ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A
North Dakota Medicaid Policy and Procedures for the Autism Applied Behavior Analysis Service
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This policy governs eligibility, medical necessity, authorization, provider qualifications, care planning, documentation, oversight, skills training, monitoring, and payment limitations for Autism Applied Behavior Analysis services provided to Medicaid-enrolled children with autism spectrum disorder in North Dakota.
Policy Summary
PayerNorth Dakota Department of Health & Human Services
PolicyAutism Applied Behavior Analysis Service
Policy CodePolicy N/A
Change TypeModified
Effective DateJuly 1, 2023
Next Review DateN/A
Key ActionSubmit a web-based Service Authorization request twice per year, with the care plan and yearly approval letter attached.
No material clinical or coverage changes in this revision.
Under 21Age requirement for eligibility
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12 monthsMaximum approval period
180 daysCare-plan reassessment interval
MonthlyRequired care-team meeting
ND MedicaidProvider enrollment
6 monthsCertification deadline
Eligibility, Continuation, and Covered Targets
Initial Autism ABA Eligibility
A child is eligible for consideration for Autism Applied Behavior Analysis (ABA) services when ALL of the following criteria are met:
ALL of the following
The child is under 21 years of age.
The child is eligible for ND Medicaid on the dates of service, consistent with 42 CFR 440.20 and North Dakota Administrative Code 75-02-02.
The child has an autism spectrum disorder diagnosis from the child's primary care provider (PCP) or a licensed medical care provider qualified to diagnose autism spectrum disorder.
The child has a current annual North Dakota Health Tracks (EPSDT) screening completed at a public health unit or by a PCP. A current screening is one completed within six months of the date the child is considered eligible for the service.
The Health Tracks screening is submitted with the packet to ND Medicaid for consideration of Autism ABA approval, and the recommendation comments support and recommend Autism ABA services.
Continuation and Annual Renewal
Continuation and annual renewal require ongoing medical necessity, care-plan maintenance, reassessment, monitoring, and required authorization activities.
ALL of the following
Approval for Autism ABA services is limited to a twelve-month period; annual review of medical necessity is required.
Annual approval is completed by updating the care plan and obtaining a North Dakota Health Tracks screening.
A comprehensive assessment and periodic reassessment are completed to determine the child's need for medical, educational, social, or other services. Assessment includes taking the child's history, identifying needs and completing related documentation, and gathering information from family members, medical providers, social workers, educators, and other sources as necessary.
The child has an annual care plan that is updated every 180 days thereafter to ensure the child continues to meet medical necessity criteria.
Covered Treatment Targets
When a need is identified, the care plan must document measurable treatment goals and the functional or developmental targets addressed by the service.
Care-plan documentation must address applicable targets
Target behaviors, measurable treatment goals, methods and frequency for assessing objectives and protocols, descriptions of aggressive or inappropriate behaviors with specific goals to address them, where the behaviors occur, and the number of Autism ABA service hours per week are documented.
Replacement of inappropriate behaviors with more conventional and functional behaviors.
Fine and gross motor skills used for age-appropriate, functional activities, as needed.
Cognitive skills related to play activity and academic skills.
Adaptive behavior and self-care skills that enable the participant to become more independent.
ND Medicaid shall not pay for program services or components of services that are of an unproven, experimental, cosmetic, or research nature; are intended solely to prepare a child for paid or unpaid employment or for vocational equipment and uniforms; are solely educational, vocational, recreational, or social; are not coverable within the preventive services benefit category, such as respite, childcare, or other custodial services; or duplicate other State Plan services.
ND Medicaid shall not pay for program services or components of services that do not relate to the child's diagnosis, symptoms, functional limitations, or medical history.
Regulatory, Screening, and Certification Requirements
Regulatory citationsmixed
42 CFR Chapter IV, Subchapter C
Medical Assistance Programs, including EPSDT
42 CFR 440.20
Federal citation referenced for Medicaid eligibility
North Dakota Administrative Code 75-02-02
North Dakota administrative code citation governing the service or eligibility
Current Health Tracks screening
Screening typeAnnual North Dakota Health Tracks (EPSDT) screening
Required timingWithin six months of the date considered eligible for the service
Submission requirementThe current screening must accompany the packet submitted to ND Medicaid and recommend Autism ABA services
Care-plan reassessment
Reassessment interval180 days
Care-plan updateThe care plan must be updated every 180 days thereafter
Required update content
Authorization, Documentation, and Denial Prevention
Prior Authorization
Twice-Yearly Service Authorization
Submit a web-based Service Authorization request twice each year: once for the annual authorization and again for the 180-day update.
Attach the applicable care plan and yearly ND Medicaid approval letter to each request.
Prior Authorization
Initial and Annual Approval
Before initial and annual approval, confirm that the child meets ND Medicaid’s eligibility and medical-necessity requirements. Annual approval requires an updated care plan and a current Health Tracks screening.
