Medicaid Applied Behavior Analysis Benefit

09/09/2021

Effective Oct. 1, 2021, EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible Medicaid members when 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 New York State (NYS) education law. 

This expansion will allow these providers to bill for ABA services. 
 

Eligibility

EmblemHealth Medicaid members may be eligible for ABA if:

  • They are under age 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), and
  • They are referred by a NYS-licensed and NYS Medicaid-enrolled physician (including psychiatrists and developmental/behavioral pediatricians), psychologists, psychiatric nurse practitioners, pediatric nurse practitioners, or physician assistants.

Referring providers should follow the criteria for diagnosing autism spectrum disorder found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and also outlined in the Clinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders (ASD).
 

Place of Service

Settings will include anywhere LBAs/CBAAs may legally provide ABA services.

  • Private/group practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings.
  • ABA services delivered through telehealth or in school-based health centers are not covered at this time. 
  • EmblemHealth does not cover ABA services as part of an Individualized Education Plan.

To find an ABA provider in our network go online or call 888-447-2526