HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) Applied behavior analysis (ABA) assists children and their families to improve the core symptoms associated with autism spectrum disorders or other developmental disabilities for which there is evidence ABA is effective, per WAC 182-501-0165. ABA services support learning, skill development, and assistance in any of the following areas or domains: Social, behavior, adaptive, motor, vocational, and/or cognitive.

(2) The medicaid agency pays for ABA services when the services:

(a) Are covered;

(b) Are medically necessary;

(c) Are within the scope of the eligible client's medical care program;

(d) Are provided to clients meeting program and clinical eligibility criteria, as described in WAC 182-531-1414;

(e) Are within currently accepted standards of evidence-based medical practice;

(f) Do not replicate ABA services paid for by other state agencies using medicaid funds;

(g) Are completed in stages, as described in WAC 182-531-1418, 182-531-1420, and 182-531-1422;

(h) Are provided by qualified health care professionals, as described in WAC 182-531-1424;

(i) Are authorized, as required within this section, chapters 182-501 and 182-502 WAC, and the agency's applicable, published medicaid provider guides; and

(j) Are billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's applicable, published medicaid provider guides.

The following definitions and those found in chapter 182-500 WAC, medical definitions, and chapter 182-531 WAC, physician-related services, apply to the medicaid agency's applied behavior analysis (ABA) program.

ABA therapy treatment plan - An individualized, goal-directed treatment plan developed by a lead behavior analysis therapist meeting the criteria in WAC 182-531-1424 (2)(a)(i)(A), in coordination with other members of the health care team, and that is inclusive of other services being provided by team members.

Applied behavior analysis or ABA - Applied behavior analysis (ABA) is an empirically validated approach to improve behavior and skills related to core impairments associated with autism and a number of other developmental disabilities. ABA involves the systematic application of scientifically validated principles of human behavior to change socially significant behaviors. ABA uses scientific methods to reliably demonstrate that behavioral improvements are caused by the prescribed interventions. ABA's focus on social significance promotes a family-centered and whole-life approach to intervention. Common methods used include: Assessment of behavior, caregiver interviews, direct observation, and collection of data on targeted behaviors. A single-case design is used to demonstrate the relationship between the environment and behavior as a means to implement client-specific ABA therapy treatment plans with specific goals and promote lasting change. ABA also includes the implementation of a functional behavior assessment to identify environmental variables that maintain challenging behavior and allow for more effective interventions to be developed that reduce challenging behaviors and teach appropriate replacement behaviors.

Autism - A diagnosis on the autism spectrum disorder, as defined by the most current diagnostic and statistical manual of mental disorders (DSM) criteria, and made or confirmed by an agency-recognized center of excellence (COE).

Autism diagnostic tool - A validated tool used to establish the presence (or absence) of autism and to make a definitive diagnosis which will be the basis for treatment decisions and assist in the development of a multidisciplinary clinical treatment plan. Examples of autism diagnostic tools include:

(a) Autism Diagnosis Interview (ADI); and

(b) Autism Diagnostic Observation Schedule (ADOS).

Autism screening tool - A tool used to detect indicators or risk factors for autism and may indicate a suspicion of the condition which would then require confirmation. Examples of screening tools include, but are not limited to:

(a) Ages and Stages Questionnaire (ASQ);

(b) Communication and Symbolic Behavior Scales (CSBS);

(c) Parent's Evaluation and Developmental Status (PEDS);

(d) Modified Checklist for Autism in Toddlers (MCHAT); and

(e) Screening Tools for Autism in Toddlers and young children (STAT).

Centers of excellence or COE - A hospital, medical center, or other health care provider that meets or exceeds standards set by the agency for specific treatments or specialty care. In this program, this term is applicable to the clinician(s) who establishes or confirms the diagnosis of an autism spectrum disorder and develops the multidisciplinary clinical treatment plan.

Comprehensive diagnostic evaluation - A medical/mental health evaluation performed by the center of excellence meeting the criteria in WAC 182-531-1418(2).

