Medicaid Reimbursement of ABA in Public Schools

by | Oct 10, 2023 | Education, Medicaid, Policy, State Resources

Please see this page for information from DMAS.  The state plan amendment was approved in September 2023 and is retroactive to July 2022.

Specifically, see this training document.  Here are some highlights:

  • LEAs need to make their own decisions regarding what they will bill as well as a rollout timeline.  Some LEAs may decide not to do this.  The State Plan Amendment was approved in late September and will be retroactive to July 1, 2022. You can work with your school division for a rollout plan.
  • Relevant chapters in the LEA Provider Manual include Chapters 2 (Provider Qualifications), 4 (Covered Services), & 6 (Utilization Reviews and Controls – i.e. Documentation Requirements)
    • Chapter 5 (Billing) includes procedure codes and if there are max units; CPT codes that can be billed include 97151, 97152, 97154, 97155, 97156, 97153, 97158
    • The updated manual including the expanded services (ABA) has not yet been posted and is in process as of 10/2023
  • SLPs, OTs, PTs already bill Medicaid for services in schools and BCBA, LBAs  and BCaBA, LABAs are in the process of being added.
  • An LBA is treated as a Healthcare Professional who is providing services in an educational setting.
  • LBAs do not need to change what they do to fit the LEA guidelines but just understand how the language applies to them.
  • An LBA who is employed by the LEA can bill Medicaid, but also, if an LEA contracts with a private LBA, they can bill Medicaid on the behalf of the LBA.  Contracted services, where the school division is paying for a contractor to provide services, can be reimbursed to the school division through the Medicaid and Schools program when all the requirements for reimbursement are met.
  • RBTs are considered unlicensed providers because they are not able to refer students to receive services under Medicaid, however, their time can be billed as long as they are under the supervision of an LBA.  RBTs are the only unlicensed individual who can participate in the assessment portion of the process and claim reimbursement. Divisions can claim for other unlicensed professionals (teachers, IAs), for providing services (not assessment) but this will be at the discretion of the licensed individual.
  • Be sure to be aware of supervision requirements
  • Medicaid services are not specific to students with IEPs (anyone with Medicaid can qualify for services if there is a need)
  • A Plan of Care is necessary – this differs from the BIP or other reports and should be separate; there are specific components needed
  • ICD-10 codes are to be identified in order to bill.  You can see common ones here.
  • Educational activities being performed by and LBA are not billable to Medicaid
  • Note, in order to bill, the BCBA must be licensed as an LBA (or LABA), must have an NPI number and register that NPI with Medicaid as a Referring Provider
  • LBAs who are employees will need to take part in the Random Moment Time Study but contractors will not (see training presentation for more information)
  • It’s important to coordinate with Medicaid Coordinators in your LEA