Child is under 21 years of age.
Child is ND Medicaid eligible on the dates of service.
Child has an autism spectrum disorder diagnosis from a PCP or other licensed provider qualified to diagnose autism.
A North Dakota Health Tracks (EPSDT) screening was completed within six months of the eligibility-review date, accompanies the submission, and recommends Autism ABA services.
Policy Overview
North Dakota Medicaid Autism Applied Behavior Analysis services support children with autism spectrum disorder through comprehensive assessment, individualized care-plan development, referral, monitoring, follow-up, caregiver training, and direct skills training. Treatment is directed toward measurable functional, behavioral, communication, adaptive, social, and developmental-participation goals identified in the care plan.
Services may be delivered in the home, community, provider facility, or an approved school setting. Skills training uses evidence-based behavioral intervention methods to help the child acquire care-plan skills and trains caregivers to implement interventions across settings, with ongoing oversight and monitoring.
Key Service Terms
Autism Medicaid ABA service
Qualifying recipientAn individual with an autism spectrum disorder (ASD) diagnosis
Included oversightOversight supporting comprehensive assessment, care plan development, referral, monitoring, and follow-up
Training includedSkills training for qualifying individuals and their caregivers
Permitted settingsThe home, community, or a provider's facility
Skills Training
Service purposeDirect service designed to assist a child in acquiring skills identified in the care plan
Intervention approach
Autism ABA Service Coverage Logic
Autism ABA Service Criteria
Autism ABA services are covered when all eligibility, medical-necessity, care-plan, reassessment, monitoring, and provider requirements are satisfied.
ABA coverage
Eligibility: The child is under 21, eligible for ND Medicaid on the dates of service, diagnosed with autism spectrum disorder by a qualified provider, and has a current Health Tracks screening recommending Autism ABA services.Under 21; screening within six months of the date considered eligible
Medical necessity and care plan: A comprehensive assessment supports an individualized care plan with target behaviors, measurable treatment goals, assessment methods and frequency, identified aggressive or inappropriate behaviors and interventions, service location, and the number of Autism ABA service hours per week.
Reassessment and renewal:
Covered Service Components
Autism ABA Skills Training
Skills Training is covered when all of the following requirements are met.
Skills Training
Care-plan focus: The service addresses formal care-plan goals and tasks and occurs in environments that promote the child's competence and positive behaviors.
Behavioral intervention: The participant receives hands-on training using evidence-based behavioral intervention methods as directed by the Service Oversight practitioner.
Caregiver training: Caregivers are trained to implement interventions across multiple settings. General assistance and support may also be provided to individuals who support, train, provide companionship to, or supervise the participant.
Authorization and Reassessment Intervals
Autism ABA services
Approval periodTwelve months
Review requirementAnnual review of medical necessity is required
Annual approval documentationAnnual approval requires an updated care plan and a Health Tracks screening
Autism ABA services
Reassessment intervalEvery 180 days
Care-plan requirementThe care plan must be updated every 180 days
Authorization requirementThe agency or school submits a web-based Service Authorization request for the annual and 180-day updates
Policy Summary
PayerNorth Dakota Department of Health & Human Services
PolicyAutism Applied Behavior Analysis Service
Policy CodePolicy N/A
Change TypeModified
Effective DateJuly 1, 2023
Next Review DateN/A
Key ActionSubmit a web-based Service Authorization request twice per year, with the care plan and yearly approval letter attached.
Each 180-day reassessment and care-plan update includes the reassessment date, updates to target behaviors, updates to measurable treatment goals, a description of improvements, and the number of hours of Autism ABA services per week.
Care-plan updates include specific mentoring techniques taught to caregivers and progress in the caregivers' ability to carry out those techniques in the home or school, as indicated on the care plan.
Each semi-annual plan update summarizes the preceding six months and addresses problems being worked on, goals accomplished or being addressed, and changes made by the caregiver to modify interventions to better cope with unwanted behaviors.
Monitoring and follow-up activities confirm that services are furnished according to the care plan, services show positive progress, and changes in the child's needs or status are reflected in the care plan.
Monitoring and follow-up include necessary adjustments to the care plan and service arrangements with skills trainers, including a monthly meeting with the skills trainer and caregiver to review progress toward goals and determine whether changes to the care plan are needed.
The agency or school submits a web-based Service Authorization request twice per year, including the annual and 180-day updates, with the care plan and yearly letter of approval attached.
Program oversight practitioners notify ND Medicaid of updates, including institutional placement and discharge from the service.
Independent organizational skills, including completing a task independently, asking for help, giving social skills, and related skills that enhance participation across school, home, and community settings and relationships; imitation; initiation of social interactions with adults and peers; reciprocal exchanges; and parallel and interactive play with peers and siblings.
