Note: Texas Medicaid managed care organizations (MCOs) must follow all aspects of the Medicaid Autism Services Policy as outlined in this draft notice. MCOs must provide all medically necessary, Medicaid-covered services to eligible clients. Providers should contact the client's specific MCO for details.
The Texas Medicaid Provider Procedure Manual (TMPPM) will be updated with the Autism Services Policy language on February 1, 2022. Autism services are covered services of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Texas Medicaid recipients who are 20 years of age or younger and meet the criteria outlined in the Medicaid Autism Services Policy.
The Medicaid Autism Services Policy includes coverage of medically necessary applied behavior analysis (ABA) services for individuals with a diagnosis of autism spectrum disorder (ASD) and provides for coordination of the service array in interdisciplinary team meetings. The Medicaid Autism Services Policy includes the following topics:
- Requirements for prior authorization for ABA evaluation and treatment
- Clinical documentation requirements
- Licensed behavior analyst (LBA) as a new provider type and descriptions of licensed assistant behavior analysts (LaBAs) and behavior technicians (BTs) who may work under the supervision of an LBA. Note: LaBAs and BTs may not enroll as Medicaid providers.
- Requirements for interdisciplinary team meetings
- Prior authorization, billing, and reimbursement for procedure codes 97151, 97153, 97154, 97155, 97156, 97158, and 99366
- Autism services delivery through managed care and fee-for-service Medicaid
The outline of the Medicaid Autism Services Policy can be found at this link. Any changes to the policy made prior to February 1, 2022, will be primarily non-substantive.
The CCP Prior Authorization Request Form will be updated to reflect the policy. Requests for prior authorization under the new policy will be accepted on or after February 1, 2022. Claims may be submitted for dates of service beginning February 1, 2022.
Since July 30, 2021, LBAs have been able to submit Texas Medicaid enrollment applications. For more information, LBAs should refer to the Licensed Behavior Analyst Providers Can Submit Texas Medicaid Enrollment Applications and TMHP’s Provider Enrollment pages.
Note: Since December 13, 2021, new LBA enrollment applications have been required to be submitted electronically through the Provider Enrollment and Management System (PEMS) portal. All applicants are encouraged to create a PEMS account at TMHP.com today to avoid delays and stay up to date on the latest developments.
To provide ABA services, you must be enrolled in Texas Medicaid, and you must be contracted and credentialed with Medicaid managed care organizations (MCOs) in your area. It’s important to start this process as soon as possible because it may take up to 150 days to complete and may be delayed by errors in submission or additional reviews. Complete the following processes to be eligible for reimbursement:
- Use the National Plan and Provider Enumeration System (NPPES) to get a National Provider Identifier (NPI) and assign yourself a taxonomy. You must have an NPI and the appropriate taxonomy for LBAs before you enroll in Texas Medicaid or credential with MCOs.
The Texas Health and Human Services Commission (HHSC) identifies 103K00000X as the appropriate taxonomy for LBAs. Getting an NPI and a taxonomy may take around 30 days.
- Complete enrollment in Texas Medicaid by visiting the How to Apply for Enrollment page on tmhp.com. You should also refer to the step-by-step guide for instructions on enrollment. The enrollment process may take up to 30 days after you submit your enrollment application. The Texas Medicaid & Healthcare Partnership (TMHP) must conduct a site visit to each LBA location of practice. As part of the enrollment process, LBAs must submit the LBA Attestation Form Regarding Location of Services to attest where they will be providing ABA services to determine whether a site visit is needed.
Contract and get credentialed with the appropriate MCOs for which you intend to be an in-network provider. Getting credentialed may take around 90 days. Review HHSC’s map of our managed care service delivery areas to know which MCOs are in your area. The Texas Association of Health Plans (TAHP) has posted information for LBAs about contracting and credentialing with MCOs. For Amerigroup, contact Keith Jackson at firstname.lastname@example.org.
- The Texas Medicaid & Healthcare Partnership (TMHP) hosted a two-part webinar, and recordings can be accessed on the TMHP Learning Management System website. A Q&A session with HHSC and TMHP, where providers will receive answers to common questions related to the Texas Medicaid Autism Services Policy, is scheduled for Tuesday, January 25, 2022. Providers can register for the Q&A session here.
The Texas Medicaid Provider Procedures Manual, Children’s Services Handbook will be updated February 1, 2022, to include autism services information.
Email questions to MedicalBenefitRequest@hhsc.state.tx.us.
For more information, call the TMHP Contact Center at 800-925-9126.