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    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthVermont Medicaid ABA Coverage Policy | OpenPayer
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    CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.229

    Applied Behavior Analysis Services

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    This policy governs Medicaid coverage, eligibility, provider qualifications, prior authorization, and non-covered services for applied behavior analysis (ABA), primarily for Vermont Medicaid beneficiaries under age 21 with specified developmental diagnoses.

    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyApplied Behavior Analysis Services
    Policy CodePolicy 4.229
    Change TypeNo material change
    Effective DateAug 1, 2021
    Next Review DateN/A
    Key ActionProviders must consult the Vermont Medicaid Fee Schedule to identify covered ABA services and determine which services require prior authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Under 21Beneficiary age requirement
    6Covered ABA service categories

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    5Eligible prescriber types
    5Non-covered categories

    ABA Coverage Eligibility and Exclusions

    ABA eligibility

    ABA services are covered when all eligibility criteria are met.

    • Enrollment and age: The beneficiary is actively enrolled in Medicaid at the time of service and is under age 21.Under age 21
    • Qualifying diagnosis: The beneficiary has a diagnosis from the latest edition of the Diagnostic and Statistical Manual of Mental Disorders of Autism Spectrum Disorder, early childhood developmental disorder, or any successor diagnosis.DSM diagnosis

    • Qualifying prescription source

      • Psychiatrist: Board certified or board eligible psychiatrist
      • Psychologist: Doctorate-level licensed psychologist
      • Pediatrician: Board certified or board eligible pediatrician
      • Neurologist: Board certified or board eligible neurologist
      • Developmental specialist: Developmental-behavioral or neurodevelopmental disabilities pediatrician
    • Medical stability: The beneficiary is medically stable and does not require ongoing 24-hour medical or nursing monitoring or procedures provided in a hospital level of care.No ongoing 24-hour monitoring or hospital-level procedures

    School-based ABA services authorized under the Individuals with Disabilities Education Act (IDEA) and reimbursed by the Agency of Education are not covered by Vermont Medicaid.

    Respite care is not covered as an applied behavior analysis service.

    Orientation and mobility services are not covered under ABA.

    Psychiatric hospitalization is not covered under ABA.

    ABA is not covered for Medicaid beneficiaries in long-term out-of-home placement or receiving care outside a community setting.

    Authorization, Documentation, and Denial Conditions

    Prior Authorization

    Check the Fee Schedule for Authorization Requirements

    Review the Vermont Medicaid Fee Schedule to identify covered ABA services and determine which services require prior authorization before delivery or billing.

    • The Fee Schedule contains the detailed list of covered services.
    • The Fee Schedule identifies services requiring prior authorization and is available on the Department of Vermont Health Access website.
    Documentation Required

    Document Beneficiary Eligibility

    Before requesting or providing ABA services, document active Medicaid enrollment, that the beneficiary is under age 21, an eligible DSM diagnosis, and a prescription for ABA from a qualifying provider.

    • Active Medicaid enrollment at the time of service.

    Policy Background

    Applied behavior analysis (ABA) is the design, implementation, and evaluation of instructional and environmental modifications intended to produce socially significant improvements in human behavior. The policy covers ABA for beneficiaries under age 21 with Autism Spectrum Disorder, early childhood developmental disorder, or a successor diagnosis. Covered services may include assessment, treatment planning, direct treatment, supervision, caregiver training, and team conferences.

    Key Terms and Provider Roles

    Applied Behavior Analysis (ABA)
    DefinitionThe design, implementation, and evaluation of instructional and environmental modifications by a behavior analyst to provide socially significant improvements in human behavior.
    Board Certified Behavior Analyst (BCBA)
    RoleAn independent practitioner who provides ABA services and supervises the work of Board Certified Assistant Behavior Analysts and Behavior Technicians.
    EducationHolds a master's degree.
    CertificationCertified through the National Behavior Analyst Certification Board (BACB).
    Board Certified Assistant Behavior Analyst (BCaBA)

    Applied Behavior Analysis Eligibility Criteria

    ABA eligibility criteria

    ABA is available to eligible Medicaid beneficiaries when all clinical and administrative criteria are met.

