ISSUE DATE: June 6, 2016 EFFECTIVE DATE: Immediately NUMBER: OMHSAS-16-07 SUBJECT: Enrollment and Payment of Provider Entities that Do Not Have a License to Provide Outpatient, Partial Hospitalization, or Family Based Mental Health Services to Use Behavioral Specialist Consultant Services and Therapeutic Staff Support Services to Provide Applied Behavioral Analysis to Children with Autism Spectrum Disorders. BY: BY: Deputy Secretary Office of Mental Health and Substance Abuse Services Deputy Secretary Office of Medical Assistance Programs SCOPE: This bulletin applies to entities that are not licensed to provide outpatient, partial hospitalization, or family based mental health services and who seek to enroll in the Medical Assistance (MA) program to use Behavioral Specialist Consultant-Autism Spectrum Disorder (BSC-ASD) services and Therapeutic Staff Support (TSS) services to provide Applied Behavioral Analysis (ABA) to children with autism spectrum disorders (ASD). PURPOSE: The purpose of this bulletin is to notify entities that provide ABA to children with ASD and do not have an outpatient, partial hospitalization, or family based mental health license how to enroll in the MA program and be paid for using BSC-ASD and TSS services to provide ABA. BACKGROUND: The MA program provides ABA to children with ASD using BSC-ASD and TSS services. The Department of Human Services (Department) has determined that the requirement set forth in MA Bulletin 01-94-01, Outpatient Psychiatric Services for Children Under 21 Years of Age, issued January 11, 1994, that a provider have a license to enroll to provide BSC services and TSS services has resulted in the inability of some entities that use highly qualified staff to provide ABA to children to enroll in the MA program. As a result, the Department has
established a process to waive the license requirement and enable entities that do not have an outpatient, partial hospitalization, or family based mental health license to provide ABA to children with ASD to enroll in the MA program. DISCUSSION: ABA is the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior or to prevent loss of attained skill or function. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA is used to develop needed skills (behavioral, social, communicative, and adaptive functioning) through the use of reinforcement, prompting, task analysis, or other appropriate interventions in order for a child or adolescent to master each step necessary to achieve a targeted behavior. In accordance with Act 62 of 2008 the State Board of Medicine, in consultation with the Department, promulgated regulations providing for the licensure of behavior specialists. In OMHSAS Bulletin 14-02, Enrollment and Payment of Licensed Providers that Provide Behavior Specialist Consultant Services to Child with Autism Spectrum Disorders, issued May 23, 2014, the Department notified providers that individuals who provide BSC services to children with ASD will need to have a behavior specialist license or other professional license whose scope of practice includes the diagnostic assessment or treatment of ASD to receive payment through the MA program for providing BSC-ASD services. As described below, the Department has established a process to enable entities that do not have an outpatient, partial hospitalization, or family based mental health license to enroll in the MA program to provide ABA to children with ASD based on the licenses held by the individuals that will be using BSC-ASD services to provide ABA. These entities will also be able to bill for using TSS services to provide ABA if their approved service description includes TSS. Entities that do not have a license to provide outpatient, partial hospitalization, or family based mental health services and enroll in the MA program must satisfy all of the Department policies and requirements, including the requirements of the Department bulletins relating to BSC-ASD and TSS, including MA Bulletin 01-94-01; MA Bulletin 01-01-05, Revisions to Policies and Procedures Relating to Mobile Therapy, Behavior Specialist Consultant and Therapeutic Staff Support Services, issued June 1, 2001; MA Bulletin 01-02-05, Reissue of Medical Assistance (MA) Bulletin Addition of Behavioral Health Rehabilitation Service to the MA Program Fee Schedule, issued March 5, 2002; MA Bulletin 08-06-15, Revision to Minimum Staff Qualifications of Therapeutic Staff Support (TSS) Workers, issued August 24, 2006; OMHSAS-16-02, Training and Supervision Requirements for Therapeutic Staff Support Workers that Implement Treatment Plans that Include Applied Behavioral Analysis, issued March 11, 2016; and OMHSAS-16-04, Training Requirements for Licensed Behavior Specialists Who Use Behavioral Specialist Consultant-Autism Spectrum Disorder Services to Provide Applied Behavioral Analysis, issued April 26 2016. 2