Day services program - An agency-approved, structured, nonresidential, facility-based group program designed to meet the needs of enrolled children through individualized ABA therapy plans of care. The program is comprehensive, providing a variety of health, social, therapeutic activities (occupational, speech, and physical therapy), supervision, support, and assistance with learning skills to perform activities of daily living, as needed.

Diagnostic and Statistical Manual of mental disorders (DSM) - A manual published by the American Psychiatric Association that provides a common language and standard criteria for the classification of mental disorders.

Family - Individuals who are in the role of parents, guardians, caregivers, and other primary support members to the child.

Lead behavior analysis therapist or LBAT - A person meeting the qualifications for lead behavior analysis therapist (LBAT) as described in WAC 182-531-1424 (2)(a).

Therapy assistant - A person meeting the qualifications for therapy assistant as described in WAC 182-531-1424 (2)(b)(ii) and having sufficient competence to perform the tasks of a therapy assistant as described in WAC 182-531-1424 (2)(b)(iii).

To be eligible for applied behavior analysis (ABA) services, clients must meet all of the following:

(1) Program eligibility:

(a) Be twenty years of age and younger;

(b) Be covered under one of the following Washington apple health (WAH) programs:

(i) Children's health care as defined in WAC 182-505-0210;

(ii) Categorically needy program (CNP); or

(iii) Medically needy program (MNP).

(2) Clinical eligibility:

(a) The client's health care record contains documentation by a clinician that may incorporate family member observations or results of diagnostic screenings, or both, establishing the presence of any of the core symptoms of an autism spectrum disorder: Functional impairment; delay in communication, behavior, and/or social interaction; or repetitive or stereotyped behavior;

(b) There is documentation by a clinician which may incorporate family member observations, that the client's behaviors are having an adverse impact on either development or communication, or both, such that:

(i) The client cannot adequately participate in home, school, or community activities because the behavior or skill deficit(s) interferes with these activities; and/or

(ii) The child exhibits challenging behavior that negatively affects the safety or health of the child or others, or impedes access to home and community activities available to other children of the same age. Examples include, but are not limited to: Self-injury, aggression towards others, destruction of property, stereotyped/repetitive behaviors, elopement, or severe disruptive behavior; and

(c) The agency's recognized center of excellence (COE) has confirmed all requirements in (a) and (b) of this subsection and all of the following:

(i) The client has a diagnosis of an autism spectrum disorder, as defined by the most current DSM version;

(ii) Either of the following:

(A) That less intrusive or less intensive behavioral interventions have been tried and have not been successful; or

(B) That no equally effective and substantially less costly alternative is available for reducing interfering behaviors, increasing prosocial skills and behaviors, or maintaining desired behaviors; and

(iii) There is a reasonable calculation the requested services will result in measurable improvement in either the client's behavior, skills, or both.

The following stages must be completed:

(1) Stage one - Referral to a center of excellence (COE) for evaluation, development of a multidisciplinary clinical treatment plan that may include applied behavior analysis (ABA), and an order/prescription for ABA;

(2) Stage two - Referral to an ABA provider (see WAC 182-531-1424 for who qualifies as an ABA provider) for an ABA assessment, which includes:

(a) A functional assessment;

(b) A skill assessment using a standardized tool, if indicated;

(c) A functional behavioral analysis, if indicated; and

(d) An ABA therapy treatment plan; and

(3) Stage three - Delivery of ABA services with the medicaid agency's authorization.

(1) A client who meets the eligibility criteria in WAC 182-531-1414 must be referred to a center of excellence (COE) for an evaluation and multidisciplinary clinical treatment plan by:

(a) The primary care provider or other licensed health care practitioner including, but not limited to, a speech therapist or occupational therapist;

(b) A school-based health care professional as the result of an individual education plan (IEP) or an early intervention health care professional as the result of an individualized family service plan (IFSP);

(c) The client's family; or

(d) The client's managed care plan, if applicable.

