BACB Practice Guidelines

Commenter cites BACB Practice Guidelines:

ABA treatment appropriateness: Determinations of focused vs comprehensive ABA and intensity should be based on individual medical necessity rather than chronological age, prior ABA duration, or diagnosis.

Cites BACB guidelines and multiple studies.

Provider Responsibilities, Prior Authorization, and Referrals

Prior Authorization

Refer to UR contractor for prior authorization when behavior exceeds AP expertise

When a primary AP determines an eligible recipient's behavior exceeds the AP’s expertise or logistical ability to fully support the recipient, the AP may refer the recipient to the recipient’s Utilization Review (UR) contractor for prior authorization to permit an ABA specialty care provider to intervene. The UR contractor may approve prior authorization for the ABA specialty care provider to complete a targeted assessment (including a functional assessment) and to implement or provide individualized interventions.

Step Therapy

Prior authorization required for ABA specialty care when AP expertise is exceeded

Prior authorization may be required to allow an ABA specialty care provider to intervene when an eligible recipient’s behavior exceeds the expertise or logistical/practical ability of the primary AP; the UR contractor approves authorization to permit targeted assessment and individualized ABA interventions.

Prior authorization pathway is invoked when behavior exceeds the AP’s expertise or capacity.

Stage 2 and Stage 3 Service Criteria

Stage 2 and Stage 3 ABA services — treatment modalities

Residential facility provision: If a residential facility is not an AP for ABA stage two and three services and the eligible recipient has a MAD recognized CDE or targeted evaluation recommending stage two, the facility must locate a MAD-enrolled ABA stage two/three AP and develop an agreement to render services at the facility.

Commenter requests clarification to allow access while waiting for MAD recognized CDE/targeted evaluation.

Comprehensive ABA services — Continuation and termination conditions

Continuation ruleServices continue until the eligible recipient no longer meets service criteria for ABA services or ages out of eligibility for comprehensive ABA services as described in the BH policy and billing manual.

AuthorityBH policy and billing manual (comprehensive ABA eligibility and age-based termination referenced in Section E of prior authorization guidance).

Applicability

Applied Behavior Analysis — Clinical Criteria

Medical necessity-driven ABA criteria (commenter recommendation) — Commenter cites BACB Practice Guidelines

Review inclusion of BACB expertise in prior authorization: When behavior exceeds the expertise or logistical ability of the primary AP, referral to the UR contractor for prior authorization to an ABA specialty care provider is appropriate; the commenter recommends inclusion of a Board Certified Behavior Analyst (BCBA) on the reviewing team to ensure appropriate determination of treatment design and dosage.

References BACB recommendation that reviewers include a Behavior Analyst experienced in ABA treatment when there are questions about appropriateness or efficacy of services.

Key Definitions

Behavior Analyst Candidate — Definition

DefinitionBehavior Analyst Candidate: a BCBA who has completed the coursework and practicum hours but lacks certification while waiting for the next offered exam or exam results and may perform the duties of a certified BCBA.

PurposeAdded to increase the pool of eligible practitioners in rural and underserved areas and to align administrative code with the Behavioral Health Policy & Billing Manual (Page 59).

ScopeIntended to be recognized as an eligible provider-level classification in the administrative code to allow practice while awaiting BCBA exam/results.

Context and Evidence

Commenters emphasize that Applied Behavior Analysis is a science focused on addressing socially significant behavior and note that the evidence base supports ABA across ages and diagnoses. They cite the BACB Practice Guidelines to support the position that ABA interventions can be effective beyond a single diagnostic group and that service intensity and modality decisions should be driven by medical necessity rather than arbitrary age limits.