PROCEDURE: Entities that do not have a license to provide outpatient, partial hospitalization, or family based mental health services and are seeking to enroll based on the license held by the individuals that will be using BSC-ASD services and TSS services to provide ABA to children with ASD must complete a Base Provider Enrollment application for Provider Type 11 and other required documents. Entities must complete the paper application for Provider Type 11 and submit the required documents by mail, facsimile, or email. The application and instructions for enrollment can be accessed at: http://www.dhs.pa.gov/provider/promise/enrollmentinformation/index.htm#.v1bure0uwuk Entities seeking to enroll to use BSC-ASD services to provide ABA should enter Specialty Type 561 (Entity BSC-ASD (ABA)) on the enrollment application. Entities seeking to also use TSS services to provide ABA should also enter Specialty Type 562 (Entity TSS (ABA)) on the enrollment application. As with all Behavioral Health Rehabilitation Services, entities that do not have a license to provide outpatient, partial hospitalization, or family based mental health services must also submit service descriptions for BSC-ASD and TSS services to the Office of Mental Health and Substance Abuse Services Children s Bureau for review and approval. The service description must be approved prior to billing the MA program for using BSC-ASD services or TSS services to provide ABA. The service description format and instructions on how to submit the service description is included in Attachment 1. Since the entities are not licensed, there is no existing Department requirement for clinical oversight of the services. For this reason providers must explain in their service description the clinical supervision and oversight of the services being provided. Enrollment in the MA program does not automatically enroll the provider in the HealthChoices program. Providers should contact the Behavioral Health Managed Care Organization(s) (BH- MCO) regarding participating in the BH-MCO s network. Billing for Services If a licensed psychologist uses BSC-ASD services to provide ABA, use the following procedure code and modifier to bill for BSC-ASD services: H0046 HP+HA. If a licensed individual other than a psychologist uses BSC-ASD services to provide ABA, use the following procedure code and modifier to bill for BSC-ASD services: H0046 HO+HA. If TSS services are used to provide ABA, use the following procedure code and modifier to bill for TSS services: H2021 UB+HA. 3
MA Fee Schedule Rate The MA fee schedule rate for BSC-ASD services provided by licensed individuals other than a psychologist is $12.25 per quarter hour. The MA fee schedule rate for BSC-ASD services provided directly by a licensed psychologist is $15.75 per quarter hour. Please note: Consistent with MAB 01-94-01, a psychologist may only bill the higher rate for services the psychologist provides. The MA fee schedule rate for TSS services is 15.00 per half hour. ATTACHMENT: Attachment 1 Format for Service Description for Provider Entities That Use Behavioral Specialist Consultant-Autism Spectrum Disorders (BSC-ASD) and Therapeutic Staff Support (TSS) Services to Provide Applied Behavioral Analysis (ABA) to Children with Autism Spectrum Disorder (ASD) and Do Not Have a License Specified in MA Bulletin 01-94-01. Questions should be directed as follows: Questions related to the PROMISe provider enrollment process can be emailed to RA- PRovApp@pa.gov or by calling 1-800-537-8862 Questions regarding the content of this bulletin can be emailed to: RA-BHRS@pa.gov 4
Attachment I FORMAT FOR SERVICE DESCRIPTION FOR PROVIDER ENTITIES THAT USE BEHAVIORAL SPECIALIST CONSULTANT-AUTISM SPECTRUM DISORDERS (BSC-ASD) SERVICES AND THERAPEUTIC STAFF SUPPORT (TSS) SERVICES TO PROVIDE APPLIED BEHAVIORAL ANALYSIS (ABA) TO CHILDREN WITH AUTISM SPECTRUM DISORDER (ASD) AND DO NOT HAVE A LICENSE SPECIFIED IN MA BULLETIN 01-94-01 A provider must have a service description (SD) approved by the Office of Mental Health and Substance Abuse Services Children s Bureau and be enrolled in the Medical Assistance (MA) program to bill the MA program to use BSC-ASD services and TSS services to provide ABA. To enroll in the MA program to bill the MA program for BSC- ASD services and TSS services used to provide ABA a provider must complete the enrollment application for Provider Type 11 and enter Specialty Types 561 (Entity BSC- ASD (ABA)) and 562 (Entity TSS (ABA)) on the enrollment application. A provider may either submit a SD and enrollment application at the same time or wait for approval of the provider s SD before submitting an enrollment application. If the provider receives approval of the provider s SD before the provider submits its enrollment application, the provider should include in its enrollment application packet a copy of the SD and the notice of approval of the SD. If the provider has not received approval of its SD before it submit its enrollment application, it should include a note with the enrollment application packet that states that it has submitted a SD to the Children s Bureau for review. Once the SD has been approved, the Children s Bureau will send a copy of the approved SD to the enrollment unit. If a provider submits an incomplete SD to the Children s Bureau, the Children s Bureau will notify the provider of the outstanding items that need to be submitted in order to proceed with a review of the SD. I. PROVIDER CONTACT INFORMATION AND TYPE: A. Name of Provider: B. Address: C. Phone: D. Fax: E. Contact Person: F. Email: G. Website: H. Provider Type: 11 I. Specialty Types: 561 (Entity BSC-ASD (ABA)) and 562 (Entity TSS (ABA)) (if also providing TSS services)
