Section 140.465 Adaptive Behavior Support Services

Section 140

Section 140.465  Adaptive

Behavior Support Services

a)         Payment

for Adaptive Behavior Support (ABS) Services.

1)         Payment

for ABS services shall be made to providers enrolled in the Illinois Medical

Assistance Program as:

A)        A

Behavioral Health Clinic (BHC), pursuant to Section 140.499; or

B)        An

independently enrolled ABS Clinician, as defined in subsection (b)(1).

2)         Independently

enrolled ABS Clinicians may bill only for services the ABS Clinician personally

provides or that are provided, under the ABS Clinician's supervision, by an ABS

Technician with whom the ABS Clinician has an established employment,

contractual, or similar relationship.

3)         The

services detailed in subsection (c) will be eligible for reimbursement pursuant

to the Department's published fee schedule when the services are:

A)        Recommended

by a licensed physician or a licensed clinical psychologist operating within

their scope of practice;

B)        Provided

to an individual under the age of 21 with a diagnosis of autism spectrum disorder

(ASD), as indicated by a comprehensive diagnostic evaluation, to prevent

disease, disability, and other health conditions or their progression, to

prolong life, and to promote physical and mental health and efficiency in

accordance with 42 CFR 440.130(c);

C)        Delivered

in an office, home, or community setting inclusive of school-based settings.

The Department reserves the right to conduct annual on-site reviews of the

locations in which ABS services are delivered;

D)        Provided

consistent with all requirements of this Section and any service limitations,

utilization controls, and prior authorization requirements (Section 140.40) established

by the Department; and

E)        Provided

for the direct benefit of the individual, which may include collaboration with,

or training of, the primary caregivers of the eligible individual.

b)         ABS

Professional Qualifications

nsistent with all requirements of this Section and any service limitations,

utilization controls, and prior authorization requirements (Section 140.40) established

by the Department; and

E)        Provided

for the direct benefit of the individual, which may include collaboration with,

or training of, the primary caregivers of the eligible individual.

b)         ABS

Professional Qualifications. ABS services may only be delivered by those

qualified professionals defined under this Section and enrolled for participation

in the Illinois Medical Assistance Program.  Qualified professionals may only

provide ABS services within their scope of practice, as defined by federal or

state law, regulation, or policy.

1)         ABS

Clinician.  An ABS Clinician is defined as an individual providing professional

services and enrolled independently or providing services as an employee of a

BHC and who meets any of the following qualifications:

A)        A Licensed Clinical

Psychologist (LCP); or

B)        A

Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst

Doctoral (BCBA-D), certified and in good standing with the Behavior Analyst

Certification Board (BACB); or

C)        A

Board Certified Assistant Behavior Analyst (BCaBA), certified and in good

standing with the BACB, delivering services under the supervision of an LCP, a BCBA,

or a BCBA-D; or

D)        Any of

the following practitioners licensed within the state of practice and who have

advanced training in developmental interventions from a Department-approved

training entity, as detailed in the applicable Department-issued provider

handbook:

i)          A

Licensed Clinical Social Worker (LCSW);

ii)         A

Licensed Clinical Professional Counselor (LCPC);

iii)        A

Licensed Marriage and Family Therapist (LMFT);

iv)        A

licensed Occupational Therapist; or

v)         A

licensed Speech-Language Pathologist.

2)         ABS

Technician

oved

training entity, as detailed in the applicable Department-issued provider

handbook:

i)          A

Licensed Clinical Social Worker (LCSW);

ii)         A

Licensed Clinical Professional Counselor (LCPC);

iii)        A

Licensed Marriage and Family Therapist (LMFT);

iv)        A

licensed Occupational Therapist; or

v)         A

licensed Speech-Language Pathologist.

2)         ABS

Technician.  An ABS Technician is defined as an individual meeting the

following qualifications, delivering services under the supervision of an

independently enrolled ABS Clinician or an ABS Clinician providing services as

an employee of a BHC:

A)        A

Registered Behavior Technician (RBT), certified and in good standing with the

Behavior Analyst Certification Board; or

B)        An

individual who is 18 years of age or older, has a high school diploma or GED,

and has received technical training in developmental interventions from a

Department-approved training entity as detailed in the applicable

Department-issued provider handbook.

3)         ABS

Technicians must receive clinical supervision from an ABS Clinician in an

amount minimally equivalent to 5% of the ABS Technician's time spent delivering

ABS services per month.

A)        Clinical

supervision by the ABS Clinician must include, at a minimum, two face-to-face,

real-time contacts per month.

B)        ABS

Technicians credentialed as an RBT must receive their clinical supervision from

an ABS Clinician credentialed as an LCP, BCBA, a BCBA-D, or a BCaBA.

