7 Alaska Admin. Code § 135.350

Current through September 25, 2024

Section 7 AAC 135.350 - Autism services

(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;

(6) repealed 5/25/2022;

(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.

7 AAC 135.350

Eff. 7/1/2018, Register 226, July 2018; am 5/25/2022, Register 242, July 2022

Authority:AS 47.05.010

AS 47.07.030