This Missouri MO HealthNet chapter establishes Medicaid coverage and reimbursement rules for two distinct programs: (1) a general behavioral health services program governing prior authorization, provider enrollment, eligibility verification, and diagnostic criteria for non-pharmaceutical behavioral health services; and (2) an Applied Behavior Analysis (ABA) services program covering assessment and intervention for Medicaid participants under age 21 diagnosed with Autism Spectrum Disorder. Facility and provider operators must meet enrollment, licensure, supervision, insurance, and documentation requirements to bill MO HealthNet, and must obtain prior authorization for covered services except emergency and inpatient hospital interventions.
View official sourceCODE OF STATE REGULATIONS 1 Denny Hoskins (3/31/25) Secretary of State rules of Department of Social Services Division 70—MO HealthNet Division Chapter 98—Behavioral Health Services Title Page 13 CSR 70-98.015 Behavioral Health Services Program ................................. 3 13 CSR 70-98.020 Prior Authorization Committee for Non-Pharmaceutical Behavioral Health Services (Rescinded November 30, 2024) ...................... 3 13 CSR 70-98.030 Applied Behavior Analysis Services .................................. 3 CODE OF STATE REGULATIONS 3 Denny Hoskins (3/31/25) Secretary of State 13 CSR 70-98—DEPARTMENT OF SOCIAL SERVICES DIVISION 70—MO HEALTHNET DIVISION TITLE 13—DEPARTMENT OF SOCIAL SERVICES Division 70—MO HealthNet Division Chapter 98—Behavioral Health Services 13 CSR 70-98.015 Behavioral Health Services Program PURPOSE: This rule establishes the regulatory basis for the pro- gram requirements of the MO HealthNet behavioral health ser- vices program. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumber- some or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet behavioral health ser - vices program shall be administered by the Department of Social Services, MO HealthNet Division (MHD). The services covered and not covered, the prior authorization requirements, and the limitations under which services are covered shall be determined by MHD and shall be included in the MO HealthNet Behavioral Health Services Provider Manual, September 1, 2023, and the Physician Provider Manual, September 1, 2023, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/mhd/provider-manuals . This rule does not incorporate any subsequent amendments or additions. Behavioral health services shall include only those which are clearly shown to be medically necessary. (2) Persons Eligible. The MO HealthNet Program pays for approved MO HealthNet behavioral health services when furnished within the provider’s scope of practice. The participant must be eligible on the date the service is furnished. Participants may have specific limitations for behavioral health services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider manual. The provider shall ascertain the patient’s MO HealthNet and managed care or other lock-in status before any service is performed. The participant’s MO HealthNet eligibility shall be verified in accordance with methodology outlined in the provider manual. Eligible participants shall have access to non-pharmaceutical behavioral health services when they are determined medically necessary using the appropriate diagnostic criteria as follows: (A) For individuals aged six (6) years and over, providers shall use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TRTM), which is incorporated by reference in this rule as published by American Psychiatric Association Publishing, 800 Maine Avenue SW, Suite 900, Washington, DC 20024, March 16, 2022. A copy of the DSM-5- TRTM is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions; (B) For individuals under the age of six (6) years, it is recommended and preferred that providers use the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5 TM), which is incorporated by reference in this rule as published by Zero to Three, 1255 23rd Street NW, Suite 350, Washington, DC 20037, December 8, 2016. A copy of the DC:0-5TM is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions; and (C) Use of the DSM-5-TR TM will be allowed when assessing children zero through five (0–5) years of age until January 1, 2029, at which time the DC:0-5TM will become required. (3) Provider Participation. To be eligible to participate as a MO HealthNet provider of behavioral health services, a provider must meet the qualifications specified by the state agency for his or her profession and be an enrolled MO HealthNet provider. (A) The enrolled MO HealthNet provider shall comply with the following requirements: 1. Maintain adequate documentation and adequate re - cords in accordance with 13 CSR 70-3.030(2)(A); and 2. On request furnish to the MO HealthNet agency, the Medicaid Audit and Compliance Unit, or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan. (4) The prior authorization requirements for behavioral health services shall be reviewed at least every twelve (12) months by the MO HealthNet Division. (5) The prior authorization process will not apply to emergency and inpatient hospital interventions. AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Original rule filed Nov. 14, 2003, effective June 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended: Filed Oct. 31, 2008, effec- tive May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Amended: Filed Aug. 16, 2024, effective April 30, 2025. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995. 13 CSR 70-98.020 Prior Authorization Committee for Non- Pharmaceutical Behavioral Health Services (Rescinded November 30, 2024) AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original rule filed Jan. 15, 2004, effective Aug. 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Rescinded: Filed May 6, 2024, effective Nov. 30, 2024. 13 CSR 70-98.030 Applied Behavior Analysis Services PURPOSE: This rule establishes the regulatory basis for coverage and reimbursement for applied behavior analysis services under the Medicaid state plan. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumber- some or expensive. This material as incorporated by reference in 4 CODE OF STATE REGULATIONS (3/31/25) Denny Hoskins Secretary of State DIVISION 70—MO HEALTHNET DIVISION 13 CSR 70-98—DEPARTMENT OF SOCIAL SERVICES this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. (A) “Applied Behavior Analysis (ABA)” means the design, im - plementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior. ABA does not include psychological testing, personality assess - ment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, or counseling. (B) “ABA Assessment for Intervention Planning” means as - sessment that is conducted according to best practice guide - lines and considers the individual’s specific strengths and concerns to inform the intervention planning process. (C) “ABA intervention” means a type of intervention that involves directly and objectively measuring potential target behaviors and environmental events that influence them; con - structing detailed, individualized behavior analytic treatment plans; using reinforcement and other scientifically validated procedures to build functional skills and reduce behaviors that jeopardize health, safety, and independent functioning; managing treatment environments to maximize client prog - ress; implementing treatment protocols repeatedly, frequently, and consistently; measuring target behaviors directly and frequently; and adjusting treatment protocols based on data. (D) “Licensed Psychologist (LP)” means an individual who is currently licensed by the psychology board of the state in which the individual is practicing. (E) “Autism Spectrum Disorder (ASD)” as defined in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders. (F) “Best practice guidelines” means guidelines described in the Missouri Autism Guidelines Initiative’s publications enti - tled Autism Spectrum Disorders: Missouri Best Practice Guidelines for Screening, Diagnosis, and Assessment as published by the Mis- souri Department of Mental Health at their website at https:// www.autismguidelines.dmh.mo.gov/pdf/Guidelines.pdf, 2010, and Autism Spectrum Disorders: Guide to Evidence-Based Inter- ventions as published by the Missouri Department of Mental Health at their website at https://www.autismguidelines.dmh. mo.gov/documents/Interventions.pdf, 2012. These guidelines are incorporated by reference and made a part of this rule and a copy of each is available for reference at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions. (G) “Diagnostic evaluation ” means evaluation conducted according to best practice guidelines in order to determine if an ASD is present; (H) “Licensed Assistant Behavior Analyst (LABA)” means an individual who is currently licensed to practice applied behav- ior analysis under the supervision of a licensed behavior ana - lyst by the behavior analyst board under which the individual is practicing. (I) “Licensed Behavior Analyst (LBA)” means an individual who is currently licensed by the behavior analyst board of the state in which the individual is practicing. (J) “Technician” means an individual who is credentialed by the Behavior Analyst Certification Board (BACB) as a Registered Behavior Technician® (RBT®). (2) Administration. (A) The MO HealthNet ABA program shall be administered by the Department of Social Services, MO HealthNet Division. ABA services covered and not covered and the limitations under which services are covered shall be determined by the MO HealthNet Division and shall be included in the MO Health - Net provider manual, which is incorporated by reference and made a part of this rule as published by the Department of So - cial Services, MO HealthNet Division, 615 Howerton Court, Jef - ferson City, MO 65109, at its website at http://manuals.momed. com/collections/collection_psy/print.pdf, August 25, 2022. This rule does not incorporate any subsequent amendments or additions. (3) Participant Criteria. (A) In order to qualify for and receive ABA services, a MO HealthNet participant must meet all of the following criteria: 1. Be under twenty-one (21) years of age; 2. Exhibit the presence of excesses and/or deficits of be - haviors that significantly interfere with home or community activities (examples include but are not limited to aggression, self-injury, and elopement); and 3. Have a diagnostic evaluation performed by a licensed physician or licensed psychologist, resulting in a diagnosis of ASD, and recommending ABA services as medically necessary. (4) Provider Criteria. (A) To direct, supervise, and render ABA services, a profes - sional shall meet the following specifications: 1. Be currently licensed as an LBA or LP; 2. In order to be reimbursed by the MO HealthNet Division for ABA services, an LP must have ABA in his/her education, training, and experience; 3. Be covered by professional liability insurance [to] with minimum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate; 4. Have no sanctions or disciplinary actions by the applica- ble state licensing board or the BACB; 5. Have no current overpayment(s) due MO HealthNet and no Medicare or Medicaid sanctions or exclusions from partici - pation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider. (B) Assistant behavior analysts who render or supervise ABA services shall meet the following qualifications: 1. Be currently licensed as an LABA; 2. Be currently supervised by an LBA. A. The supervisory relationship must be documented in writing; 3. Be covered by professional liability insurance with min - imum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate; 4. Have no sanctions or disciplinary actions by the state licensing board or BACB; 5. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from partici - pation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider. (C) Technicians who render ABA services shall— 1. Be credentialed by the BACB as an RBT ®; 2. Work under the supervision of an LBA, LP (if officially granted supervisory privileges by the BACB), or LABA to the extent allowed for holders of the latter credential and at the CODE OF STATE REGULATIONS 5 Denny Hoskins (3/31/25) Secretary of State 13 CSR 70-98—DEPARTMENT OF SOCIAL SERVICES DIVISION 70—MO HEALTHNET DIVISION discretion of the supervising LBA. RBT ®s are required by the BACB to be supervised by LBAs who are also Board Certified Behavior Analysts, Board Certified Behavior Analysts-Doctoral, Board Certified Assistant Behavior Analysts, or members of a professional group officially granted supervisory privileges by the BACB. A. The supervisory relationship must be documented in writing; and 3. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from partici - pation in federally funded programs. (5) Covered Services and Limitations. (A) MO HealthNet covered ABA services (ABA assessment for intervention planning and ABA intervention) must be— 1. Medically necessary; 2. Precertified by MO HealthNet or its designee; 3. Delivered in accordance with the participant’s treat- ment plan; and 4. Overseen and delivered by providers who meet criteria specified herein. (B) Medical necessity for initial ABA assessment for interven - tion planning shall be determined based on a diagnostic eval - uation. Medical necessity for periodic reassessments shall be determined based on rationale for reassessment, to include but not limited to such considerations as readministration of tools, new behavior observed, new environment and participant responding differently, or lack of adequate progress. Medical necessity for ABA intervention shall be determined based on an ABA assessment for intervention planning for initial interven - tion. Medical necessity for continued ABA intervention beyond the initial precertification period shall be determined based upon requested documentation including but not limited to updated treatment plan and progress graphs. If progress is not evident, identification of barriers to progress and strategies to improve effectiveness of interventions are required. (C) ABA intervention services may be precertified for a time period not to exceed one hundred eighty (180) days. Services provided without precertification shall not be considered for reimbursement, except in the case of retroactive MO HealthNet eligibility. (D) Service Limitations. 1. Services shall be based upon the individual needs of the child and must give consideration to the child’s age, school attendance requirements, and other daily activities as docu - mented in the treatment plan. 2. Services must be delivered in a clinically appropriate setting for the behavior being treated. (6) Not Medically Necessary/Non-Covered Services. The follow - ing services do not meet medical necessity criteria, nor qualify as MO HealthNet covered ABA services: (A) Intervention services rendered when measurable func - tional improvement is not expected and services are not neces- sary to maintain function or prevent deterioration; (B) Services that are solely educational are not covered. ABA treatment goals, objectives, and procedures that may be re - lated in some way to educational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; (C) Services that are solely vocational or recreational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to vocational or recreational ac - tivities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; and (D) Custodial care is not an ABA service and is not covered as part of this benefit. Developing, restoring, or maintaining self- help, daily living, or safety skills as part of an ABA treatment plan does not constitute custodial care and are covered. (7) ABA Treatment Plan. (A) ABA intervention services shall be rendered in accor - dance with the individual’s treatment plan. The treatment plan shall— 1. Be person centered and individualized; 2. Be developed by an LBA or LP; 3. Be based on the ABA assessment for intervention plan - ning; 4. Include assessment and treatment protocols for address- ing each of the target behaviors; 5. Include training to enable LABAs and RBT ®s to imple - ment assessment and treatment protocols; 6. Include training and support to enable parents and other caregivers to participate in treatment planning and treat- ment plan implementation; 7. Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and 8. Be consistent with applicable professional standards and guidelines relating to the practice of ABA as well as state Medicaid laws and regulations and applicable Missouri licen - sure laws and regulations. (8) Reimbursement Methodology. (A) MO HealthNet shall provide reimbursement for ABA ser - vices to enrolled LBAs or LPs who are currently licensed and in good standing with the state. Payment for services rendered by LABAs shall be made to the LBA supervising and employing these personnel. Payment for services rendered by technicians shall be made to the LBA or LP supervising and employing these personnel. If the LBA or LP operates through an agency or corporate entity, payment may be made to that agency or entity. Reimbursement for ABA services shall not be made to or for services rendered by a parent, a legal guardian, or other legally responsible person. (B) Reimbursement for ABA services is made on a fee-for-ser - vices basis. The maximum allowable fee for a unit of service has been determined by the MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and cus - tomary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services precertified by MO HealthNet or its designee. (C) The fee schedule and any annual/periodic adjustments to the fee schedule are published at https://dss.mo.gov/mhd/ providers/pages/cptagree.htm. The fee schedule is incorpo - rated by reference and made a part of this rule as published by the Department of Social Services, Division of Legal Services, 221 West High Street, Jefferson City, MO 65101, at its website at https://apps.dss.mo.gov/fmsFeeSchedules/default.aspx, Au - gust 25, 2022. This rule does not incorporate any subsequent amendments or additions. AUTHORITY: sections 208.201 and 660.017, RSMo 2016*. Original rule filed Dec. 14, 2015, effective July 30, 2016. Amended: Filed Aug. 25, 2022, effective March 30, 2023. *Original authority: 208.201, RSMo 1987, amended 2007; 660.017, RSMo 1993, amended 1995.