Current through November 28, 2024
(a) The department
will pay for the following rehabilitative autism services provided to a
recipient listed in
7
AAC 135.020(e) or (f) if provided by
a provider identified in
7
AAC 135.300;
(1)
initial behavior identification assessment;
(2) behavior identification
reassessment;
(3) adaptive behavior
treatment by protocol;
(4) group
adaptive behavior treatment by protocol;
(5) family adaptive behavior treatment
guidance;
(6) adaptive behavior
treatment by protocol modification,
(b) The department will pay for an initial
behavior identification assessment if it is conducted by a licensed behavior
analyst or licensed assistant behavior analyst, and if it
(1) interprets information from multiple
informants and data sources, including
(A) a
referral from a mental health professional, as defined in
AS
47.30.915, or a health care professional who
is qualified based on that individual's training, education, experience and
scope of practice to assess and diagnose autism spectrum disorders in children;
(B) direct observation of the
recipient in different settings and situations;
(C) information on the recipient's skill
deficits, deficient adaptive behaviors, or maladaptive behaviors from the
following sources:
(i) in-pereon observation
of the recipient;
(ii) structured
interviews with the guardian or caregiver;
(iii) administration of standardized and
nonstandardized tests;
(iv) a
detailed behavioral history;
(v)
interpretation of test results; and results; and
(D) additional information, if it exists,
from the following collateral sources:
(i)
intellectual and achievement tests;
(ii) developmental assessments;
(iii) assessments of comorbid mental health
conditions;
(iv) evaluations of
family functioning and needs;
(v)
results of neuropsychological testing;
(vi) results of other standardized
psychometric tests, including measures of general psychopathology; and
(2) results
in a written report that
(A) identifies the
skill deficits and deficient adaptive behaviors or maladaptive behaviors that
should be the focus of treatment;
(B) indicates if the recipient's behavior and
level of functioning interferes with the recipient's ability to adequately
participate in age appropriate home, school, or community activities;
(C) indicates if the recipient's behavior
poses a danger to the recipient or others;
(D) indicates that the treatment goals and
treatment targets, in the professional judgment of the behavior analyst, is
expected to result in measurable improvement in either the recipient's
behaviors or level of functioning or both;
(E) Identifies the potential functional
relationship between behavior and environmental factors;
(F) identifies motivational and contextual
factors that may be used in the course of treatment to assist with modification
and reinforcement of behavior;
(G)
recommends services and protocols that form the basis for an individualized
treatment plan; and
(H) avoids
duplication of services by ensuring that a listing of all current services
being delivered to the recipient is provided, including
(i) home and community-based waiver services
through plans of care developed under 7 AAC 130;
(ii) behavioral health treatment
plans;
(iii) individualized
education plans offered through school-based services under 7 AAC
115,600;
(iv) individualized family
service plans under
AS
47.20.100;
(v) services covered under third-party
insurance payers; and
(vi) any
privately funded services that families seek through private foundations and
private donation campaigns.
(c) Not more frequently than once every six
months, the department will pay for a behavior identification reassessment if
conducted by a licensed behavior analyst or licensed assistant behavior analyst
to obtain prior authorization under
7
AAC 135.040(d) to extend autism
services. The reassessment must establish
(1)
the recipient's measured progress over the course of treatment;
(2) an adjusted baseline in the areas of
social skills, communication skills, language skiils, adaptive behaviors, and
maladaptive behaviors that are the focus of treatment;
(3) recommended updates to the recipient's
treatment plan; and
(4) an
estimated timeline and number of treatment hours necessary to achieve each of
the recipient's treatment goals.
(d) The department will pay for adaptive
behavior treatment by protocol conducted by a provider identified in
7
AAC 135.300(a) if the
(1) treatment adheres to the protocols
identified by a licensed behavior analyst; and
(2) service is used to introduce and
reinforce incremental change in recipient skills and behavior.
(e) The department will pay for
group adaptive behavior treatment by protocol conducted by a provider listed in
7
AAC 135.300(a) if the service is
provided
(1) to a group with at least two and
not more than eight recipients;
(2)
according to the protocols identified in the treatment plan created by a
licensed behavior analyst; and
(3)
to assist with the development of individually identified social
skills.