(2) The COE must provide a comprehensive diagnostic evaluation and multidisciplinary clinical treatment plan that includes:

(a) Results of routine developmental screening performed by the child's primary care provider at well child visits, as available;

(b) Audiology and vision assessment results, as available, or documentation that vision and hearing were determined to be within normal limits during assessment and not a barrier to completing a valid evaluation;

(c) The name of the completed autism screening questionnaire, including date completed and significant results, as available;

(d) Documentation of how the diagnosis was made or confirmed by a COE physician or psychologist that includes:

(i) Results of formal diagnostic procedures performed by a clinician, including name of measure, dates, and results, as available; and/or

(ii) Clinical findings and observations used to confirm the diagnosis;

(e) If available, documentation of a formal cognitive and/or developmental assessment performed by the COE or another qualified clinician, including name of measure, dates, results, and standardized scores providing verbal, nonverbal, and full-scale scores. This may include school or early childhood education records. Examples of these assessment tools are:

(i) Mullen Scales of Early Learning;

(ii) Wechsler Individual Achievement Test; or

(iii) Bayley Scales of Infant and Toddler Development;

(f) If available, documentation of a formal adaptive behavior assessment performed by the COE or another qualified clinician, including name of measure, dates, results, and standardized scores providing scores of each domain. Examples of these assessment tools are:

(i) Vineland Adaptive Behavior Scales; or

(ii) Adaptive Behavior Assessment System (ABAS);

(g) Expanded laboratory evaluation, if indicated;

(h) Documentation that the client's behaviors or skill deficits are having an adverse impact on development or communication, or demonstrating injurious behavior, such that:

(i) The client cannot adequately participate in home, school, or community activities because behavior or skill deficit(s) interferes with these activities; or

(ii) The client presents a safety risk to self or others;

(i) Documentation that, if applied behavior analysis (ABA) is included in the multidisciplinary clinical treatment plan:

(i) Less intrusive or less intensive behavioral interventions have been tried and were not successful; or

(ii) There is no equally effective alternative available for reducing interfering behaviors, increasing prosocial behaviors, or maintaining desired behaviors;

(j) Recommendations that consider the full range of autism treatments with ABA as a treatment component, if clinically indicated;

(k) A statement that the evaluating and prescribing provider believes that there is a reasonable calculation that the requested ABA services will result in measurable improvement in the client's behavior or skills; and

(l) An order/prescription for ABA services. If ordered/prescribed, a copy of the COE's comprehensive diagnostic evaluation and multidisciplinary clinical treatment plan must be forwarded to the family-selected ABA provider in WAC 182-531-1424(2) or provided to the family to forward to the selected ABA provider.

(1) If the center of excellence's (COE's) evaluating and prescribing provider orders applied behavior analysis (ABA) services, the client may begin stage two - ABA assessment, functional analysis, and ABA therapy treatment plan development.

(2) Prior to implementing the ABA therapy treatment plan, the ABA provider must receive prior authorization from the medicaid agency. The prior authorization request, including the assessment and ABA therapy treatment plan, must be received by the agency within sixty days of the family scheduling the functional assessment. The client and family select the setting in which to receive services and by which ABA provider. ABA services are rendered in one of the following settings:

(a) Day services program - This is an agency-approved, outpatient facility or clinic-based program that:

(i) Provides multidisciplinary services in a short-term day treatment program setting;

(ii) Delivers comprehensive intensive services;

(iii) Embeds early, intensive behavioral interventions in a developmentally appropriate context;

(iv) Provides a developmentally appropriate ABA therapy treatment plan for each child;

(v) Includes family support and training; and

(vi) Includes multidisciplinary team members as clinically indicated to include a lead behavior analysis therapist (LBAT), therapy assistant, occupational therapist, speech therapist, physical therapist, psychologist, medical clinician, and dietician.

(b) Home, office, clinic, and community-based program (i.e., natural setting) - This is a program that:

(i) May be used after discharge from a day services program (see (a) of this subsection);

(ii) Provides a developmentally appropriate ABA therapy treatment plan for each child;

(iii) Provides ABA services in the home (wherever the child resides), office, clinic, or community setting, as required to accomplish the goals in the ABA therapy treatment plan. Examples of community settings are: A park, restaurant, child care, early childhood education, or school and must be included in the ABA therapy treatment plan with services being provided by the medicaid-enrolled LBAT or therapy assistant approved to provide services via authorization;

(iv) Requires recertification of medical necessity through continued authorization; and

(v) Includes family education, support, and training.

