Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15

Sec. 12. (a) ABA therapy services shall be available to an individual who:

1. (1) is eligible for Medicaid services;
2. (2) has been diagnosed as having autism spectrum disorder by a qualified provider; and
3. (3) has a completed diagnostic evaluation.

A qualified provider, when completing such evaluation, shall utilize the most recent version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) at the time of the evaluation and include a recommended treatment referral for ABA therapy services.

(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. (1) A health services provider in psychology (HSPP).
2. (2) A licensed or board certified behavior analyst.
3. (3) A credentialed registered behavior technician (RBT).

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

1. (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. (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. Treatment plans shall be focused on addressing specific behavioral issues and community integration. All treatment plans shall include a projected length of therapy. The treatment plan shall be based on criteria such as the individual's:

1. (1) needs;
2. (2) age;
3. (3) school attendance, including any homeschooling; and
4. (4) other daily activities as documented in the treatment plan not otherwise excluded from coverage under subsection (I) [sic, subsection (k)].

(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. (1) The individual's treatment plan and supporting documentation.
2. (2) The number of therapy hours requested and supporting documentation.
3. (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 not to exceed forty (40) hours per week. ABA therapy services extending beyond forty (40) hours per week of direct therapy must be medically necessary and requires additional prior authorization. The office shall not approve any prior authorization request that provides ABA therapy services for a period longer than six (6) months at one (1) time.

(i) Determinations for hours and duration shall not be based upon any of the following:

1. (1) Other therapies that do not address the specific behaviors being targeted.
2. (2) Any standardized formulas used to deduct hours based upon daily living activities.

(j) Short term, adjunctive hours may be requested outside of the standard therapy prior authorization if one (1) of the following conditions occurs:

1. (1) Sudden increase in self-injurious behaviors.
2. (2) Sudden increase in aggression or aggressive behaviors.
3. (3) Increase in elopement behaviors.
4. (4) Regression in major self-care or language activities.
5. (5) A shift in family or home dynamic.
6. (6) Development of a non-mental health related comorbidity or health crisis with the patient.

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

1. (1) Focus solely on recreational outcomes.
2. (2) Focus solely on educational outcomes.
3. (3) Are duplicative, such as services rendered under an individualized educational plan that address the same behavioral goals using the same techniques as the treatment plan.

(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; filed Jan 30, 2019, 8:35 a.m.: 20190227-IR-405180249FRA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)