    Eligibility for care

    • Active Medicaid enrollment: The beneficiary is actively enrolled in Medicaid at the time of service.
    • Age requirement: The beneficiary is under age 21.Under age 21
    • Eligible diagnosis: The beneficiary has a diagnosis from the latest edition of the Diagnostic and Statistical Manual of Mental Disorders of Autism Spectrum Disorder, early childhood developmental disorder, or any successor diagnosis.DSM diagnosis

    Applied Behavior Analysis Services

    Applied behavior analysis

    Medically necessary ABA may include at least one of the following covered services:

    Covered ABA service: Functional assessment and analysis; treatment plan development; direct treatment; program supervision; parent/caregiver training; or team conferences.At least 1 covered ABA service

    The Vermont Medicaid Fee Schedule determines which services require prior authorization.

    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyApplied Behavior Analysis Services
    Policy CodePolicy 4.229
    Change TypeNo material change
    Effective DateAug 1, 2021
    Next Review DateN/A
    Key ActionProviders must consult the Vermont Medicaid Fee Schedule to identify covered ABA services and determine which services require prior authorization.
    SourceLink
    On This Page
    ABA Coverage Eligibility and ExclusionsAuthorization, Documentation, and Denial ConditionsPolicy BackgroundKey Terms and Provider RolesApplied Behavior Analysis Eligibility CriteriaApplied Behavior Analysis Services
  1. Age under 21.
  2. A diagnosis, using the latest DSM edition, of Autism Spectrum Disorder, early childhood developmental disorder, or any successor diagnosis.
  3. A prescription from a board-certified or board-eligible psychiatrist, pediatrician, or neurologist; a doctorate-level licensed psychologist; or a developmental-behavioral or neurodevelopmental disabilities pediatrician.
    4. Documentation Required

    Verify Provider Credentialing

    Document that each BCBA or BCaBA providing ABA services is licensed in Vermont, works within the scope of practice, and is enrolled in Vermont Medicaid.

    • Verify current Vermont licensure.
    • Confirm services are provided within the professional’s scope of practice.
    • Confirm enrollment in Vermont Medicaid.

    Unsupported block type: billing_rule

    Denial Risk

    Eligibility-Related Denial Conditions

    ABA services may be denied when required beneficiary eligibility criteria are not met or documented.

    • Medicaid enrollment is inactive at the time of service.
    • The beneficiary is age 21 or older.
    • The beneficiary lacks an eligible DSM diagnosis of Autism Spectrum Disorder, early childhood developmental disorder, or a successor diagnosis.
    • The beneficiary lacks a prescription for ABA from a qualifying provider.
    Denial Risk

    Hospital-Level Care Exclusion

    ABA services may be denied when the beneficiary is not medically stable or requires ongoing hospital-level care.

    • The beneficiary requires ongoing 24-hour medical or nursing monitoring.
    • The beneficiary requires procedures provided in a hospital level of care on an ongoing basis.
    Denial Risk

    Provider Qualification and Enrollment Denials

    ABA services may be denied when the rendering BCBA or BCaBA does not meet Vermont qualification and enrollment requirements.

    • No Vermont license.
    • Practice outside the professional’s scope of practice.
    • Failure to meet Vermont Medicaid enrollment requirements.
    Denial Risk

    Non-Covered Services and Settings

    Vermont Medicaid will not authorize ABA services in the following excluded services or settings.

    • School-based ABA services authorized under the Individuals with Disabilities Education Act (IDEA) and reimbursed by the Agency of Education.
    • Respite care.
    • Orientation and mobility services.
    • Psychiatric hospitalization.
    • Services for Medicaid beneficiaries in long-term out-of-home placement or care outside a community setting.
    EducationHolds a minimum of a bachelor's degree.
    CertificationCertified through the National Behavior Analyst Certification Board (BACB).
    SupervisionDirectly supervised by a BCBA.
    RoleMay supervise the work of Behavior Technicians.
    Behavior Technician (BT/RBT)
    EducationHolds a bachelor's degree or is pursuing a bachelor's degree; relevant experience may be exchanged for a degree.
    RegistrationIncludes a Registered Behavior Technician (RBT).
    SupervisionPractices under close, ongoing supervision of a BCBA or BCaBA supervisor.
    RoleProvides ABA services as a Behavior Technician.

  4. Qualifying prescription source

    • Psychiatrist: Board certified or board eligible psychiatrist
    • Psychologist: Doctorate-level licensed psychologist
    • Pediatrician: Board certified or board eligible pediatrician
    • Neurologist: Board certified or board eligible neurologist
    • Developmental specialist: Developmental-behavioral or neurodevelopmental disabilities pediatrician
  5. Medical stability: The beneficiary is medically stable and does not require ongoing 24-hour medical or nursing monitoring or procedures provided in a hospital level of care.No ongoing 24-hour monitoring or hospital-level procedures