(3) An assessment, as described in WAC 182-531-1416(2), must be conducted and an ABA therapy treatment plan developed by an LBAT in the chosen setting. The ABA therapy treatment plan must follow the agency's ABA therapy treatment plan report template and:

(a) Be signed by the LBAT responsible for the plan development and oversight;

(b) Be time-limited (e.g., three or six months) and based on the COE's comprehensive diagnostic evaluation (see WAC 182-531-1418(2)) that took place no more than twelve months before the ABA assessment;

(c) Address the behaviors, skill deficit(s), and symptoms that prevent the client from adequately participating in home, school, community activities, or present a safety risk to self or others;

(d) Be specific and individualized to the client;

(e) Be client-centered, family-focused, community-based, culturally competent, and minimally intrusive;

(f) Take into account all school or other community resources available to the client, assure that the requested services are not redundant, but are in coordination with, other services already being provided or otherwise available, and coordinate services (e.g., from school and special education or from early intervention programs and early intervention providers) with other interventions and treatments (e.g., speech therapy, occupational therapy, physical therapy, family counseling, and medication management);

(g) Focus on family engagement and training;

(h) Identify and describe in detail the targeted behaviors and symptoms;

(i) Include objective, baseline measurement levels for each target behavior/symptom in terms of frequency, intensity, and duration, including use of curriculum-based measures, single-case studies, or other generally accepted assessment tools;

(j) Include a comprehensive description of treatment interventions, or type of treatment interventions, and techniques specific to each of the targeted behaviors/symptoms, (e.g., discrete trial training, reinforcement, picture exchange, communication systems, etc.) including documentation of the number of service hours, in terms of frequency and duration, for each intervention;

(k) Establish treatment goals and objective measures of progress for each intervention specified to be accomplished in the three- to six-month treatment period;

(l) Incorporate strategies for generalized learning skills;

(m) Integrate family education, goals, training, support services, and modeling and coaching family/child interaction;

(n) Incorporate strategies for coordinating treatment with school-based special education programs and community-based early intervention programs, and plan for transition through a continuum of treatments, services, and settings; and

(o) Include measurable discharge criteria and a discharge plan.

(1) The medicaid agency requires prior authorization (PA) of applied behavior analysis (ABA) services prior to delivery. Documents that support the PA and that must be submitted to the agency for consideration, as described in WAC 182-501-0163, are:

(a) The comprehensive diagnostic evaluation and multidisciplinary clinical treatment plan completed by the center of excellence (COE) described in WAC 182-531-1418(2);

(b) The ABA assessment and ABA therapy treatment plan described in WAC 182-531-1420(3); and

(c) Other documents required as described in the agency's medicaid provider guides.

(2) After the services are prior authorized, the ABA therapy treatment plan is implemented by the lead behavior analysis therapist (LBAT) or a therapy assistant in conjunction with other care team members. The LBAT is responsible for communicating and collaborating with other care team members to assure consistency in approaches to achieve treatment goals. If services are rendered by a therapy assistant, the therapy assistant must:

(a) Assess the client's response to techniques and report that response to the LBAT;

(b) Provide direct on-site services in the client's natural setting found in the home, office, clinic, or community, or in the day services program;

(c) Be directly supervised by an LBAT for a minimum of five percent of total direct care per week (e.g., one hour per twenty hours of care);

(d) Consult with the LBAT when considering modification to technique, when barriers and challenges occur that prohibit implementation of plan, and as otherwise clinically indicated (see WAC 182-531-1426 for appropriate procedures and physical interventions and WAC 182-531-1428 for prohibited procedures and physical interventions);

(e) Assure family involvement through modeling, coaching, and training to support generalization and maintenance of achieved behaviors;

(f) Keep documentation of each visit with the client and family to include targeted behavior, interventions, response, modifications in techniques, and a plan for the next visit, along with behavior tracking sheets that record and graph data collected for each visit; and

(g) Maintain documentation of family's confirmation that the visit occurred, recording signature, and date.