A functional communication system, which may include expressive verbal language, receptive language, nonverbal communication skills, and augmentative communication.
Increased engagement and flexibility in developmentally appropriate behaviors, including play, attending, responding to environmental cues from training staff and others, and cooperation with instructions.
Instructions to peers and following instructions from peers, following routines, self-monitoring, and sequencing behavior.
For services provided in school and approved on an Individualized Education Program (IEP) or other educational plan, a care plan written by a Board Certified Behavior Analyst (BCBA) is still required.
Referral and related activities may link the eligible child with medical, social, educational providers, or other programs and services that address identified needs and achieve care-plan goals.
Updates include the reassessment date, target-behavior updates, measurable treatment-goal updates, improvements, and Autism ABA service hours per week
Certification for certain degree-qualified skills trainers
Applicable individualsIndividuals with an approved bachelor's or master's degree who enroll to provide skills training
Certification deadlineWithin six months of enrollment
ND Medicaid determines medical necessity and issues an approval letter for the provider.
Documentation Required
Assessment and Care Plan
Complete a comprehensive assessment and maintain a specific care plan based on the child’s history, identified needs, and information from family members and other relevant providers. The plan must describe target behaviors, measurable goals, assessment methods and frequency, protocols, behaviors to address, service location, and weekly Autism ABA hours.
Include specific mentoring techniques taught to caregivers and progress in the caregivers’ ability to use them at home or school.
School-based services approved through an IEP or other educational plan still require a BCBA-written care plan.
Documentation Required
Semiannual Reassessment and Update
Reassess the child and update the care plan every 180 days to confirm continuing medical necessity and document current needs and progress. Each semiannual update must include the reassessment date, updated target behaviors and measurable goals, improvements, and weekly Autism ABA hours.
Summarize the preceding six months.
Address problems being worked on and goals accomplished or addressed.
Describe caregiver changes to interventions used to better manage unwanted behaviors.
Maintain an annual care plan in addition to the 180-day updates.
Documentation Required
Monitoring and Progress Documentation
Monitor and follow up with the child, caregiver, skills trainers, providers, and other relevant parties to verify that services follow the care plan, demonstrate positive progress, and reflect changes in the child’s needs or status.
Make necessary adjustments to the care plan and service arrangements.
Meet monthly with the skills trainer and caregiver to review goal progress and the need for care-plan changes.
Document implementation, progress, follow-up, and changes to the care plan.
Documentation Required
Skills Training Service Note
Document each Skills Training service event in sufficient detail to show that the service directly benefits the child and supports the goals and tasks in the care plan.
Record who participated or who was present.
Record the time and location.
Describe the service event and training provided.
Record data related to the goal.
Documentation Required
Required Plan-of-Care Contents
Include all required recipient and service information in the plan of care for each Medicaid recipient receiving Autism ABA therapy services.
Name, age, date of service, and service duration/time.
Family composition, current residence, education level or educational setting, and work or employment status.
Placement history, including facility and admission and discharge dates; narrative history or background; presenting concerns; diagnosis, if applicable; and behavioral patterns.
Names of treating practitioners, legal responsible party, treatment goals or primary plan of action, and summary of progress and goals.
Available medical needs, health status, medication list, immunization record, and recent medical appointments.
BCBA signature and signature date.
Documentation Required
Status Changes and Privacy
Notify ND Medicaid of institutional placement and discharge from the service. Protect all health information submitted to ND Medicaid in accordance with HIPAA requirements.
Update program records and the care plan when the child’s placement or status changes.
Use appropriate safeguards when transmitting protected health information.
Denial Risk
Eligibility Criteria Not Met
Children who do not meet the eligibility requirements are not eligible for consideration for Autism ABA services through ND Medicaid, creating a denial risk.
The child is 21 or older.
The child is not ND Medicaid eligible on the dates of service.
The child lacks a qualifying autism spectrum disorder diagnosis from an appropriately qualified provider.
The required Health Tracks screening is absent, older than six months, does not accompany the packet, or does not recommend Autism ABA services.
Denial Risk
Annual Renewal Requirements Missing
Annual renewal may be denied when the required medical-necessity review or supporting updates are incomplete.
Annual medical necessity has not been reviewed or supported.
The annual care plan is missing or not updated.
The 180-day care-plan update or reassessment is missing when required.
A current Health Tracks screening has not been completed and submitted with the recommendation supporting Autism ABA services.
Denial Risk
Incomplete Authorization Packet
An incomplete Service Authorization packet may delay or prevent approval. Submit the required authorization materials and ensure that the documentation supports the requested services.
Web-based Service Authorization request for the annual or 180-day cycle.
Current care plan and yearly ND Medicaid approval letter.
Clinical goals, target behaviors, measurable treatment goals, service frequency, and progress or reassessment information.
