COMAR 10.09.34

Chapter 34 Therapeutic Behavioral Services

This chapter governs Maryland Medicaid (Medical Assistance) coverage of Therapeutic Behavioral Services (TBS) — intensive, one-to-one rehabilitative behavioral interventions delivered in community settings. Providers must employ trained therapeutic behavioral aides supervised by licensed healthcare professionals, develop individualized behavioral plans, and obtain preauthorization from the Department. Services are limited to participants under age 21 who have a mental health diagnosis placing their current living arrangement at risk, and may not be billed when delivered in inpatient, residential, or crisis residential settings.

Code of Maryland Regulations

Chapter 34 Therapeutic Behavioral Services

Administrative History

Effective date: November 24, 2005 (32:23 Md. R. 1827)

Regulation .01B
 amended effective May 2, 2011 (38:9 Md. R. 552); December 12, 2022 (49:25 Md. R. 1050)

Regulation .02A
 amended effective February 15, 2016 (43:3 Md. R. 273); December 12, 2022 (49:25 Md. R. 1050)

Regulation .03B
 amended effective December 12, 2022 (49:25 Md. R. 1050)

Regulation .04
 amended effective December 12, 2022 (49:25 Md. R. 1050)

Regulation .04D
 amended effective July 4, 2016 (43:13 Md. R. 712)

Regulation .06C
 amended effective February 15, 2016 (43:3 Md. R. 273); December 12, 2022 (49:25 Md. R. 1050); August 21, 2023 (50:16 Md. R. 726)

Authority

Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland

.01 Definitions.

A.
 In this chapter, the following terms have the meanings indicated.

B.
 Terms Defined.

(1)
 “Behavioral plan” means an individualized written plan for therapeutic behavioral services which includes the components specified in 
Regulation .03B(1) of this chapter
.

(2)
 “Department” means the Maryland Department of Health, the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396(a)—(v).

(3)
 “Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provider” means any health care provider acting within the scope of the provider's practice who:

(a)
 Screens, evaluates, or identifies a condition; and

(b)
 Recommends treatment.

(4)
 “Medically necessary” means that the service or benefit is:

(a)
 Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b)
 Consistent with current accepted standards of good medical practice;

(c)
 The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and

(d)
 Not primarily for the convenience of the consumer, family, or provider.

(5)
 “Participant” means an individual who is certified as eligible for and is receiving Medical Assistance benefits.

(6)
 “Preauthorization” means the approval required from the Department, or its designee, before services may be rendered.

(7)
 “Prescribed” means ordered in writing and signed by an EPSDT provider who has examined the participant and diagnosed the 
[
recipient's
] 
participant’s medical condition.

(8)
 “Program” means the Maryland Medical Assistance Program.

(9)
 “Rehabilitative service” means a medical or remedial service prescribed by a licensed physician or authorized practitioner under 
Health Occupations Article, Annotated Code of Maryland
, or the jurisdiction where services are rendered for:

(a)
 Maximum reduction of physical or mental disability; and

(b)
 Restoration of a participant’s best possible functional level.

(10)
 “Therapeutic behavioral aide” means an individual who is:

(a)
 A health care professional or a nonprofessional who is supervised by an individual who is licensed, certified, or otherwise legally authorized to provide mental health services independently in the state where the service is rendered;

(b)
 Trained and supervised by a therapeutic behavioral service provider to implement a behavior plan; and

(c)
 Available on-site to provide one-to-one behavioral assistance and intervention to accomplish outcomes specified in the behavioral plan.

(11)
 “Therapeutic behavioral assessment” means a comprehensive assessment of a participant and, if applicable, a participant’s family that:

(a)
 Is performed by a licensed or certified health care professional;

(b)
 Addresses the medical and behavioral needs for therapeutic behavioral services;

(c)
 Includes the risk of needing placement in a more restrictive living arrangement because of the behavior; and

(d)
 Includes development of a behavioral plan.

(12)
 “Therapeutic behavioral service” means an intensive, rehabilitative service that is documented in the written behavioral plan and is intended to:

(a)
 Provide the participant with behavioral management skills to effectively manage the behaviors or symptoms that place the participant at risk for a higher level of care; and

(b)
 Restore the participant’s previously acquired behavior skills and enable the participant to develop appropriate behavior management skills.

