Ill. Admin. Code tit. 89 § 140.465

Current through Register Vol. 48, No. 50, December 13, 2024

Section 140.465 - Adaptive Behavior Support Services

a) Payment for Adaptive Behavior Support (ABS) Services.

1) Payment for ABS services shall be made to providers enrolled in the Illinois Medical Assistance Program as:

A) A Behavioral Health Clinic (BHC), pursuant to Section 140.499; or

B) An independently enrolled ABS Clinician, as defined in subsection (b)(1).

2) Independently enrolled ABS Clinicians may bill only for services the ABS Clinician personally provides or that are provided, under the ABS Clinician's supervision, by an ABS Technician with whom the ABS Clinician has an established employment, contractual, or similar relationship.

3) The services detailed in subsection (c) will be eligible for reimbursement pursuant to the Department's published fee schedule when the services are:

A) Recommended by a licensed physician or a licensed clinical psychologist operating within their scope of practice;

B) Provided to an individual under the age of 21 with a diagnosis of autism spectrum disorder (ASD), as indicated by a comprehensive diagnostic evaluation, to prevent disease, disability, and other health conditions or their progression, to prolong life, and to promote physical and mental health and efficiency in accordance with 42 CFR 440.130(c);

C) Delivered in an office, home, or community setting inclusive of school-based settings. The Department reserves the right to conduct annual on-site reviews of the locations in which ABS services are delivered;

D) Provided consistent with all requirements of this Section and any service limitations, utilization controls, and prior authorization requirements (Section 140.40) established by the Department; and

E) Provided for the direct benefit of the individual, which may include collaboration with, or training of, the primary caregivers of the eligible individual.

b) ABS Professional Qualifications. ABS services may only be delivered by those qualified professionals defined under this Section and enrolled for participation in the Illinois Medical Assistance Program. Qualified professionals may only provide ABS services within their scope of practice, as defined by federal or state law, regulation, or policy.

1) ABS Clinician. An ABS Clinician is defined as an individual providing professional services and enrolled independently or providing services as an employee of a BHC and who meets any of the following qualifications:

A) A Licensed Clinical Psychologist (LCP); or

B) A Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst Doctoral (BCBA-D), certified and in good standing with the Behavior Analyst Certification Board (BACB); or

C) A Board Certified Assistant Behavior Analyst (BCaBA), certified and in good standing with the BACB, delivering services under the supervision of an LCP, a BCBA, or a BCBA-D; or

D) Any of the following practitioners licensed within the state of practice and who have advanced training in developmental interventions from a Department-approved training entity, as detailed in the applicable Department-issued provider handbook:

i) A Licensed Clinical Social Worker (LCSW);

ii) A Licensed Clinical Professional Counselor (LCPC);

iii) A Licensed Marriage and Family Therapist (LMFT);

iv) A licensed Occupational Therapist; or

v) A licensed Speech-Language Pathologist.

2) ABS Technician. An ABS Technician is defined as an individual meeting the following qualifications, delivering services under the supervision of an independently enrolled ABS Clinician or an ABS Clinician providing services as an employee of a BHC:

A) A Registered Behavior Technician (RBT), certified and in good standing with the Behavior Analyst Certification Board; or

B) An individual who is 18 years of age or older, has a high school diploma or GED, and has received technical training in developmental interventions from a Department-approved training entity as detailed in the applicable Department-issued provider handbook.

3) ABS Technicians must receive clinical supervision from an ABS Clinician in an amount minimally equivalent to 5% of the ABS Technician's time spent delivering ABS services per month.

A) Clinical supervision by the ABS Clinician must include, at a minimum, two face-to-face, real-time contacts per month.

B) ABS Technicians credentialed as an RBT must receive their clinical supervision from an ABS Clinician credentialed as an LCP, BCBA, a BCBA-D, or a BCaBA.

C) ABS Technicians not credentialed as an RBT who meet the qualifications of subsection (b)(2)(B) must receive their clinical supervision from an LCP or from an ABS Clinician credentialed as described in subsection (b)(1)(D).

c) Covered ABS Services. The following services are established as qualified ABS services when rendered by an ABS Clinician or ABS Technician:

1) Behavior Assessment and Treatment Planning (BATP). BATP is the formal process of assessing an individual's current maladaptive or disruptive behaviors, functional skills, skill deficits, skill acquisition and maintenance of skills, and developing or updating individualized treatment goals, objectives and service recommendations based upon the assessment findings. Additional BATP functions include: administering, scoring, and interpreting the assessments; interviews with the individual's parents or guardians; non-face-to-face analysis of treatment history; and discussing findings and recommendations with the individual and their parent or guardian, as appropriate.

A) The BATP must:

i) Be completed prior to the initiation of Behavior Analysis Intervention (BAI) services and reviewed and updated, as necessary, once every 180 days thereafter;

ii) Be reviewed, approved, and signed by an ABS Clinician; and

iii) Be signed by, and a copy provided to, the individual and the individual's parent or guardian, as appropriate, upon completion or revision.

B) BATP services may be subject to prior authorization, pursuant to Section 140.40.

2) Behavior Analysis Intervention (BAI). BAI services consist of evidence-based interventions identified on the individual's BATP that use behavioral stimuli and consequences to produce socially significant improvement in behavior. BAI services include: direct observation, measurement, and functional analysis of the relationships between environment and behavior; and, parent/caregiver coaching and training for the immediate and direct clinical benefit of the individual.

A) BAI services must be delivered consistent with evidence-based practice guidelines using one of the following HFS-recognized treatment modalities:

i) Comprehensive Applied Behavior Analysis (ABA). Comprehensive ABA addresses developmental gains in individuals exhibiting adaptive living skill deficits, impairments in social skill or communication skill acquisition, or severe behaviors (harm to self, others, or property). This service is generally targeted towards individuals aged six years and younger; however, a request for this service cannot be denied based on this age recommendation alone;

ii) Focused ABA. Focused ABA functions as an adjunct service supporting the delivery of a broad array of therapeutic support services, generally providing targeted intervention to a limited number of key functional skills or challenging behaviors; or,

iii) Developmental intervention.

B) BAI services delivered using the Comprehensive or Focused ABA modality must be rendered by ABS Clinicians credentialed as an LCP, BCBA, or a BCaBA, or by ABS Technicians credentialed as an RBT.

C) BAI services may be subject to prior authorization, pursuant to Section 140.40.

3) The following functions or activities are not covered services under this Section:

A) Comprehensive diagnostic evaluation (CDE) services;

B) Any activities that include Restraint or Seclusion as defined in 405 ILCS 5/1-125 and 405 ILCS 5/1-126;

C) Traditional psychological, psychiatric, and mental health assessment, such as psychological testing, personality assessment, intellectual assessment, and neuropsychological assessment;

D) Traditional and atypical clinical interventions for behavioral health needs, such as: psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, and counseling;

E) Activities that are solely educational in nature or for educational purposes;

F) Activities that are solely vocational or recreational in nature; and

G) Educational services provided under an individualized family service plan (IFSP) or an individualized educational program (IEP), as required under the federal Individuals with Disabilities Education Act (20 U.S.C. 1400 et seq.).

Ill. Admin. Code tit. 89, § 140.465

Repealed at 15 Ill. Reg. 17318, effective November 18, 1991

New Section 140.465 added at 48 Ill. Reg. 864, effective 12/27/2023