Required plan-of-care contents and any related supporting documentation.
Denial Risk
Provider Qualification Deficiency
ND Medicaid payment is available only for actively enrolled providers who meet the applicable licensure, certification, supervision, and qualification requirements.
Service Oversight must be provided by a licensed BCBA, licensed BCBA-doctoral, registered behavior analyst, or licensed clinical psychologist.
Skills Trainers must hold an accepted credential or license, such as RBT, BCAT, RBA, BCaBA, BCBA or BCBA-D, applicable social-work or counseling licensure, speech-language pathology, occupational therapy, or physical therapy credentials.
Certain approved bachelor’s or master’s degree holders must become an RBT or BCAT within six months of enrollment; additional degrees require case-by-case review and supporting documentation.
Skills Training must be supervised by a qualified Service Oversight practitioner within North Dakota scope-of-practice laws.
Agencies and schools must maintain staff training for unsafe, crisis, and unstable situations and ensure Service Oversight staff meet qualification requirements.
Denial Risk
Excluded Service Purpose
ND Medicaid will not pay for services or components that fall outside the covered medical purpose of Autism ABA services.
Unproven, experimental, cosmetic, or research services.
Services unrelated to the child’s diagnosis, symptoms, functional limitations, or medical history.
Services intended solely to prepare the child for paid or unpaid employment, or vocational equipment and uniforms.
Services that are solely educational, vocational, recreational, or social.
Noncoverable preventive-services items such as respite, childcare, or custodial services.
Services that duplicate other State Plan services.
Hands-on training using evidence-based behavioral intervention methods as directed by Service Oversight practitioners
Training environmentsEnvironments that promote the participant's competence and positive behaviors
Caregiver componentTraining caregivers to implement interventions across multiple settings
Comprehensive assessment
Clinical processTaking the child's history and identifying the child's needs
Information reviewedInformation from family members, medical providers, social workers, and educators, if necessary
ResultA complete assessment and a specific care plan that may be periodically revised
Monitoring and follow-up
PurposeVerify that the care plan is implemented and adequately addresses the eligible child's needs
Progress reviewDetermine whether services follow the care plan and show positive progress
必要 adjustmentsReflect changes in the child's needs or status through necessary adjustments to the care plan and service arrangements
Required contactMonthly meeting with the skills trainer and caregiver to review progress and the need for care-plan changes
The child continues to meet medical-necessity criteria, receives a reassessment and care-plan update every 180 days, and receives an annual medical-necessity review with an updated care plan and Health Tracks screening.
180-day updates; annual approval
Monitoring and follow-up: Monitoring confirms that services are delivered according to the care plan, positive progress is occurring, changes in the child's needs or status are reflected, and necessary care-plan or service-arrangement adjustments are made. A monthly meeting with the skills trainer and caregiver reviews progress and the need for changes.Monthly review; reassessment at 180 days
Qualified providers and oversight: Services are delivered by ND Medicaid-enrolled, qualified providers. Service Oversight is provided by a qualified oversight practitioner, and Skills Training is supervised within the practitioner's scope of practice by a qualified Service Oversight practitioner.
Approved settings: Services may occur in the home, community, provider facility, or an approved school setting; school-based services must have a care plan written by a Board Certified Behavior Analyst.
Monthly review: The skills trainer meets with the Service Oversight practitioner and caregiver to review progress on formal training objectives and the need for care-plan changes.At least monthly
Service documentation: Documentation identifies who was present, the time, the location, the event or service provided, and goal data.
Service Oversight
Service Oversight is covered when all of the following oversight responsibilities are performed.
Assessment: The practitioner takes the child's history, identifies needs, completes related documentation, and gathers information from family members, medical providers, social workers, educators, or other relevant sources as necessary to form a complete assessment.
Care-plan development and revision: The practitioner develops and periodically revises a specific care plan describing target behaviors, measurable treatment goals, assessment methods and frequency, aggressive or inappropriate behaviors and goals to address them, service location, and weekly Autism ABA service hours.
Reassessment: The practitioner completes a reassessment at 180 days and updates the care plan every 180 days, including the reassessment date, target-behavior and measurable-goal updates, improvements, service hours, a six-month summary, problems addressed, goals accomplished or addressed, and caregiver intervention changes.180 days
Monitoring and follow-up: The practitioner verifies that services are furnished according to the care plan, positive progress is occurring, changes in the child's needs or status are reflected, and necessary adjustments are made to the care plan and service arrangements.
Caregiver and provider coordination: The practitioner participates in the required monthly meeting with the skills trainer and caregiver to review progress on goals and the need for care-plan changes, and makes referrals or related arrangements to connect the child with needed services.Monthly meeting
Status notification: The practitioner notifies ND Medicaid of institutional placement and discharge from the service.