(13)
 “Therapeutic behavioral service provider” means:

(a)
 A Developmental Disabilities Administration provider meeting criteria set forth in 
COMAR 10.22.02
;

(b)
 An outpatient mental health clinic approved under 
COMAR 10.21.20
;

(c)
 A mental health mobile treatment unit meeting criteria set forth in 
COMAR 10.09.59
; or

(d)
 A psychiatric rehabilitation program approved under 
COMAR 10.21.29
.

.02 Conditions for Provider Participation.

A.
 A therapeutic behavioral service provider shall:

(1)
 Ensure that therapeutic behavioral aides are trained and supervised in:

(a)
 Principles of behavior change and childhood development;

(b)
 Clinically accepted techniques for decreasing or eliminating maladaptive behaviors;

(c)
 Implementing a behavioral plan;

(d)
 Identifying the needs and characteristics of the participant; and

(e)
 Documenting interventions and outcomes;

(2)
 If the therapeutic aide is not licensed or certified by a health practice licensure board to practice independently, ensure that a licensed healthcare practitioner shall:

(a)
 Meet at least once every 2 weeks with the aide and review the progress and develop a plan of care for each participant assigned to the aide; and

(b)
 At least once a month, observe the participant’s progress and needs with the participant’s parent or guardian; and

(3)
 Provide a written progress note that is completed for each time period that a therapeutic behavioral aide spends with the participant and includes:

(a)
 The location, date, start time, and end time of the service;

(b)
 The name of the parent, guardian, or individual who customarily provides care present during the service;

(c)
 A brief description of the service provided, including reference to the behavioral plan;

(d)
 A description of the participant’s behaviors or symptoms; and

(e)
 The signature of the behavioral aide.

B.
 General requirements for provider participation in the Program are set forth in 
COMAR 10.09.36
.

.03 Covered Services.

A.
 The Program covers the services listed in this chapter when the services are:

(1)
 Diagnosed, identified, and prescribed by an EPSDT provider to be medically necessary;

(2)
 Preauthorized by the Department or its designee; and

(3)
 Delivered in accordance with the behavioral plan.

B.
 The following services are covered:

(1)
 Therapeutic behavioral assessment and reassessment that includes:

(a)
 Development of a behavioral plan with the participant and parent, guardian, or individual who customarily provides care which specifically:

(i)
 Identifies the target behaviors or symptoms that are placing the current living arrangement at risk or presenting a barrier to transition to a less restrictive living arrangement;

(ii)
 Defines specific interventions to be used to resolve the behaviors or symptoms, including how a therapeutic aide will implement therapeutic behavioral services;

(iii)
 Defines outcome measures that can be used to demonstrate the decreasing frequency of targeted behaviors;

(iv)
 Defines alternative behaviors;

(v)
 Defines the clinically accepted techniques for behavior change, including where, when, and the frequency of the techniques to be used and the risks and benefits of each;

(vi)
 Details the strategies and skills for the participant and parent, guardian, or individual who customarily provides cares to provide continuity of care when therapeutic behavioral services are discontinued;

(vii)
 Details emergency procedures to be implemented when the participant exhibits behaviors that pose harm to self or others;

(viii)
 Contains written informed consent before implementation, of the parent or legal guardian, or if the participant is 18 years old or older, written informed consent of the participant; and

(ix)
 Identifies the level or type of licensed healthcare professional responsible for monitoring the behavioral plan; and

(b)
 Determination if therapeutic behavioral services are needed;

(2)
 Therapeutic behavioral services that:

(a)
 Provide one-to-one intervention for a specified period of time at the appropriate site in accordance with the behavioral plan; and

(b)
 May include, but are not limited to:

(i)
 Assisting the participant to engage in or remain engaged in appropriate activities;

(ii)
 Minimizing the participant’s impulsive behavior;

(iii)
 Providing immediate behavioral reinforcements;

(iv)
 Providing time structuring activities; and

(v)
 Collaboration with and support for parent, guardian, or individual who customarily provides care in the effort to provide ongoing behavioral support.

Cross References

10.09.23.04D(2)(k)

10.09.34.01B(1)

.04 Limitations.

