The Family and Social Services Administration made changes to its proposal to reign in Medicaid spending on a common behavioral treatment. The agency is keeping the lifetime limit on Applied Behavioral Analysis, or ABA, therapy but is introducing coverage tiers based on need.
In December, FSSA announced it would limit Medicaid members to 30 hours of comprehensive ABA services per week, for a maximum of three years.
Now, the agency is establishing three tiers of services based on “levels” of an individual’s diagnosis of Autism Spectrum Disorder, or ASD. The agency said depending on a person’s needs, they can qualify for three tiers of services: 30 hours, 32 hours or 38 hours. People who are not diagnosed with ASD, but have “a documented disability for which ABA therapy is deemed medically necessary” qualify for 38 hours per week.
Following the three-year limit, the agency said individuals may still qualify for “limited hour, behavior specific, focused ABA based on medical necessity.”
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FSSA said it no longer plans to apply the lifetime limit retroactively — meaning that everyone’s three-year limit will begin on April 1, when the rule officially goes into effect.
The agency said it will continue to require prior authorization for services. It said prior authorization with peer review may be required for individuals that require services for two or more years.
Abigail is our health reporter. Contact them at aruhman@wboi.org.