Medicaid Funding in Texas

On June 15, 2019 Governor Abbott signed HB1 which included Rider 32: Intensive Behavioral Intervention. Contingent on the Health and Human Services Commission (HHSC) adding intensive behavioral intervention (IBI) as a Medicaid benefit for persons under age 20 with a diagnosis of Autism Spectrum Disorder, HHSC may expend funds appropriated above in Strategy A.1.5, Children, to reimburse for provision of IBI services.

 

Updates:

6/3/2022:  We are hearing that many providers are struggling with getting TMHP approval to begin seeing Medicaid clients. Please make sure that you complete the TMHP enrollment process, obtain state approval and contract and credential with each MCO prior to providing services to Texas Medicaid clients. The entire process can take approximately 180 days.  Please also make sure that you are familiar with the TMHP Provider handbooks Volume 1 and Volume 2- Children's Services Handbook, as well as each MCOs Provider handbook. There are identified differences between the prior authorization process and the continuity of care authorization process for each MCO.  See FAQ's below for more information on the prior authorization process.

3/1/2022: Revised rates for 97153 and 97154 are effective as of March 1, 2022.

2/24/2022: TMHP has agreed to enroll BCBA organizations as providers, not as individual entities. They are still working out the kinks in this process, but, if you are considering enrolling it may be beneficial to wait until the organization enrollment process if fully up and running.

2/1/2022:  The new ABA benefit is official available, families seeking information about providers who have completed the contracting and credentialing process should reach out to their Managed Care Organization Service Coordinator/ Case Manager and search the online directory under "Licensed Behavior Analyst/ LBA" or "Autism Services". The Autism Society of Texas is also keeping an "unofficial directory" here:

Medicaid Coverage for ABA Begins 2/1/22! – Autism Society of Texas (texasautismsociety.org)

Unsure of your MCO or who you should contract and credential with as a Licensed Behavior Analyst? See the State MCO map, here:

Texas Medicaid CHIP SDA Map effective January 2022

12/22/2021:  TMHP has released a new online Provider Enrollment System (PEMS). The Link to PEMS is available below:

Provider Enrollment and Management System (PEMS) | TMHP

11/5/2021: Revised rates have been released for Texas Medicaid. New Rates can be found below, changes are specific to the 97153 and 97154 codes only.

 5/2/2021: The rate hearing for the ABA benefit through Texas Medicaid was completed on 3/16/2021. The final state  plan, final rates, and go-ahead to begin contracting and credentialing with the Managed Care Organizations have yet to be completed/ released.

 

7/14/2020: Per HHSC they are "assessing the implementation and timeline (of the ABA benefit) in light of COVID-19 activities"

2/18/2020:  HHSC responded to public comment regarding ECI services and informed stakeholders on 2/6/2020 about Telehealth options for ABA through Texas Medicaid.

Comment: A couple commenters recommended that applied behavioral analysis and provider delivering these services be added to the Telehealth Services Medical Policy.

 

Response: HHSC is currently reviewing public comments related to the draft Autism Services policy that was posted September 24 - October 7, 2019. That policy included the proposed addition of applied behavior analysis and the addition of licensed behavior analysts as eligible for enrollment with Texas Medicaid. As proposed, procedure codes 97151, 97155, 97156, 97158, and 99366 would be reimbursed when services were remotely delivered. Providers should indicate that remote delivery occurred using the 95 modifier. There is not a specific deadline by which HHSC expects to make final policy decisions and post responses to public comments on that draft policy. Final policy decisions, including those regarding the role of telehealth and the use of modifiers, will be available in the HHSC responses to public comments on that policy.

12/18/2019: TxABA PPG was notified by providers and families that they were hearing from various Medicaid funding sources that ABA/ IBI was delayed to 2021 due to lack of funds.  TxABA PPG followed up with HHSC and received confirmation that HHSC plans to roll out ABA/IBI services in Spring 2020 as planned and is standing by that timeline. 

11/20/2019: TxABA PPG has been informed of the following timeline for implementation:

Currently, HHSC is finalizing revisions to the state plan and responding to public comments.

Public Comments on the draft policy were submitted to HHSC with an October 7, 2019.  At this time, we are still awaiting the revised policy.

Rate hearings that were set to occur on or about December 13, 2019 in Austin have been pushed back to early 2020; date is TBD.

Implementation will occur sometime in 2020; exact date is TBD.

TxABA PPG held a town hall discussion via GoToMeeting on August 28th to provide additional updates. If you would like a copy of the meeting minutes, please e-mail TxABA PPG at: behavioranalysispublicpolicytx@gmail.com

TxABA PPG has put together an FAQ list, below, we will continue to update this information as we have it.

Throughout the FAQ section, we will refer to Board Certified Behavior Analysts (BCBA's) as Licensed Behavior Analysts (LBA's). Licensure is required for BCBA's to practice in the state and Medicaid will require licensure.

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FAQ's (6.3.22 update)

  • Do I need to contact my Senator, Representative or the Governor’s offices to get the bill passed?