(1) Stage one. The center of excellence's (COE's) evaluating and prescribing providers must function as a multidisciplinary team whether facility-based or practitioner-based.

(a) The qualifications for a COE are:

(i) The entity or individual employs:

(A) A person or persons licensed under Title 18 RCW who is experienced in the diagnosis and treatment of autism spectrum disorders and has a specialty in one of the following:

(I) Neurology;

(II) Pediatric neurology;

(III) Developmental pediatrics;

(IV) Psychology;

(V) Pediatric psychiatry; or

(VI) Psychiatry; and

(B) A licensed midlevel practitioner (i.e., advanced registered nurse practitioner (ARNP) or physician assistant (PA)) who has been trained by and works under the tutelage of one of the specialists in (a)(i)(A) of this subsection and meets the qualifications in (a)(ii) of this subsection; or

(C) Another qualified medical provider who, within the discretion of the medicaid agency, meets qualifications in (a)(ii) of this subsection.

(ii) The entity or individual has been prequalified by the medicaid agency as meeting or employing persons meeting the following criteria:

(A) For physicians or psychologists only, have sufficient expertise to diagnose an autism spectrum disorder using a validated diagnostic tool or to confirm the diagnosis through observing the client's behavior, reviewing the documentation available from the client's primary care provider, reviewing the child's individualized education plan (IEP) or individualized family service plan (IFSP), and interviewing family members;

(B) Have sufficient experience in or knowledge of the medically necessary use of applied behavior analysis (ABA); and

(C) Are sufficiently qualified to conduct and document a comprehensive diagnostic evaluation, and to develop a multidisciplinary clinical treatment plan as described in WAC 182-531-1418(2); and

(iii) The entity or individual has a core provider agreement (CPA) with the agency or is a performing provider on an approved CPA with the agency, unless the client is covered under a managed care organization or has other third-party insurance.

(b) Examples of providers who can qualify and be paid for these services as a designated COE are:

(i) Multidisciplinary clinics;

(ii) Individual qualified provider offices; and

(iii) Neurodevelopmental centers.

(2) Stages two and three. Regardless of the service delivery option, ABA providers must meet the specified minimum qualifications and comply with applicable state laws.

(a) Lead behavior analysis therapist (LBAT).

(i) Requirements.

(A) The LBAT must be:

(I) Able to practice independently by being licensed by the department of health (DOH) as a physician, psychologist, or licensed mental health practitioner under Title 18 RCW in good standing with no license restrictions; or

(II) Employed by or contracted with an agency that is enrolled as a participating provider and licensed by DOH as a hospital, a residential treatment facility, or an in-home services agency with a home health service category to provide ABA services, and be able to practice independently by being licensed by DOH as a physician, psychologist, licensed mental health practitioner, or credentialed as a counselor under Title 18 RCW in good standing with no license restrictions; or

(III) Employed or contracted with an agency that is enrolled as a participating provider and licensed by the department of social and health services' division of behavioral health and recovery (DBHR) with certification to provide ABA services, and be able to meet the staff requirements specified in chapter 388-877A WAC.

(B) The LBAT must:

(I) Enroll as a performing/servicing provider and be authorized to supervise ancillary providers; and

(II) Be a board-certified behavior analyst (BCBA) with proof of board certification through the Behavior Analysis Certification Board; or

(III) Either have two hundred forty hours of course work related to behavior analysis and seven hundred fifty hours of supervision under a BCBA, or have two years of practical experience in designing and implementing comprehensive ABA therapy treatment plans.

(ii) Role. The LBAT must:

(A) Develop and maintain an ABA therapy treatment plan that is comprehensive, incorporating treatment being provided by other health care professionals, and that states how all treatment will be coordinated, as applicable; and

(B) Supervise a minimum of five percent of the total direct care provided by the therapy assistant per week (e.g., one hour per twenty hours of care).