A.
 To be eligible for therapeutic behavioral services the:

(1)
 Participant shall be younger than 21 years old and enrolled in the Program;

(2)
 Participant shall be assessed as having behaviors or symptoms related to a mental health diagnosis that places the individual's current living arrangement at risk and creates a risk for a more restrictive placement, or prevents transition to a less restrictive placement;

(3)
 Participant’s behaviors or symptoms shall be safely and effectively treated in the community; and

(4)
 Participant’s parent, guardian, or individual who customarily provides care shall be present during the provision of all therapeutic behavioral services to participate in the behavioral plan, unless there are clinical goals specifically addressed in the behavior plan that need to be achieved requiring that the parent, guardian, or individual who customarily provides care not be present.

B.
 Therapeutic behavioral services shall meet the definition of rehabilitation services.

C.
 Therapeutic behavioral services shall be:

(1)
 Decreased proportionally when indicated by the participant’s progress;

(2)
 Discontinued when the targeted outcomes have been reached; or

(3)
 Reassessed for new targeted outcomes if progress on the current outcomes is not being achieved.

D.
 A therapeutic behavioral service provider may not bill the Program for:

(1)
 Services that are:

(a)
 Provided in:

(i)
 An intermediate care facility;

(ii)
 An institution for mental disease;

(iii)
 A hospital; or

(iv)
 A crisis residential program;

(b)
 Habilitative, custodial, or activities of daily living;

(c)
 Not authorized by the Department or its designee;

(d)
 Provided by a therapeutic behavioral aide who is a member of the participant’s immediate family or who resides in the participant’s home;

(e)
 Not medically necessary;

(f)
 Beyond the provider's scope of practice;

(g)
 Not performed under the supervision of a licensed health care provider;

(h)
 Rendered but not appropriately documented;

(i)
 Part of another service paid for by the State; or

(j)
 Rendered by mail, telephone, or otherwise not one-to-one, in person;

(2)
 Services that duplicate the care and custody provided by another State agency pursuant to a court order or a voluntary placement agreement;

(3)
 Respite services;

(4)
 Seclusion or restrictive techniques;

(5)
 Completion of forms or reports;

(6)
 Broken or missed appointments; or

(7)
 Travel to and from site of service.

.05 Preauthorization.

A.
 The Department or its designee shall require preauthorization for therapeutic behavioral services.

B.
 The initial authorization shall be given for not more than 60 calendar days.

C.
 Additional authorization beyond the initial authorization shall be requested at a minimum, every 60 days and in advance of the expiration of the previous authorization.

D.
 Authorization may only be given if the therapeutic behavioral service continues to be effective and progress towards the specified goals is documented.

Cross References

10.09.23.06F

.06 Payment Procedures.

A.
 Request for payment of services shall be submitted in accordance with 
COMAR 10.09.36.04
.

B.
 Billing time limitations for claims submitted pursuant to this chapter as set forth in 
COMAR 10.09.36.06
.

C.
 Reimbursement for services covered under this chapter is as follows:

(1)
 For dates of service from November 1, 2021 through June 30, 2022:

(a)
 Initial therapeutic assessment and reassessment at a rate of $136.12; and

(b)
 Therapeutic behavioral services at a rate of:

(i)
 $29.50 for the first 30 minutes; and

(ii)
 $14.75 for each additional 15 minutes.

(2)
 Effective July 1, 2022:

(a)
 Initial therapeutic assessment and reassessment at a rate of $145.99; and

(b)
 Therapeutic behavioral services at a rate of:

(i)
 $31.64 for the first 30 minutes; and

(ii)
 $15.82 for each additional 15 minutes.

.07 Recovery and Reimbursement.

Recovery and reimbursement shall be as set forth in 
COMAR 10.09.36.07
.

.08 Cause for Suspension or Removal and Imposition of Sanctions.

Causes for suspension or removal and imposition of sanctions shall be as set forth in 
COMAR 10.09.36.08
.

.09 Appeal Procedures.

Appeals procedures shall be as set forth in accordance with 
COMAR 10.09.36.09
.

.10 Interpretive Regulation.

This chapter shall be interpreted as set forth in 
COMAR 10.09.36.10
.