Sec. 10.09.28.04. Covered Services

A. The Program covers the ABA services set forth in §B of this regulation when the services are:

(1) Medically necessary;

(2) Preauthorized by the Program or its designee; and

(3) Delivered in accordance with the participant’s treatment plan.

B. The Program covers the following ABA services:

(1) An ABA assessment, which is a behavior identification assessment that:

(a) Is administered in person with a participant and the participant’s parent or caregiver by:

(i) A licensed psychologist;

(ii) A licensed BCBA-D; or

(iii) A licensed BCBA;

(b) Addresses the behavioral needs for ABA services; and

(c) Includes:

(i) An interview, direct observation, record review, data collection, and analysis;

(ii) An assessment of the participant’s current level of functioning, skills deficits, and maladaptive behaviors using validated instruments;

(iii) Analysis of past data;

(iv) Scoring and interpreting the assessment;

(v) Preparing the treatment plan and report; and

(vi) Discussion of the findings;

(2) A behavior identification supporting assessment which is a follow-up assessment that is administered:

(a) In person, by an RBT or BCaBA, with a participant present; and

(b) Under the direction of a licensed psychologist, a licensed BCBA-D, or a licensed BCBA;

(3) An exposure behavior identification supporting assessment which is a follow-up assessment that:

(a) Is conducted on a participant with specific, severe destructive behaviors in a structured, safe environment;

(b) Is administered in person by a a licensed psychologist, a licensed BCBA-D, or a licensed BCBA, with the assistance of two or more BCaBAs or RBTs;

(c) Exposes the participant to a customized series of social and environmental conditions associated with the destructive behaviors; and

(d) Uses structured testing to examine events, cues, responses, and consequences associated with the behaviors;

(4) An adaptive behavior treatment with protocol modification which is an in-person service that:

(a) Is conducted on a participant with specific, severe destructive behaviors in an environment that is:

(i) Customized;

(ii) Structured; and

(iii) Safe;

(b) Is administered in-person by a licensed psychologist, a licensed BCBA-D, or a licensed BCBA, with the assistance of two or more BCaBAs or RBTs;

(c) Includes in-person direction of two or more technicians eliciting behavioral effects or exposing the participant to specific environmental conditions and treatment; and

(d) Refines and modifies ineffective components of the treatment;

(5) Group adaptive behavior treatment by protocol which is an in-person service provided to a group of two or more participants by:

(a) A licensed psychologist, a licensed BCBA-D, a licensed BCBA; or

(b) A BCaBA or an RBT under the direction of a licensed psychologist, a licensed BCBA-D or a licensed BCBA, utilizing a behavioral intervention protocol designed in advance by the psychologist, the BCBA-D or the BCBA, who may or may not provide in-person direction of a technician during the treatment;

(6) Multiple-family group adaptive behavior treatment guidance that:

(a) Is provided in person with parents or caregivers of multiple participants without the presence of the participants by:

(i) A licensed psychologist;

(ii) A licensed BCBA-D; or

(iii) A licensed BCBA;

(b) Identifies maladaptive behaviors and skills deficits; and

(c) Instructs parents or caregivers on how to utilize ABA treatments to reduce maladaptive behaviors and skills deficits;

(7) Family adaptive behavior treatment guidance which:

(a) Is provided in person with a participant’s parent or caregiver, with or without the presence of the participant by:

(i) A licensed psychologist;

(ii) A licensed BCBA-D;

(iii) A licensed BCBA; or

(iv) A BCaBA;

(b) Identifies maladaptive behaviors and skills deficits; and

(c) Instructs the parent or caregiver on how to utilize ABA strategies to reduce maladaptive behaviors and skill deficits;

(8) A behavior identification reassessment which is a follow-up assessment that:

(a) Is performed in person with a participant and a participant’s parent or caregiver every 180 days by:

(i) A licensed psychologist;

(ii) A licensed BCBA-D; or

(iii) A licensed BCBA;

(b) Evaluates the progress toward each behavior treatment goal using objective, quantifiable measures and includes the results of validated instruments;

(c) Includes a revision of the treatment plan based on progress; and

(d) Includes a clinical recommendation as to whether ABA services continue to be medically necessary;

(9) Group adaptive behavior treatment with protocol modification which is a service that is:

(a) Provided in person to multiple participants by:

(i) A licensed psychologist;

(ii) A licensed BCBA-D; or

(iii) A licensed BCBA;

(b) Focused on social skills training; and

(c) Aimed at identifying and targeting individual participants’ social deficits and maladaptive behaviors;

(10) Adaptive behavior treatment direction of a technician which is the clinical direction and oversight of a BCaBA or an RBT by a licensed psychologist, a licensed BCBA-D or a licensed BCBA that:

(a) Requires the psychologist, the BCBA-D or the BCBA to directly or remotely observe the BCaBA or the RBT administering ABA services to the participant, group of participants, parent, or caregiver;

(b) Is performed on an ongoing basis, equal to at least 10 percent of the amount of hours that the BCaBA or the RBT is providing direct ABA services to the participant, or group of participants; and

(c) Is performed in person at least 25 percent of the time;

(11) Adaptive behavior treatment by protocol which is an in-person service provided to a participant by:

(a) A licensed psychologist, a licensed BCBA-D, a licensed BCBA; or

(b) A BCaBA or an RBT under the direction of a licensed psychologist, a licensed BCBA-D or a licensed BCBA utilizing a behavioral intervention designed in advance by the psychologist, the BCBA-D or the BCBA, who may or may not provide in-person or remote direction during the treatment; and

(12) Adaptive behavior treatment planning which is an ongoing indirect service that:

(a) Is performed by a licensed psychologist, a licensed BCBA-D or a licensed BCBA; and

(b) Includes:

(i) Development and revision of the treatment plan and goals;

(ii) Data analysis; and

(iii) Real-time, direct communication and coordination with the participant’s other service providers.

C. ABA services shall only be provided by a psychologist, BCBA, BCBA-D, BCaBA, or RBT.

D. ABA services shall be initially preauthorized for a period not to exceed 180 days.

E. Additional preauthorization beyond the initial preauthorization shall be requested every 180 days, in advance of the expiration of the previous preauthorization.

F. The provider shall maintain documentation of each service delivered under the participant’s treatment plan, which, at a minimum, includes:

(1) The location, date, start time, and end time of the service;

(2) A brief description of the service provided, including reference to the treatment plan;

(3) A description of the participant’s behaviors or symptoms in measurable terms;

(4) A description of the participant’s parent or caregiver’s participation in the ABA treatment sessions, including the parent or the caregiver’s name and relationship to the participant, date and time of participation; and

(5) A legible signature, along with the printed or typed name of the individual providing care, with the appropriate title.