(b) Therapy assistant. Requirements.

(i) Therapy assistants must be:

(A) Able to practice independently by being licensed by DOH as a licensed mental health practitioner or credentialed as a counselor under Title 18 RCW in good standing with no license restrictions; or

(B) Employed by or contracted with an agency that is enrolled as a participating provider and licensed by DOH as a hospital, a residential treatment facility, or an in-home services agency with a home health service category to provide ABA services, and be able to practice independently by being licensed by DOH as a licensed mental health practitioner or credentialed as a counselor under Title 18 RCW in good standing with no license restrictions; or

(C) Employed by or contracted with an agency that is enrolled as a participating provider and licensed by DBHR as a community mental health agency with certification to provide ABA services, and be able to meet the staff requirements specified in chapter 388-877A WAC;

(ii) The therapy assistant must:

(A) Have sixty hours of ABA training that includes applicable ABA principles and techniques, services, and caring for a child with core symptoms of autism; and

(B) Have a written letter of attestation signed by the lead LBAT that the therapy assistant has demonstrated competency in implementing ABA therapy treatment plans and delivering ABA services prior to providing services without supervision to covered clients; and

(C) Enroll as a performing/servicing provider.

(iii) Role. The therapy assistant must:

(A) Deliver services according to the ABA therapy treatment plan; and

(B) Be supervised by an LBAT who meets the requirements in (a)(i) of this subsection; and

(C) Review the ABA therapy treatment plan and the client's progress with the LBAT at least every two weeks for documentation of supervision, and make changes as indicated by the child's response.

(c) Licensure for facility-based day program setting. This applies to the model described in WAC 182-531-1420 (2)(a). Outpatient hospital facilities providing these services must meet the applicable DOH licensure requirements. Clinics and nonhospital-based facilities providing these services must be licensed as a community mental health agency by DBHR, as described in chapter 388-877A WAC. Providers rendering direct ABA services must meet the qualifications and applicable licensure or certification requirements as described in this subsection, as applicable. Other providers serving as members of the multidisciplinary care team must be licensed or certified under Title 18 RCW, as required.

In the course of receiving applied behavior analysis (ABA) services, when a client's behavior presents a threat of injury to self or others or significant damage to property, steps must be taken to protect the client and others from harm, or to prevent significant property damage.

(1) Protective restrictive procedures include, but are not limited to:

(a) Requiring a client to leave an area with physical force (i.e., physically holding and moving the client) for protection of the client, others, or property;

(b) Physical restraint to prevent the free movement of part or all of the client's body when the client's behavior poses an immediate risk to physical safety. Restraint in a prone or supine position (i.e., with the client lying on the stomach or back, respectively) is prohibited; and

(c) Mechanical restraint that limits the client's free movement or prevents self-injurious behavior (e.g., a helmet for head-banging, hand mittens or arm splints for biting, etc.). Mechanical restraint in a prone position (lying on the stomach) is prohibited.

(2) Protective physical interventions include, but are not limited to:

(a) Hand, arm, and leg holds;

(b) Standing holds;

(c) Physically holding and moving a client who is resisting; and

(d) Head holds. Physical control of the head is permitted only to interrupt biting or self-injury such as head banging.

The medicaid agency prohibits the use of the following procedures and physical restrictions for clients receiving applied behavior analysis (ABA) services:

(1) Procedures that are prohibited include:

(a) Corporal/physical punishment;

(b) The application of any electric shock or stimulus to a client's body;

(c) Forced compliance, including exercise, when it is not for protection;

(d) Locking a client alone in a room;

(e) Overcorrection;

(f) Physical or mechanical restraint in a prone position where the client is lying on his/her stomach;

(g) Physical restraint in a supine position where the client is lying on his/her back;

(h) Removing, withholding, or taking away money, tokens, points, or activities that a client has previously earned;

(i) Requiring a client to re-earn money or items purchased previously;

(j) Withholding or modifying food as a consequence for behavior (e.g., withholding dessert because the client was aggressive);

(k) Restraint chairs; and

(l) Restraint boards.