C)        ABS

Technicians not credentialed as an RBT who meet the qualifications of subsection

r month.

A)        Clinical

supervision by the ABS Clinician must include, at a minimum, two face-to-face,

real-time contacts per month.

B)        ABS

Technicians credentialed as an RBT must receive their clinical supervision from

an ABS Clinician credentialed as an LCP, BCBA, a BCBA-D, or a BCaBA.

C)        ABS

Technicians not credentialed as an RBT who meet the qualifications of subsection

(b)(2)(B) must receive their clinical supervision from an LCP or from an ABS

Clinician credentialed as described in subsection (b)(1)(D).

c)         Covered

ABS Services.  The following services are established as qualified ABS services

when rendered by an ABS Clinician or ABS Technician:

1)         Behavior

Assessment and Treatment Planning (BATP). BATP is the formal process of

assessing an individual's current maladaptive or disruptive behaviors,

functional skills, skill deficits, skill acquisition and maintenance of skills,

and developing or updating individualized treatment goals, objectives and

service recommendations based upon the assessment findings.  Additional BATP

functions include: administering, scoring, and interpreting the assessments;

interviews with the individual's parents or guardians; non-face-to-face

analysis of treatment history; and discussing findings and recommendations with

the individual and their parent or guardian, as appropriate.

A)        The

BATP must:

i)          Be

completed prior to the initiation of Behavior Analysis Intervention (BAI)

services and reviewed and updated, as necessary, once every 180 days thereafter;

ii)         Be

reviewed, approved, and signed by an ABS Clinician; and

iii)        Be

signed by, and a copy provided to, the individual and the individual's parent

or guardian, as appropriate, upon completion or revision.

B)        BATP

services may be subject to prior authorization, pursuant to Section 140.40.

2)         Behavior

Analysis Intervention (BAI)

y, once every 180 days thereafter;

ii)         Be

reviewed, approved, and signed by an ABS Clinician; and

iii)        Be

signed by, and a copy provided to, the individual and the individual's parent

or guardian, as appropriate, upon completion or revision.

B)        BATP

services may be subject to prior authorization, pursuant to Section 140.40.

2)         Behavior

Analysis Intervention (BAI). BAI services consist of evidence-based

interventions identified on the individual's BATP that use behavioral stimuli

and consequences to produce socially significant improvement in behavior.  BAI

services include: direct observation, measurement, and functional analysis of

the relationships between environment and behavior; and, parent/caregiver

coaching and training for the immediate and direct clinical benefit of the

individual.

A)        BAI

services must be delivered consistent with evidence-based practice guidelines

using one of the following HFS-recognized treatment modalities:

i)          Comprehensive

Applied Behavior Analysis (ABA).  Comprehensive ABA addresses developmental

gains in individuals exhibiting adaptive living skill deficits, impairments in

social skill or communication skill acquisition, or severe behaviors (harm to

self, others, or property).  This service is generally targeted towards

individuals aged six years and younger; however, a request for this service

cannot be denied based on this age recommendation alone;

ii)         Focused

ABA. Focused ABA functions as an adjunct service supporting the delivery of a

broad array of therapeutic support services, generally providing targeted

intervention to a limited number of key functional skills or challenging

behaviors; or,

iii)        Developmental

intervention.

B)        BAI

services delivered using the Comprehensive or Focused ABA modality must be

rendered by ABS Clinicians credentialed as an LCP, BCBA, or a BCaBA, or by ABS

Technicians credentialed as an RBT

y of therapeutic support services, generally providing targeted

intervention to a limited number of key functional skills or challenging

behaviors; or,

iii)        Developmental

intervention.

B)        BAI

services delivered using the Comprehensive or Focused ABA modality must be

rendered by ABS Clinicians credentialed as an LCP, BCBA, or a BCaBA, or by ABS

Technicians credentialed as an RBT.

C)        BAI

services may be subject to prior authorization, pursuant to Section 140.40.

3)         The

following functions or activities are not covered services under this Section:

A)        Comprehensive

diagnostic evaluation (CDE) services;

B)        Any

activities that include Restraint or Seclusion as defined in 405 ILCS 5/1-125

and 405 ILCS 5/1-126;

C)        Traditional

psychological, psychiatric, and mental health assessment, such as psychological

testing, personality assessment, intellectual assessment, and

neuropsychological assessment;

D)        Traditional

and atypical clinical interventions for behavioral health needs, such as:

psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy,

family therapy, and counseling;

E)        Activities

that are solely educational in nature or for educational purposes;

F)         Activities

that are solely vocational or recreational in nature; and

G)        Educational

services provided under an individualized family service plan (IFSP) or an

individualized educational program (IEP), as required under the federal

Individuals with Disabilities Education Act (20 U.S.C. 1400 et seq.).