J. MA Provider ID: (If the provider has not completed its enrollment in the MA program and been issued an MA provider number, state that the provider does not yet have an MA provider number.) II. SERVICE Identify the service(s) the provider will use to provide ABA BSC-ASD services TSS services III. QUALIFICATIONS AND LICENSES AND CERTIFICATIONS As stated in OMHSAS Bulletin 14-02, individuals who provide BSC services to children with ASD must have a behavior specialist license or other professional license whose scope of practice includes the diagnostic assessment or treatment of ASD to receive payment through the MA program for providing BSC-ASD services. List the educational level, degrees, training, certification, licensing and any other relevant qualifications of the staff that will be using BSC-ASD services to provide ABA. Include that staff will be required to confirm that they have knowledge and skills to provide ABA. If the provider will also be providing TSS services, list the educational level, degrees, training, certification, licensing and any other relevant qualifications of the staff that will be using TSS services to provide ABA. Include how the provider has ensured that staff understand the basic principles of ABA and have received training to enable them to carry out the specific procedures and techniques used in the treatment plans they are implementing. State whether the provider has ongoing training expectations for staff, and, if so, describe what they are. Submit a copy of all licenses and any certifications held by the staff that will be using BSC-ASD and TSS services to provide ABA. Because the provider is being enrolled based on the licenses held by the individuals that will be using BSC-ASD services to provide ABA, submit copies of any licenses or certifications of any newly hired duals within 60 days of their hire. Submit a copy of any licenses or certifications held by the provider 2
IV. COUNTY(IES) SERVED Identify the county(ies) where the provider will be providing services. List all counties where children will be receiving the services, not just the county where the provider is located. Do not include counties that the service(s) may expand to in the future. Provide information about any communications the provider has had with the staff from the county or counties where services will be provided. For example, often providers submit letters of support from county MH/ID staff or the CASSP coordinator to show they have had discussions with county staff regarding the services the provider wishes to offer. If the provider has not received documentation of support from county staff, please describe the efforts the provider has made to communicate with county staff about the services the provider intends to provide. Please identify the county staff members that may have been involved in developing this service and what their feedback has been. If the provider wishes to expand services into additional counties, the provider should request approval from the Children s Bureau and include in the request information about any communications the provider has had with the staff from the county or counties where the provider wished to expand services. V. TARGET POPULATION Please describe the following if applicable: Specific age range of children to be served. Any specialized areas of clinical focus related to the ASD diagnosis (e.g. non-verbal, behaviorally aggressive, etc.). If the provider will specialize in the treatment of specific age ranges or clinical populations, or limit treatment to certain treatment settings, please provide a brief description of these specializations or limitations. VI. SERVICE DESIGN Describe the goals of the services the provider intends to provide and how these goals will be achieved. Treatment activities, interventions, and goals are different aspects of a service and each should be clearly described. Include the following: The non-aversive techniques that will be used to achieve the goals of the services. 3