(2) Physical interventions using any of the following are not permitted under any circumstances:

(a) Any intervention that causes pain to the client and/or uses pressure points (whether for brief or extended periods);

(b) Obstruction of the client's airway and/or excessive pressure on the chest, lungs, sternum, and diaphragm;

(c) Hyperextension (pushing or pulling limbs, joints, fingers, thumbs or neck beyond normal limits in any direction) or putting the client in significant risk of hyperextension;

(d) Joint or skin torsion (twisting/turning in opposite directions);

(e) Direct physical contact covering the face;

(f) Straddling or sitting on the torso;

(g) Any of the following specific physical techniques:

(i) Arm or other joint locks (e.g., holding one or both arms behind back and applying pressure, pulling or lifting);

(ii) A "sleeper hold" or any maneuver that puts weight or pressure on any artery, or otherwise obstructs or restricts circulation;

(iii) Wrestling holds, body throws, or other martial arts techniques;

(iv) Prone restraint (client lying on the stomach);

(v) Supine restraint (client lying on the back);

(vi) A head hold where the client's head is used as a lever to control movement of other body parts;

(vii) Any maneuver that forces the client to the floor on his/her knees or hands and knees;

(viii) Any technique that keeps the client off balance (e.g., shoving, tripping, pushing on the backs of the knees, pulling on the client's legs or arms, swinging or spinning the client around, etc.); and

(ix) Any technique that restrains a client face-first vertically against a wall or post.

(h) Excessive force (i.e., using more force than is necessary; beyond resisting with like force);

(i) Any maneuver that involves punching, hitting, slapping, poking, pinching or shoving the client;

(j) Use of bed side rails for staff convenience or to purposely restrain a client unnecessarily.

(1) The medicaid agency covers only the following ABA services delivered in settings described in stage two, as noted in WAC 182-531-1420 (1) and (2), for eligible clients:

(a) The ABA assessments to determine the relationship between environmental events and behaviors;

(b) The direct provision of ABA services by the therapy assistant or lead behavior analysis therapist (LBAT);

(c) Initial ABA assessment and development of a written, initial ABA therapy treatment plan, limited to one per year;

(d) Additional ABA assessments and revisions of the initial ABA therapy treatment plan to meet client's needs, limited to four per year;

(e) Supervision of the therapy assistant;

(f) Training of family members to carry out the approved ABA therapy treatment plans;

(g) Observation of the family (or other plan implementer) and the individual's behavior to assure correct implementation of the approved ABA therapy treatment plan;

(h) Observation of the client's behavior to determine the effectiveness of the approved ABA therapy treatment plan; and

(i) On-site assistance in a difficult or crisis situation.

(2) The agency covers the following services, which may be provided in conjunction with ABA services under other agency programs and be consistent with the program rules:

(a) Speech and language therapy;

(b) Occupational therapy;

(c) Physical therapy;

(d) Counseling;

(e) Interpreter services;

(f) Dietician services; and

(g) Transportation services.

(3) The agency does not authorize payment of ABA services if the services are duplicative of services being rendered in another setting.

(4) Limits in amount or frequency of the covered services described in this section are subject to the provisions in WAC 182-501-0169, limitation extension.

The medicaid agency does not cover the following services including, but not limited to:

(1) Autism camps;

(2) Dolphin therapy;

(3) Equine therapy/hippo therapy;

(4) Language development training;

(5) Primarily educational services;

(6) Recreational therapy;

(7) Respite care;

(8) Safety monitoring services;

(9) School-based health care services or early intervention program-based services, unless prior authorized and as described in WAC 182-531-1420 (2)(b)(iii);

(10) Vocational rehabilitation;

(11) Life coaching; and

(12) Treatment that is unproven or investigational (e.g., holding therapy, Higashi (day life therapy), auditory integration therapy, etc.).

(1) The medicaid agency requires prior authorization (PA) and recertification of the medical necessity of applied behavior analysis (ABA) services.

(2) Requirements for PA requests are described in WAC 182-531-1422(1).

