Applied behavior analysis services FAQ for providers

Updated applied behavior analysis services FAQ for providers

Effective January 1, 2023: Applied behavior analysis (ABA) services

1. What are ABA services?

ABA is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

ABA is a therapeutic approach in understanding the relationship between learning how behavior works and real situations in the environment. Behavioral analysis helps us to understand:

• How behavior works.
• How behavior is affected by the environment.
• How learning takes place.

2. What is the goal of ABA services?

The goal of ABA services is to increase behaviors that are useful and decrease behaviors that are harmful and affect learning.

3. Who is eligible to receive services?

• Enrollees may be eligible for ABA if they are under the age of 21 and have received a diagnosis of autism spectrum disorder and/or Rett syndromeas defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
• The enrollee must be referred by a New York state (NYS) licensed and NYS Medicaid enrolled physician (including psychiatrists and developmental/behavioral pediatricians), psychologist, or psychiatric nurse practitioner.
• Referring providers should follow the criteria for diagnosing autism spectrum disorder found in the DSM-5 and also outlined in theClinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders(ASD).

4. Where can ABA services take place?

ABA services can be delivered in a private practice, settings where patients/clients reside
full-time or part-time, clinics, hospitals, residences, and community settings. Note that ABA services provided at schools are not covered under Medicaid.

5. How does a member access ABA services?

Parents reach out to a participating ABA provider (we can provide referrals). The provider will ask some questions to determine appropriateness of request/referral and will request authorization from the health plan.

6. ABA provider requirements:

• ABA services are provided by licensed behavior analyst (LBA), certified behavior analyst assistant (CBAA) working under the supervision of LBAs, or other individuals specified under Article 167 of NYS education law (op.nysed.gov/prof/aba/abafaq.htm).
• CBAAs must be supervised by an LBA. LBAs bill for services of CBAAs under their supervision and can supervise up to six CBAAs.
• LBAs may form a group practice. CBAAs may work in a group practice but cannot own a group practice.
• The New York State Education Department recognizes unlicensed aides as individuals who can provide certain services and/or activities under the supervision of a multi-disciplinary team providing ABA services.
• LBAs and CBAAs may work in any setting that may legally provide ABA services. Examples of such settings may include private practice, settings where patients/clients reside full-time or part‑time, clinics, hospitals, residences, and community settings.
• LBAs and CBAAs must enroll in the NYS Medicaid program.
• Provider enrollment and maintenance information can be found at emedny.org/info/ProviderEnrollment/index.aspx:
  • LBAs can enroll as billing or ordering/prescribing/referring/attending (OPRA)
    non-billing provider (OPRA enrollment for Medicaid Managed Care [MMC] participation for providers not servicing fee for services [FFS] recipients).
  • CBAAs enroll as an OPRA non-billing provider (CBAAs cannot bill).
  • Unlicensed aides cannot enroll as a provider.

7. Are authorizations required?

Yes, authorizations are required.

8. How is billing for ABA services completed?

• Providers should bill on a professional claim.
• The following are allowable CPT^® codes for MMC.

Note: Medicaid does not cover CPT codes 0362T and 0373T and schools as a place of service. 

* Effective April 1, 2023