Florida Medicaid to cover certain autism treatments

On June 14, 2012 the Florida Agency for Health Care Administration (AHCA) issued a revised Medicaid alert regarding payment for autism spectrum disorders.

A federal judge recently ordered Florida Medicaid to cover Applied Behavior Analysis (ABA) for the treatment of autism spectrum disorders for children under the age of 21, effective April 2, 2012.

The AHCA says it intends to appeal this ruling. If the federal ruling is overturned, Medicaid will cease to cover these services for the treatment of autism spectrum disorders. Any such action on this matter will be posted on the AHCA website.

Meanwhile, the Florida Medicaid Management Information System is now ready to accept claims for ABA services for children under 21 with autism spectrum disorder.

Information on how to bill for these services, clarification on recoupment, and revised billing instructions are provided below.

How to bill for ABA services for children under 21 with autism spectrum disorder

The AHCA has indicated that it will not attempt to recoup payments for ABA services if it is successful in its appeal, but reserves the right to recoup payments for services not rendered in accordance with the provider alerts or subsequent guidance from AHCA.

The AHCA alert describes provider qualifications, recipient eligibility criteria, prior authorization request process, service codes and reimbursement rates, billing process, place of service codes and instructions for managed care plans.

The information contained herein incorporates portions of the alert issued by the Florida Agency for Health Care Administration. This information supersedes previous alerts posted on on the AHCA website on April 2, 2012, April 17, 2012 and May 17, 2012.

If you need assistance in regard to billing, the Medicaid Fair Hearing process, or other Medicaid issues, please contact Bruce D. Lamb or any other member of Gunster’s health law practice. For more information, download our Heath Law brochure (pdf).

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The revised alert includes the following criteria:

1.	The services require prior authorization.
2.	Provider Qualifications:ABA services must be rendered only by the following provider types who are enrolled in the Medicaid program and have received prior authorization from Medicaid for the service:
	•	Certified behavior analysts and behavior assistants enrolled under the Developmental Disabilities waiver program (see page 1-16 and 1-17 of the Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook for provider qualifications);
	•	Infant Toddler Developmental Specialists who have certification in behavior analysis and are enrolled as an Early Intervention Services Provider (see page 1-4 of the Early Intervention Services Coverage and Limitations Handbook for ITDS enrollment criteria); or
	•	Qualified treating practitioners of Therapeutic Behavioral On-Site Service – Behavior Management Services and behavioral health technicians providing Therapeutic Behavioral On-Site – Therapeutic Support Services working under a Medicaid-enrolled provider type 05 – Community Behavioral Health Services Provider (see pages 2-1-39 and 2-1-41 of the Medicaid Community Behavioral Health Services Coverage and Limitations Handbook for provider qualifications). Therapeutic behavioral on-site behavior management services must be provided by a certified behavior analyst or certified associate behavioral analyst. Therapeutic behavioral on-site therapeutic support services must be provided, at a minimum, by a behavioral health technician supervised by a master’s level practitioner.
3.	Recipient Eligibility Criteria: Qualified treating practitioners may render medically necessary ABA to a child having any of the following ICD-9 diagnosis codes: 299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91.
4.	Prior Authorization Request Process: ABA services must be prior approved by Medicaid. If a physician determines that a Medicaid eligible child diagnosed with an autism spectrum disorder needs Applied Behavior Analysis (ABA), the provider must submit a request to the Medicaid area office. The following information must be included:
	(1)	Recipient name, date of birth, Medicaid ID, and current mailing address
	(2)	Requesting provider name, national provider identifier, address, and telephone and fax numbers
	(3)	Diagnosis of recipient and diagnosis code
	(4)	If already assessed, expected duration of ABA treatment
	(5)	The primary focus of ABA treatment
	(6)	Medical records that document the diagnosis of autism spectrum disorder.
	An optional form for this purpose is available online at www.ahca.myflorida.com/chcup. Prior authorization documentation as described above must be submitted to the recipient’s Medicaid area office. Contact information for the area offices can be found at http://mymedicaid-florida.com/. If Medicaid approves the service, an authorization will be sent to the physician and the recipient or the recipient’s parent or guardian. If services are not approved, the physician and recipient or the recipient’s parent or guardian will receive notification of the denial and instructions on how to request a Medicaid Fair Hearing.
5.	Service Codes and Reimbursement Rates: Instructions for Developmental Disability Waiver Providers are available through AHCA’s website.
6.	Billing Process: To bill for the services, providers must submit claims in accordance with the Provider Reimbursement Handbook, CMS-1500 located at http://www.mymedicaid-florida.com. All claims for ABA services for children with autism spectrum disorders must be billed fee-for-service, even for those recipients enrolled in a Medicaid managed care plan. When billing for services for treatment of autism spectrum disorders, the claim must include one of the following primary diagnoses: 299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91. Billing will be allowed for dates of service beginning with the date of prior authorization, but not for dates before 4/2/2012.
7.	Instructions for Managed Care Plans:Managed care plans are not currently required to authorize or cover Applied Behavior Analysis Services for the treatment of autism spectrum disorders. If a child enrolled in a Medicaid managed care plan requires ABA services, the plan may refer the recipient to any of the identified qualifying providers to receive the service under Medicaid fee-for-service. Alternatively, the managed care plan may refer the recipient to the Medicaid area office for assistance with finding a qualified provider. Managed care plans must share information on how to access ABA services with their contracted community behavioral health and physician providers.

This publication is for general information only. It is not legal advice, and legal counsel should be contacted before any action is taken that might be influenced by this publication.

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