(3) The agency may reduce or deny services requested based on medical necessity (refer to subsection (5) of this section) when completing PA or recertification responsibilities.

(4) The following are requirements for recertification of ABA services:

(a) Continued ABA services require the agency's authorization. Authorization is granted in three-month increments, or longer at the agency's discretion;

(b) The lead behavior analysis therapist (LBAT) must request authorization for continuing services three weeks prior to the expiration date of the current authorization. A reevaluation and revised ABA therapy treatment plan documenting the client's progress and showing measurable changes in the frequency, intensity, and duration of the targeted behavior/symptoms addressed in the previously authorized ABA therapy treatment plan must be submitted with this request. Documentation must include:

(i) Projection of eventual outcome;

(ii) Assessment instruments;

(iii) Developmental markers of readiness; and

(iv) Evidence of coordination with providers; and

(c) In deciding whether to authorize continued ABA services, the agency may obtain the evaluating and prescribing center of excellence (COE) provider's review and recommendation. This COE provider must review the ABA therapy treatment plan, conduct a face-to-face visit with the child, facilitate a multidisciplinary record review of the client's progress, hold a family conference, or request a second opinion before recommending continued ABA services. Services will continue pending recertification.

(5) Basis for denial and/or reduction of services includes, but is not limited to, the following:

(a) Lack of medical necessity, for example:

(i) Failure to respond to ABA services, even after trying different ABA techniques and approaches, if applicable; or

(ii) Absence of meaningful, measurable, functional improvement changes or progress has plateaued without documentation of significant interfering events (e.g., serious physical illness, major family disruption, change of residence, etc.), if applicable. For changes to be meaningful they must be:

(A) Confirmed through data;

(B) Documented in charts and graphs;

(C) Durable over time beyond the end of the actual treatment session; and

(D) Generalizable outside of the treatment setting to the client's residence and the larger community within which the client resides; or

(b) Noncompliance as demonstrated by a pattern of failure of the family to:

(i) Keep appointments;

(ii) Attend treatment sessions;

(iii) Attend scheduled family training sessions;

(iv) Complete homework assignments; and

(v) Apply training as directed by the therapy assistant or LBAT. Absences that are reasonably justified (e.g., illness) are not considered part of the pattern.

(1) Telemedicine is when a health care practitioner uses HIPAA compliant, interactive, real-time audio and video telecommunications (including web-based applications) to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located. Using telemedicine enables the health care practitioner and the client to interact in real-time communication as if they were having a face-to-face session. Telemedicine allows medicaid agency clients, particularly those in medically underserved areas of the state, improved access to essential health care services that may not otherwise be available without traveling long distances.

(2) Telemedicine may be used to provide the following authorized services:

(a) Program supervision when the client is present; and

(b) Family training, which does not require the client's presence.

(3) The lead behavior analysis therapist (LBAT):

(a) May use telemedicine to supervise the therapy assistant's delivery of ABA services to the client and/or family; and

(b) Is responsible for determining that telemedicine can be performed without compromising the outcome of the ABA therapy treatment plan.

(4) The agency does not cover the following services as telemedicine:

(a) E-mail, telephone, and facsimile transmissions;

(b) Installation or maintenance of any telecommunication devices or systems; or

(c) Purchase, rental, or repair of telemedicine equipment.

(5) Originating site. An originating site is the physical location of the eligible agency client at the time the professional service is provided by the LBAT through telemedicine. The originating site is eligible to be paid a facility fee per completed transmission. Approved originating sites are:

(a) Clinic;

(b) Community setting;

(c) Home;

(d) Office; and

(e) Outpatient facility.

(6) Distance site. A distant site is the physical location where the LBAT provides the services listed in subsection (2) of this section to an eligible agency client through telemedicine.

(7) To be paid for providing ABA services via telemedicine, providers must bill the agency using the agency's current published Applied Behavior Analysis (ABA) Medicaid Provider Guide.

(8) If the LBAT or therapy assistant performs a separately identifiable service for the client on the same day as the telemedicine service, documentation for both services must be clearly and separately identified in the client's medical record.