PURPOSE: This rule establishes the regulatory basis for coverage and reimbursement for applied behavior analysis services under the Medicaid state plan.

1. (1) The following definitions will be used in administering this rule:

   1. (A) Applied Behavior Analysis (ABA)—the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, 13 CSR 70-98

including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior. ABA does not include psychological testing, personality assessment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, or counseling;

1. (B) Autism Spectrum Disorder (ASD)—as defined in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association;
2. (C) Best practice guidelines—guidelines described in the Missouri Autism Guidelines Initiative’s publications entitled Autism Spectrum Disorders: Missouri Best Practice Guidelines for Screening, Diagnosis, and Assessment and Autism Spectrum Disorders: Guide to Evidence-Based Interventions;
3. (D) Diagnostic evaluation—evaluation conducted according to best practice guidelines in order to determine if an ASD is present;
4. (E) Licensed Behavior Analyst (LBA)—an individual who is currently licensed by the Missouri Behavior Analyst Advisory Board to practice ABA independently;
5. (F) ABA qualified Licensed Psychologist (LP)—an individual who is currently licensed by Missouri to practice psychology and who has ABA in the scope of his/her education, training, and competence;
6. (G) Licensed Assistant Behavior Analyst (LABA)—an individual who is currently licensed by Missouri to practice applied behavior analysis under the supervision of an LBA;
7. (H) Technician—an individual who is credentialed by the Behavior Analyst Certification Board (BACB) as a Registered Behavior Technician™ (RBT™);
8. (I) ABA Assessment for Intervention Planning—assessment that is conducted according to best practice guidelines and considers the individual’s specific strengths and concerns to inform the intervention planning process; and
9. (J) ABA intervention—involves directly and objectively measuring potential target behaviors and environmental events that influence them; constructing detailed, individualized behavior analytic treatment plans; using reinforcement and other scientifically validated procedures to build functional skills and reduce behaviors that jeopardize health, safety, and independent functioning; managing treatment environments to maximize client progress; implementing treatment protocols repeatedly, frequently, and consistently; measuring target behaviors directly and frequently; and adjusting treatment protocols based on data.

1. (2) Recipient Criteria.

   1. (A) In order to qualify for and receive ABA services, a MO HealthNet participant must meet all of the following criteria. The participant must—

      1. 1. Be under 21 years of age;
      2. 2. Exhibit the presence of excesses

and/or deficits of behaviors that significantly interfere with home or community activities (examples include, but are not limited to, aggression, self-injury, elopement);

1. 3. Have a diagnostic evaluation per-

formed by a licensed physician or licensed psychologist, resulting in a diagnosis of ASD, and recommending ABA services as medically necessary.

1. (3) Provider Criteria.

   1. (A) To direct, supervise, and render ABA services, a professional shall meet the following specifications:

      1. 1. Be currently licensed by Missouri as

an LBA or LP;

1. 2. Be covered by professional liability

insurance to limits of one (1) million dollars per occurrence, three (3) million dollars aggregate;

1. 3. Have no sanctions or disciplinary

actions by the applicable state licensing board or the BACB;

1. 4. Have no current overpayment(s) due

MO HealthNet and no Medicare or Medicaid sanctions or exclusions from participation in federally funded programs; and

1. 5. Be currently enrolled with MO

HealthNet as a provider.

1. (B) Assistant behavior analysts who render or supervise ABA services shall meet the following qualifications:

   1. 1. Be currently licensed by Missouri as

an LABA;

1. 2. Be currently supervised by a Missouri

LBA;

1. A. The supervisory relationship must

be documented in writing;

1. 3. Be covered by professional liability

insurance to limits of one (1) million dollars per occurrence, three (3) million dollars aggregate;

1. 4. Have no sanctions or disciplinary

actions by the state licensing board or BACB;

1. 5. Have no current overpayment(s) due

MO HealthNet and no Medicaid or Medicare sanctions or exclusions from participation in federally funded programs; and

1. 6. Be currently enrolled with MO

HealthNet as a provider.

1. (C) Technicians who render ABA services shall—

   1. 1. Be credentialed by the BACB as an

RBT;

1. 2. Work under the supervision of an

LBA, LP (if officially granted supervisory privileges by the BACB), or LABA to the extent allowed for holders of the latter credential and at the discretion of the supervising LBA. RBTs are required by the BACB to be supervised by LBAs who are also Board Certified Behavior Analysts, Board Certified Behavior Analysts-Doctoral, Board Certified Assistant Behavior Analysts, or members of a professional group officially granted supervisory privileges by the BACB;

1. A. The supervisory relationship must

be documented in writing; and

1. 3. Have no current overpayment(s) due

MO HealthNet and no Medicaid or Medicare sanctions or exclusions from participation in federally funded programs.