How a child s progress towards goals will be measured and how a child s need for a lesser level of care will be assessed. If children with comorbid diagnoses will be served, how their needs will be addressed. Location of treatment (home, community, school, office). Maximum caseload staff providing services will have at any one time. Describe any restrictive procedures that will be used by staff using BSC-ASD or TSS services to deliver ABA. If no restrictive procedures will be used, please state that staff using BSC-ASD or TSS services to provide ABA will not be utilizing restrictive procedures. If staff using BSC-ASD or TSS services to provide ABA will be using restrictive procedures, please state under what circumstances restrictive procedures will be used and describe the training staff have received in the use of restrictive procedures, including the date, source, content, and the length of the most recent training. The response must be consistent with MA Bulletin OMHSAS-02-01, The Use of Seclusion and Restraint in Mental Health Facilities and Programs. VII. TREATMENT PLANNING AND CROSS-SYSTEM COLLABORATION Describe how the services will be individualized to each child and family. Describe how individualized treatment plans or other behavior plans are developed, including if behavioral assessment (e.g., Functional Behavior Assessment) will be used. Explain when interagency planning will occur and who will participate in this planning. Explain how a multi-system approach to service delivery will be achieved. It is preferable that this response includes activities in addition to the Interagency Service Planning Team (ISPT) meetings. VIII. CULTURAL COMPETENCE Describe how cultural and ethnic values of the child and family will be considered as part of development and delivery of services. Include the following: How the child s and family s cultural values and concerns will be assessed, and how once assessed, this information will be used in treatment. How activities and interventions incorporate cultural traditions or values. The training staff has received related to cultural competency, including who provided the training. 4
IX. COMMUNITY INTEGRATION Describe how services will support the child s integration into the neighborhood or community where he or she lives, attends school, etc. Describe the following: How the service facilitates the child s involvement in prosocial activities in the community or at school. How the service promotes the ongoing cultivation of new resources and opportunities within the community. X. SUPERVISION AND CLINICAL OVERSIGHT Each provider must have a clinical supervisor who is a licensed mental health professional, who confirms that he or she has knowledge and skills to provide ABA. The duties of the clinical supervisor include direction, administration, and supervision of the services, development of policies and procedures relating to the provision of the services, administrative supervision of the personnel, and supervision of staff training and development. Provide the qualification and professional title of the individual responsible for supervision, and clinical oversight of the services. Describe the nature of the supervision and oversight (e.g., clinical or administrative), the amount and frequency of supervision or oversight (e.g. number of hours on a weekly or monthly basis), and the format of supervision, oversight, or monitoring (group vs. individual). Minimum supervision requirements for the TSS service can be found in MA Bulletin 01-01-05, Revisions to Policies and Procedures Relating to Mobile Therapy, Behavior Specialist Consultant and Therapeutic Staff Support Services, and OMHSAS-16-02, Training and Supervision Requirements for Therapeutic Staff Support Workers that Implement Treatment Plans that Include Applied Behavioral Analysis. If the provider will also be using TSS services to provide ABA include the following: Identify the supervisors of TSS workers. Include the supervisor s qualifications and the number of TSS workers the individual will supervise. If not described above, also provide the number of hours, frequency (e.g., weekly or monthly) and format of supervision (e.g. group vs. individual). Identify the individuals responsible for monitoring and assessing the delivery of TSS services and describe the monitoring and assessment. You may also provide an organizational chart. 5
XI. RATE The rates for providing BSC-ASD and TSS services are listed on the MA Fee Schedule. Additional guidance for submitting service descriptions: To avoid confusion, please be sure to use consistent language throughout the SD. Please number the pages of the SD for easier reference. Each SD is reviewed regarding clinical integrity of the service and for consistency with MA program regulations and requirements. Electronic submissions are preferred. While copies of staff licenses and documentation of county support can be submitted as a PDF, the SD needs to be submitted in WORD format. If there is a substantial change in a service that the Office of Mental Health and Substance Abuse Services Children s Bureau has approved, the provider must submit a new SD in accordance with Medical Assistance Bulletin 01-96-11, Procedures for Service Descriptions. Submit the SD and all supporting materials using the following addresses: Ra-ServDescriptions@pa.gov or Department of Human Services PO Box 2675 OMHSAS-CT-11 th Floor Harrisburg, PA 17105 ***electronic submission preferred**** 6