Georgia Medicaid Requirements for ABA Therapy
Amazing news...Georgia Medicaid began covering ABA therapy in January 2018. But what does that mean for families who have the state insurance plans as their insurance?
ABA therapy has previously only been covered by private insurances but thanks to laws, such as Ava’s Law, ABA coverage is becoming more generalized and coverage is going to be extended even to the age of 20. This means more access to ABA therapy services to families across Georgia and more assistance to cover the cost of therapy (depending on your specific plan benefits).
Throughout my time as Case Manager, assisting families with the intake process, guiding families through the needed documents to get their authorizations in place, and learning about medicaid, I have found a lot of families have struggled with either having or obtaining the correct documentation for an ABA medicaid authorization. In order to better help our families that we serve and families in our community, I have decided to compile all of the needed information below. This can be used not only as a reference for families interested in therapy, but also a way to better prepare families for the ABA therapy authorization process.
I will be touching on the 3 most important documents/ information required for authorization: medicaid diagnosis requirements, requirements for diagnosis tools, and other documents requested. These are described below and hopefully will help families better understand everything needed!
1. Diagnosis Requirements:
According to the medicaid handbook, they require a “diagnosis in accordance to the DSM-V [DSM-5] standards.” What that means, is that your child will need a diagnosis that has two parts:
(1) a formal diagnosis with a medical code (ex: F84.0) (2) a level of severity for autism (ex: level 1- requiring support, level 2- requiring substantial support, level 3- requiring very substantial support)
It is also important to note, that medicaid only covers ABA therapy for children with specific diagnoses listed below. Unfortunately they will not approve services if the child does not have one of these diagnoses, even if they need therapy.
ICD 10 CM Code Description
● F84.0 Autistic Disorder
● F84.2 Rett’s Syndrome
● F84.3 Other childhood disintegrative disorders
● F84.5 Asperger’s Syndrome
● F84.8 Other pervasive developmental disorders
● F84.9 Pervasive developmental disorder, unspecified
In order to get the correct diagnosis, most families find they have to reach out to a specialist or get a referral from their pediatrician for a specialist. The types of specialist who can diagnosis include developmental pediatricans, psychologists, psychiatrists, and some early intervention programs.
2. Diagnosis Tool Requirement:
Once seen by the specialist- they will perform an evaluation which should utilize tools to determine your child’s official diagnosis. The types of tools that may be utilized, and MOST IMPORTANTLY,are required for a medicaid authorization, are listed below:
● Autism Diagnosis Interview – Revised (ADI-R): The ADI-R is a comprehensive interview that is used for individuals suspected of having autism or other autism spectrum disorders. The interview can be used to assess both children and adults, as long as their mental age is above 2 year.
● Autism Diagnostic Observation Schedule–2: The ADOS-2 assesses and diagnoses autism spectrum disorders across age, developmental level, and language skills. It is an assessment that looks at 4 different aspects of a client:
● Social interaction
● Restricted and repetitive behaviour
● Childhood Autism Rating Scale (CARS-2): CARS-2 is another tool that is used to “identify children with autism and distinguish them from developmentally disabled children who are not autistic”. It uses direct behavior observation to assess a client and has been modified to assess children on the “high-functioning end of the autism spectrum.”.
● Gilliam Autism Rating Scale – Second Edition (GARS-2): The GARS-2 is by both clinicians, but also by teachers, to help identify or diagnose autism. It can be used on individuals 3 years to 22 years. It is also a tool which can establish the severity of an autism diagnosis and assess a client in 3 different areas:
● Stereotyped Behaviour
● Social Interaction
Recommendations from the CDC also suggest that “no single tool should be used as the basis for diagnosis.” This means that a complete psychological evaluation/diagnosis should evaluate your child with more than one of the tools listed above.
3. Other documents requested:
Medicaid also requests a child’s IFSP (Individualized Family Service Plan) and/ or IEP (Individualized Education Plan) to be submitted along with their diagnosis information and plan of care. If you child has been involved with Babies Can’t Wait or is involved with the school
system, be prepared to submit their most recent plan. This does not include the IEP progress reports, which do not provide the full information given in the complete IEP. These documents are not a requirement but are additional information that is helpful to obtaining the authorization.
Once your child has obtained all of this information, it can be submitted by a medicaid provider to authorize ABA services. As I said above, this authorization lasts for 3-6 months and can authorize anywhere from 10-30 hours per week for your child (which will depend on the recommendation from the BCBA supervisor).
While medicaid approval for ABA therapy is truly a blessing for so many families who need access to this therapy, the necessary information required has become an issue for some of the families who have began the therapy process. Our ultimate goal is to help make these requirements more known to families, so that the authorization process is smoother for both the therapy providers and the parents needing help!
For more information on medicaid and requirements, feel free to visit
https://medicaid.georgia.gov/sites/medicaid.georgia.gov/files/related_files/document/Fre quently_Asked_Questions-Members_ASD.pdf https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/A utism%20Spectrum%20Disorder%20Services%20October%202018%20201810011430 00.pdf
https://www.pearsonclinical.co.uk/Psychology/ChildMentalHealth/ChildAutisticSpectrumDisorder s/GilliamAutismRatingScale-SecondEdition(GARS-2)/GilliamAutismRatingScale-SecondEdition( GARS-2).aspx https://www.wpspublish.com/store/p/2645/adi-r-autism-diagnostic-interview-revised https://www.pearsonclinical.com/psychology/products/100000164/childhood-autism-rating-scale -second-edition-cars2.html https://www.pearsonclinical.com.au/products/view/502 https://medicaid.georgia.gov/autism-spectrum-disorder https://medicaid.georgia.gov/sites/medicaid.georgia.gov/files/related_files/document/Frequently _Asked_Questions-Members_ASD.pdf https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Autism% 20Spectrum%20Disorder%20Services%20October%202018%2020181001143000.pdf