Current through Register Vol. 50, No. 9, September 20, 2024
A.
Medicaid covered ABA-based therapy services must be:
1. medically necessary;
2. prior authorized by the Medicaid Program
or its designee; and
3. delivered
in accordance with the recipients treatment plan.
B. Services must be provided directly or
billed by behavior analysts licensed by the Louisiana Behavior Analyst
Board.
C. Medical necessity for
ABA-based therapy services shall be determined according to the provisions of
the Louisiana Administrative Code (LAC), Title 50, Part I,
Chapter 11 (Louisiana Register, Volume 37, Number
1).
D. ABA-based therapy services
may be prior authorized for a time period not to exceed 180 days. Services
provided without prior authorization shall not be considered for reimbursement,
except in the case of retroactive Medicaid eligibility.
E. Service Limitations
1. Services shall be based upon the
individual needs of the child, and must give consideration to the childs age,
school attendance requirements, and other daily activities as documented in the
treatment plan.
2. Services must be
delivered in a natural setting (e.g., home and community-based settings,
including schools and clinics).
a. Services
delivered in a school must not duplicate services rendered under an
individualized family service plan (IFSP) or an individualized educational
program (IEP) as required under the federal Individuals with Disabilities
Education Act (IDEA).
3.
Any services delivered by direct line staff must be under the supervision of a
lead behavior therapist who is a Louisiana licensed behavior analyst.
F. Not Medically
Necessary/Non-Covered Services. The following services do not meet medical
necessity criteria, nor qualify as Medicaid covered ABA-based therapy services:
1. therapy services rendered when measureable
functional improvement or continued clinical benefit is not expected, and
therapy is not necessary for maintenance of function or to prevent
deterioration;
2. services that are
primarily educational in nature;
3.
services delivered outside of the school setting that are duplicative services
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. treatment whose purpose is vocationally-
or recreationally-based; and
5.
custodial care;
a. for purposes of these
provisions, custodial care:
i.shall be
defined as care that is provided primarily to assist in the activities of daily
living (ADLs), such as bathing, dressing, eating, and maintaining personal
hygiene and safety;
ii. is
provided primarily for maintaining the recipient's or anyone else's safety;
or
iii. could be provided by
persons without professional skills or training.
6. - 6.d. Repealed.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
