La. Admin. Code tit. 50 § XV-301

Current through Register Vol. 50, No. 11, November 20, 2024

Section XV-301 - Covered Services and Limitations

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.

La. Admin. Code tit. 50, § XV-301

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41927 (5/1/2015), Amended by the Department of Health, Bureau of Health Services Financing, LR 432498 (12/1/2017), Amended LR 481729, Amended LR 482755 (11/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.