    • No! The Governor signed HB1, on June 15, 2019. HB 1 includes Rider 32: Intensive Behavioral Intervention. Contingent on the Health and Human Services Commission (HHSC) adding intensive behavioral intervention (IBI) as a Medicaid benefit for persons under age 20 with a diagnosis of Autism Spectrum Disorder, HHSC may expend funds appropriated above in Strategy A.1.5, Children, to reimburse for provision of IBI services.

 

  • When will this go into effect?

    • HB1 goes into effect on September 1, 2019

    • The initial draft of the revised HHSC Autism Policy, including IBI/ABA, was available for review in late September, 2019.  Public comments were due on 10/7/2019. 

    • Rate hearings will be  in early 2020 in Austin. An exact date and location is to be determined. Please note, this is a recent change and the hearing is no longer formally set for December 13, 2019.

    • At the rate hearing, HHSC will be hearing public testimony regarding their proposed rates. Rates may or may not be revised following this hearing.

    • This benefit is effective 2/1/2022 and revised rates will be implemented on 3/1/2022.

 

  • My child is enrolled in the HHSC CAP Program, will I lose funding?

    • Funding for the HHSC Children's Autism Program will continue for two years according to the recently approved State budget. Beyond that, we cannot say what will continue, though the TxABA Public Policy Group intends to monitor the situation closely, supporting continuation of the HHSC Children's Autism Program because some families without insurance will not qualify for Medicaid funding and cannot afford to pay for ABA services out of their own pocket.

  • Will all ABA Providers accept Medicaid?

    • No, just like private insurance, an ABA program can elect to go “in network” with any funding source.An ABA provider will need to contract and credential with the MCO's (Managed Care Organizations) before they can provide services.

  • Will there be wait lists?

    • This will vary clinic by clinic; but, yes, there will probably be some type of wait for services.

  • I’m a provider, how do I contract with Medicaid/ the MCO’s (Managed Care Organizations)?

    • The first step in this process will be to enroll with TMHP using the PEMS system. A link to the PEMS systems is included in the updates above. You should also reference the MCO service area map to determine which MCOs are in your area. You will need to contract and credential with those MCOs before providing services. the entire process can take up to 180 days to complete. If you are providing services in a center, TMHP will complete a site visit before approving your application.

  • How long will it take to complete the contracting and credentialing process?

    • Much like private insurance, it may take as much as 180 days to complete this process. While this seems like a long time, please be aware that HHSC/ The MCO’s will be inundated with numerous contracting and credentialing packets. You can help to speed up the process by ensuring that your packets are complete and accurate and/or that you follow the steps outlined above.

  • How do I obtain prior authorization for assessment or treatment for a client with Texas Medicaid?​

    • First, you should ensure that the individual is actively enrolled in Texas Medicaid, use the TMHP portal and the Tex Med Connect link to verify eligibility and ensure that Medicaid is the primary funding source (the client does not have a commercial insurance plan and Medicaid).​

    • Next, ensure that the rendering LBA has been approved by TMHP and is in network with the clients MCO.

    • Ensure the client's diagnostic report meets medical necessity criterion: is no older than three years, includes background information including trauma history and co-morbid diagnosis, includes a valid diagnostic tool, includes symptomology associated with ASD and includes a level 1,2, or 3.

    • Obtain a referral for ABA- review the TMHP Provider Manual, Volume 2: Children's Services Handbook, for specifics regarding what must be included within the referral. 

    • Submit required documents to the MCO per the MCO's provider manual for prior authorization. Be sure to include the diagnostic evaluation, referral and prior authorization form specific to that MCO. 

 

  • What are the rates?

    • The revised rates are included in the updates above in the form of a table. Rates are per 15 minute unit of time, except for the last two rates, which are per meeting.

  • What services will LBA's be able to bill?

    • HHSC is using the standard Category 1 CPT codes, specifically: 97151, 97153, 97154, 97155,  97156 and 97158. In addition, they are allowing for IDT meetings to take place using code 99366.

  • Will LBA's have to provide services directly?

    • HHSC will be adopting a tiered service delivery model, with LBAs, LaBA's and a behavior technician. The Behavior Technician must be either an RBT, ABAT or a BCAT.

 

  • Why does this apply to only individuals age 20 and under?

    • The Center for Medicaid Services (CMS) at the Federal level, advised state Medicaid offices in July 2014 that they needed to pay for ANY medically necessary treatment for autism spectrum disorders, including ABA.CMS indicated that the benefit applies through a program within Medicaid called EPSDT (Early Periodic Screening Detection and Treatment). EPSDT is for children, individuals under age 21, and is a more robust benefit. The intent is to prevent, treat or decrease the risk of chronic illness or disease of any kind- from diabetes to autism. 

 

  • Will this apply to CHIP?

    • Funding will apply to all areas of Medicaid where EPSDT is applicable. At this time THSteps (EPSDT) is not a benefit for children enrolled in CHIP or CHIP Perinatal.   We hope to continue to advocate for the inclusion of CHIP in the future.

 

  • Will ISD’s be able to bill Medicaid for behavioral services?

    • ISD billing through SHARS has not been included in the initial policy.

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Texas Needs Medicaid Funding 02.18.2019.
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