(f) The
department will pay for family adaptive behavior treatment guidance provided by
a licensed behavior analyst or assistant behavior analyst, or by an autism
behavior technician, to
(1) instruct a
recipient's guardian and caregivers on the recipient's identified problem
behaviors and deficit skills; and
(2) teach a recipient's guardian and
caregivers to use planned treatment protocols to intervene with the recipient
to reinforce change and to maintain treatment progress.
(g) After the initial six months of planned
services provided in accordance with
7
AAC 135.040(c)(19)(A) and (B), and
the initial behavior identification assessment authorized in
7
AAC 135.040(c)(19)(E), to receive
payment for any of the additional recipient services identified in (a) - (f) of
this section, a provider must obtain prior authorization under
7
AAC 135.040(d) and meet the
requirements of (c) and (h) - (j) of this section.
(h) To receive payment for autism services a
provider must develop and update as needed an individual treatment plan that
includes
(1) recommended protocols for service
provision;
(2) objective,
measurable, and developmentally appropriate treatment goals related to skills
development, improvement in adaptive functioning and modification of problem
behavior, and other relevant diagnostic criteria for autism spectrum disorder
as listed in the
Diagnostic and Statistical Manual of Mental
Disorders, adopted by reference in
7
AAC 160.900;
(3) the anticipated timeline for improvement
based on the initial behavior identification assessment and subsequent behavior
identification reassessments conducted over the duration of treatment;
and
(4) interventions with a
recipient's guardian and caregivers designed to reinforce treatment and
treatment progress.
(i)
To receive payment for autism services provided under this section, a provider
must maintain a clinical record in accordance with
7
AAC 135.130, The clinical record also must include
(1) verification of a diagnosis of autism
spectrum disorder from a mental health professional as defined in
AS
47.30.915, or a health care professional who
is qualified based on that individual's scope of practice, training, education,
and experience to assess and diagnose autism spectrum disorders in
children;
(2) an initial behavior
identification assessment under (b) of this section, and
(3) any behavior identification reassessment
under (c) of this section.
(j) Except as set out in (k)(9)(C) of this
section, autism services may be provided in the following settings:
(1) the recipient's home, school, and
community;
(2) a behavior analyst's
office;
(3) an outpatient
clinic;
(4) another appropriate
community setting.
(k)
The department will not pay for any of the following services or interventions
as a Medicaid covered service under this section:
(1) a service listed under
7
AAC 105.110 or
7
AAC 135.010(d);
(2) respite for the family;
(3) increasing the recipient's social
activity;
(4) addressing a
recipient's antisocial behavior or legal problems;
(5) autism service provided by a recipient's
immediate family member, foster parent, or legal guardian, unless a court has
authorized that legal guardian to provide those services under AS
13,26.316;
(7) a behavioral health
rehabilitation service under
7
AAC 135.010(c) provided concurrently
with an autism service;
(8) when a
licensed behavior analyst, licensed assistant behavior analyst, or autism
behavior technician acts as a different kind of paid treatment provider or
caregiver at the same time;
(9)
claims by a licensed behavior analyst, licensed assistant behavior analyst, or
autism behavior technician that include time spent
(A) assisting a recipient with school work
for the sole purpose of education in the home, school, or community;
(B) providing leisure or social activities
solely for the purpose of entertainment, play, or recreation; or
(C) providing autism services to a patient in
an outpatient hospital, general acute care hospital, inpatient psychiatric
hospital, residential psychiatric treatment center, intermediate care facility,
skilled nursing facility, or intermediate care facility for individuals with an
intellectual disability or related condition, except for services for which the
department gives prior authorization to specifically assist the recipient with
discharge planning from these care facilities.
(l) Notwithstanding any other provision of
this section, the department will pay for authorized behavioral health clinic
services under
7
AAC 135.010(b), any service listed in
7
AAC 110.210(b), or any required
medical service on the same day a recipient receives approved autism services
under this chapter.
(m) To avoid a
break in treatment, a provider of autism services shall submit a request for
additional authorized periods of autism services 14 days before the end of the
previously authorized period of treatment. The prior authorization request must
include a behavior identification reassessment under (c) of this section, and
an updated treatment plan under (g) and (h) of this section.
(n) The department will pay for the following
autism services provided during the same 15-minute time increment as a Medicaid
covered service under this section:
(1)
adaptive behavioral health treatment by protocol;
(2) adaptive behavioral health treatment by
protocol modification.
Authority:AS
47.05.010
AS
47.07.030
