Effective September 15, 2014, Medically Necessary Behavioral Health Treatments (BHT), including Applied Behavioral Analysis (ABA) will be a covered benefit for SCFHP Medi-Cal members 0 to 21 years of age, including those who have special health care needs. These services will be covered under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program, and must meet the Department of Health Care Services (DHCS) criteria and be prior authorized by SCFHP.
In order to be eligible for ABA-based therapy services, an SCFHP member must meet all of the following Medi-Cal coverage criteria. The member must:
- Be 0 to 21 years of age and have a diagnosis of ASD;
- Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities (examples include, but are not limited to aggression, self-injury, elopement, etc.);
- Be medically stable and without a need for 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities (ICF/ID);
- Have a comprehensive diagnostic evaluation that indicates ABA-based therapy services are medically necessary and recognized as therapeutically appropriate; and
- Have a prescription for ABA-based therapy services ordered by a licensed physician and surgeon or a licensed psychologist.
SCFHP will provide additional clarifications upon receipt of DHCS' final guidance. If you have patients who may qualify for BHT/ABA services, please fax an authorization request to 1-408-874-1957.