Coverage Information

POLICY:

General Criteria

Behavior analysis services are covered when all of the following conditions are met:

• Services are determined to be medically necessary as defined by the applicable payer.
• Services do not duplicate another service or level of care. Services meet the criteria specified in this policy and any additional requirements established by the applicable payer.

Coverage, frequency, and authorization requirements are subject to the terms and conditions of the individual payer contract.

Specific Criteria

Covered behavior analysis services may include, but are not limited to, the following, subject to applicable payer guidelines, fee schedules, and authorization requirements:

• Behavior Assessment: Typically limited to one assessment per fiscal year, per recipient, unless otherwise authorized by the applicable payer.
  • Must be completed within required payer timeframes from the start of the assessment.
• Behavior Analysis
  • May be authorized for up to 40 hours per week, per recipient, or as otherwise approved by the applicable payer.
  • Services consist of interventions identified in the recipient's behavior plan to reduce maladaptive behaviors and improve functional skills.
  • Services may include:
    • Implementation of behavior analysis interventions.
    • Ongoing monitoring and assessment of progress toward treatment goals.
    • Interventions such as discrete trial teaching, task analysis training, differential reinforcement, non-contingent reinforcement, chaining, prompting, fading, shaping, response cost, and extinction procedures.
    • Training of the recipient's family, caregivers, and other involved persons on implementation of the behavior plan and intervention strategies, when clinically appropriate and consistent with payer requirements.
• Behavior Reassessment: Typically limited to up to three per fiscal year, per recipient, unless otherwise authorized by the applicable payer.
• Early and Periodic Screening, Diagnosis, and Treatment: For recipients enrolled in Florida Medicaid who are under the age of 21 years, services may be covered in accordance with federal EPSDT requirements.
  • Pursuant to section 1905(a) of the Social Security Act (42 U.S.C. § 1396d(a)), medically necessary services to correct or ameliorate a defect, condition, or physical or mental illness may be authorized even if such services exceed the limitations described in this policy or the associated fee schedule.
  • Additional authorization requirements may apply in accordance with Florida Medicaid's General Policies.

When ongoing coverage is no longer authorized, medically necessary, or clinically appropriate, services are discharged or transitioned in accordance with Appendix 24 - Discharge and Transition of Services Policy.