COVID-19 Telehealth Policy Update to ABA Coverage

On Friday, March 13, 2020, President Donald Trump declared a national emergency due to coronavirus disease 2019 (COVID-19) and Governor Henry McMaster declared a state of emergency for the state of South Carolina. As a part of the state’s preparation and response to COVID-19, the South Carolina Department of Health and Human Services (SCDHHS) is announcing additional temporary modifications to policies related to telehealth coverage.

Reimbursement for the telephonic services addressed below is available if the interaction with a Healthy Connections Medicaid member includes at least one telephonic component. Interactions that also include video interaction may also be billed, but other forms of electronic communication, such as email and instant and text messaging, are not eligible for reimbursement. Services provided pursuant to the current SCDHHS telemedicine coverage policy should continue to be billed according to those guidelines. SCDHHS will begin accepting claims for the changes noted below no later than April 15, 2020, for dates of services on or after this bulletin’s date. These temporary policy changes will be in effect for the duration of the federally declared public health emergency unless rescinded or superseded by SCDHHS prior to the end of the emergency.

The telehealth policy modifications outlined below were developed in consultation with clinical professionals and thought leaders throughout the South Carolina provider community and are intended to balance immediate treatment needs that are not appropriate for deferral with the safety and efficacy of remote service delivery. In all circumstances, the services identified below must meet standard requirements for medical necessity.

Applied Behavior Analysis (ABA)

ABA is a broad discipline that is closely associated with its intensive application to treat individuals diagnosed with autism spectrum disorder (ASD). Reimbursement for ABA services, as articulated in South Carolina’s State Plan, relies upon a provider network of mostly master-level board-certified behavior analysts (BCBAs) supervising paraprofessional registered behavior technicians (RBTs), who directly engage individuals in daily activities to both model and direct behaviors to mold a beneficiary’s social interactions and response. In many cases, beneficiaries are unable to self-direct or self-engage and the intensive engagement of the RBT, particularly early in a treatment cycle, is necessary for it to be effective.

While there is some limited evidence that BCBAs may effectively supervise and consult via telemedicine, there is not clinical indication or prevailing evidence that RBTs can conduct in-person, high-volume therapy through remote means. As a result, recent social distancing policies, as well as school and business closures in response to COVID-19, have substantially interrupted the provision of ABA services under the prevailing practice models in South Carolina.

Accordingly, and in order to support social distancing while maintaining the clinical appropriateness of the provision of ABA, SCDHHS is taking two temporary steps to ensure clinically relevant services are reimbursed during the COVID-19 emergency:

• SCDHHS is authorizing remote supervision of RBTs using the codes and guidelines detailed later in this bulletin; and,
• In those instances where families elect to decline face-to-face therapy from an RBT, SCDHHS is allowing for the reimbursement of remote consultation by supervisory providers and supervision of parents providing ABA in a limited capacity.

Unless otherwise noted, SCDHHS is not suspending or modifying any other portion of the State Plan or relevant provider manuals, and all services must be delivered within the guidelines and limitations noted in this bulletin, as well as relevant State Plan or provider manual provisions.

Remote Supervision

In such instances where families and providers elect to engage in continued face-to-face adaptive behavior treatment by protocol (97153), SCDHHS is authorizing synchronous audio/visual supervision of RBTs and other therapists using telemedicine. In order to ensure continuity of care, SCDHHS is also authorizing assessments of established patients so that plans of care can remain current and relevant for beneficiaries. The services and limitations listed below are consistent with current State Plan limitations. Services provided via telemedicine are to be reimbursed in lieu of, not in addition to, those provided face-to-face and reimbursed in a manner consistent with the authorities and limitations detailed in the State Plan and provider manual. When services are provided in a manner consistent with the existing State Plan and provider manual, providers should disregard the provisions of this bulletin.

* Only reimbursable if family continues to receive 97153

The codes above may be billed using the ‘GT’ modifier.

Consultation of Parent-Directed Activities

If families choose not to engage in face-to-face interaction with an RBT or other therapist, SCDHHS is authorizing reimbursement for consultation by providers authorized to practice independently, when provided through a parent or family member. This allowance aims to assist parents responding to social distancing requirements while ensuring continuity of care in a manner that is supported in medical literature [1] . This provision is available only to families and beneficiaries that have elected to discontinue otherwise authorized face-to-face RBT-directed treatments, and the services detailed in this portion of the bulletin cannot be billed intermittently or concurrently with ABA therapies otherwise meeting the standards of the State Plan or relevant provider manuals.

The services and limitations listed below are consistent with current State Plan limitations and services provided via telemedicine are to be reimbursed in lieu of, not in addition to, those provided face-to-face and reimbursed in a manner consistent with the authorities and limitations detailed in the State Plan and provider manual. The services and limitations detailed below do not apply to services provided and reimbursed in a manner consistent with current SCDHHS policies and procedures, except for the non-supplementation provision noted earlier.

* May be provided at a ratio of those authorized by the beneficiary’s individual plan of care (IPOC)

The services reimbursed under this section of the bulletin are to be billed using the ‘CR’ modifier.

Administrative Flexibilities

SCDHHS has issued guidance to managed care organizations (MCOs) to operate with necessary flexibility to ensure continuity of care with respect to prior authorization and documentation requirements for providers. SCDHHS will continue to monitor the provider community and address any issues between providers, beneficiaries and MCOs as needed. 

In addition, the Centers for Medicare and Medicaid Services (CMS) has issued guidance on HIPAA enforcement discretion regarding services authorized for telemedicine, which is available here: https://www.hhs.gov/sites/default/files/hipaa-and-covid-19-limited-hipaa-waiver-bulletin-508.pdf

Finally, SCDHHS has submitted an 1135 waiver to CMS for a variety of administrative flexibilities.  SCDHHS will issue further bulletins as CMS acts on the waiver.

Limitations and Clarification

Providers engaging in telemedicine services are required to ensure that the quality of care delivered is the same as if engaging the beneficiary in a face-to-face format. Not all interventions and services or beneficiaries are suited for delivery via telemedicine, and families and providers should use professional judgement when deciding to offer services via telemedicine or defer services due to the current public health emergency. Finally, SCDHHS has not varied the scope of billable or non-billable activities with this bulletin, only the appropriate mode of delivery.

Families and beneficiaries should be given every opportunity to make informed decisions about the receipt of services via telemedicine, including the clinical appropriateness of the intervention, its limitations, privacy and confidentiality and the effect the provider’s setting has on each of these issues.

With the flexibilities noted above, several exclusions remain in place during the COVID-19 response to ensure that Medicaid reimbursement is available only when the quality of patient care remains at a clinically appropriate level:

• Only individual services are eligible for telemedicine. Group or multi-family interventions are not reimbursable, nor are services when staff-to-beneficiary ratio is greater than one-to-one.
• Providers may not conduct interventions remotely with more than one individual concurrently and must conclude any intervention or visit with one patient before commencing an intervention or visit with the next.
• Providers must still follow the course of therapy and limitations detailed in the IPOC or service authorization.

Additional guidance regarding coverage policy will be communicated in future bulletins as needed. 

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

[1] Lindgren S, Wacker D, Suess A, et al. Telehealth and Autism: Treating Challenging Behavior at Lower Cost. Pediatrics. 2016;137(S2):e20152851O.

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