Effective October 1, 2021: Applied behavior analysis (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.

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 syndrome as 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 the Clinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders (ASD).

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.

Billing for ABA services:

Providers should bill on a professional claim.
The plan will not reimburse providers for ABA services billed for less than 60 minutes (four units) per date of service. Reimbursement for ABA services in increments of 15 minutes can be billed once this date of service minimum has been met.
Allowable CPT® codes for MMC: