Medicaid Applied Behavior Analysis Benefit

09/09/2021

Delayed: The New York State Department of Health has decided to postpone the inclusion of Medicaid Applied Behavioral Analysis (ABA) services into Managed Care. Effective Oct. 1, 2021, ABA services will be covered by Medicaid Fee-For-Service until further notice. For more information, refer to the September 2021 Medicaid Update.
 

Effective Oct. 1, 2021, Medicaid fee-for-service will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth 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. 
  • Medicaid does not cover ABA services as part of an Individualized Education Plan.