Section 405IAC5-22-12. Applied behavioral analysis therapy services

   (a) ABA therapy services shall be available to an individual who:

(1) is eligible for Medicaid services;

(2) has been diagnosed as having autism spectrum disorder by a qualified provider; and

(3) has a completed diagnostic evaluation. A qualified provider, when completing such evaluation, shall:

(A) utilize a standardized assessment tool approved by the office; and

(B) include a recommended treatment referral for ABA therapy services, including projected length of treatment.

  (b) Services shall be available from the time of initial diagnosis through twenty (20) years of age.

  (c) The following providers may provide ABA therapy services:

(1) A health services provider in psychology (HSPP).

(2) A licensed or board certified behavior analyst.

(3) A credentialed registered behavior technician (RBT).

  (d) Services shall be reimbursed subject to the following restrictions:

(1) Services performed by a bachelor-level board certified behavior analyst (BCaBA) or a credentialed RBT shall be supervised by a master's (BCBA) or doctoral level board certified behavior analyst (BCBA-D), or an HSPP.

(2) Services provided by a credentialed RBT shall be reimbursed at seventy-five percent (75%) of the rate on file.

  (e) A provider described in subsection (c) shall develop a treatment plan for each recipient eligible for services under this section. The treatment plan shall be based on criteria such as the individual's:

(1) needs;

(2) age;

(3) school attendance; and

(4) other daily activities as documented in the treatment plan not otherwise excluded from coverage under subsection (i).

  (f) All covered ABA therapy services shall be subject to prior authorization. A provider shall abide by the prior authorization requirements under 405 IAC 5-3, with the exception that a BCBA may also submit a prior authorization request to the office for review and approval. Each prior authorization request shall include, at a minimum, the following:

(1) The individual's treatment plan and supporting documentation.

(2) The number of therapy hours requested and supporting documentation.

(3) Other documentation as requested by the office.

  (g) Prior approval for the initial course of treatment may be approved for up to six (6) months. In order to continue providing ABA therapy services, a provider shall submit a new prior authorization request and receive approval. The prior authorization request shall include an updated treatment plan along with the documentation specified in subsection (f)(2) and (f)(3).

  (h) ABA therapy services shall only be available to a recipient for a period of three (3) years and shall not exceed a period of forty (40) hours per week. Additional ABA therapy services must be medically necessary and requires prior authorization. The office shall not approve any prior authorization request that provides ABA therapy services for a period longer than six (6) months.

  (i) As follows, coverage under this section shall not be available for services that:

(1) Focus solely on recreational outcomes.

(2) Focus solely on educational outcomes.

(3) Are duplicative, such as services rendered under an individualized educational plan.

(4) Are provided by a registered behavior technician in the home or school setting.

(Office of the Secretary of Family and Social Services; 405 IAC 5-22-12; filed Jan 7, 2016, 8:00 a.m.: 20160203-IR-405140337FRA; errata filed May 4, 2016, 12:47 p.m.: 20160518-IR-405160170ACA)