1. (4) Covered Services and Limitations.

   1. (A) MO HealthNet covered ABA services (ABA assessment for intervention planning and ABA intervention) must be—

      1. 1. Medically necessary;
      2. 2. Precertified by MO HealthNet or its

designee;

1. 3. Delivered in accordance with the

recipient’s treatment plan; and

1. 4. Overseen and delivered by providers

who meet criteria specified herein.

1. (B) Medical necessity for ABA assessment for intervention planning shall be determined based on a diagnostic evaluation. Medical necessity for ABA intervention shall be determined based on an ABA assessment for intervention planning for initial intervention. Medical necessity for continued ABA intervention beyond the initial precertification period shall be determined based upon requested documentation including, but not limited to, updated treatment plan and progress graphs.
2. (C) ABA intervention services may be precertified for a time period not to exceed one hundred-eighty (180) days. Services provided without precertification shall not be considered for reimbursement, except in the case of retroactive MO HealthNet eligibility.

3. (D) Service Limitations.

   1. 1. Services shall be based upon the indi-

vidual needs of the child and must give consideration to the child’s age, school attendance requirements, and other daily activities as documented in the treatment plan.

1. 2. Services must be delivered in a clini-

cally appropriate setting for the behavior being treated.

1. (5) Not Medically Necessary/Non-Covered Services. The following services do not meet medically necessity criteria, nor qualify as MO HealthNet covered ABA services:

   1. (A) Intervention services rendered when measureable functional improvement is not expected and services are not necessary to maintain function or prevent deterioration;
   2. (B) Services that are solely educational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to educational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered;
   3. (C) Educational services provided under an individualized family service plan (IFSP) or an individualized educational program (IEP), as required under the federal Individuals with Disabilities Education Act (IDEA);
   4. (D) Services that are solely vocational or recreational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to vocational or recreational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; and
   5. (E) Custodial care is not an ABA service and is not covered as part of this benefit. Developing, restoring, or maintaining selfhelp, daily living, or safety skills as part of an ABA treatment plan does not constitute custodial care and are covered.

2. (6) ABA Treatment Plan.

   1. (A) ABA intervention services shall be rendered in accordance with the individual’s treatment plan. The treatment plan shall—

      1. 1. Be person centered and individual-

ized;

1. 2. Be developed by an LBA or LP;
2. 3. Be based on the ABA assessment for

intervention planning

1. 4. Delineate the baseline levels of target

behaviors;

1. 5. Specify longand short-term objec-

tives that are defined in observable, measureable, behavioral terms;

1. 6. Specify the criteria that will be used

to determine achievement of objectives;

1. 7. Include assessment and treatment

protocols for addressing each of the target behaviors;

1. 8. Clearly identify the schedule of ser-

vices planned and the individuals responsible for delivering the services, including frequent review of data on target behaviors and adjustments in the treatment plan and/or protocols by the LBA or LP as needed;

1. 9. Include training to enable LABAs and

RBTs to implement assessment and treatment protocols.

1. 10. Include training and support to

enable parents and other caregivers to participate in treatment planning and treatment plan implementation;

1. 11. Include care coordination involving

the parents or caregiver(s), school, state disability programs, and others as applicable; and

1. 12. Be consistent with applicable profes-

sional standards and guidelines relating to the practice of ABA as well as state Medicaid laws and regulations and applicable Missouri licensure laws and regulations.

1. (7) Reimbursement Methodology.

   1. (A) MO HealthNet shall provide reimbursement for ABA services to enrolled LBAs or LPs who are currently licensed and in good standing with the state. Payment for services rendered by LABAs shall be made to the LBA supervising and employing these personnel. Payment for services rendered by technicians shall be made to the LBA or LP supervising and employing these personnel. If the LBA or LP operates through an agency or corporate entity, payment may be made to that agency or entity. Reimbursement for ABA services shall not be made to or for services rendered by a parent, a legal guardian, or other legally responsible person.
   2. (B) Reimbursement for ABA services is made on a fee-for-services basis. The maximum allowable fee for a unit of service has been determined by the MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services authorized by the Medicaid agency or its designee.
   3. (C) The fee schedule and any annual/periodic adjustments to the fee schedule are published at http://www.dss.mo.gov/mhd/providers/index .htm.

AUTHORITY: section 208.201, RSMo Supp. 2013.* Original rule filed Dec. 14, 2015, effective July 30, 2016.

*Original authority: 208.201, RSMo 1987, amended 2007.