Policy Council for Children and Families: Intensive Behavioral Intervention (IBI) for Children on the Autism Spectrum

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Presentation: Intensive Behavioral Intervention for children on the autism spectrum. Dr. Van Ramshorst and Leslie Smart made the presentation. The benefit came out of Rider 32 from the last session.

Rider 32. Intensive Behavioral Intervention. Contingent on the Health and Human Services Commission (HHSC) adding intensive behavioral intervention (IBI) as a Medicaid benefit for persons under age 20 with a diagnosis of Autism Spectrum Disorder, HHSC may expend funds appropriated above in Strategy A.1.5, Children, to reimburse for provision of IBI services.
From Autism Speaks: Applied Behavior Analysis (ABA) is a therapy based on the science of learning and behavior. Behavior analysis helps us to understand:

  • How behavior works
  • How behavior is affected by the environment
  • How learning takes place

ABA therapy applies our understanding of how behavior works to real situations. The goal is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning.

ABA therapy programs can help:

  • Increase language and communication skills
  • Improve attention, focus, social skills, memory, and academics
  • Decrease problem behaviors

The methods of behavior analysis have been used and studied for decades. They have helped many kinds of learners gain different skills – from healthier lifestyles to learning a new language. Therapists have used ABA to help children with autism and related developmental disorders since the 1960s.

Intensive behavioral intervention (IBI) is a highly specialized, individualized program of instruction and behavioral intervention. IBI is similar to intensive Applied Behavior Analysis (ABA) programming and is based on a functional, behavioral, and skills assessment of an individual’s treatment needs.The primary goal of IBI is to reduce behavioral excesses, such as tantrums and acting out behaviors, and to increase or teach replacement behaviors that are socially valuable to the individual.

  • IBI programs are intensive with one-on-one direct services provided 20-30 hours per week with a paraprofessional.
  • A Board Certified Behavior Analyst (BCBA) or IBI Director develops, manages, and trains paraprofessional on the implementation of the programming.
  • Sessions are conducted in-home and/or in-center


Autism Services Policy

  • Incorporation of Applied Behavioral Analysis (ABA) including Intensive Behavioral Intervention (IBI) into existing service packages for: Children & Youth (Birth through age 20) With a diagnosis of Autism Spectrum Disorder (ASD)
  • Service to be delivered in: Home Community Clinic Settings
  • Utilization of an interdisciplinary model of care including individual & legal guardian
  • Also including, but not limited to, the following disciplines: Physical Therapy Occupational Therapy Speech Therapy Outpatient Behavioral Health Services

Implementation Plan Steps Include:

  • New Medicaid Benefit
  • Establish payment rate
  • Public rate hearing: December 13, 2019
  • Seek approval from Centers for Medicare & Medicaid Services (CMS), as needed
  • Draft Policy for Public Comment
  • Post in September 2019
  • Interested parties should sign up for GovDelivery
  • Implementation goal: Spring 2020

HHSC plans on engaging external and internal stakeholders throughout the implementation process. Stakeholders include:

  • Parents/Caregivers/Legal Guardians
  • Provider groups
  • Children’s advocacy organizations
  • Other interested parties

The initiative will be communicated to the public through:

  • Advisory Committee Presentations
    • The Texas Autism Council, August 9, 2019
    • The State Medicaid Managed Care Advisory Committee, August 13, 2019
    • The Policy Council for Children and Families, September 9, 2019
  • Public Comment on Policy – September 2019
  • Public Rate Hearing – December 13, 2019

They will also be looking at telehealth and telemedicine as ABA service delivery options.

Q: My understanding is that there’s a category for IBI certification. Are there any IBI providers out there operating currently? HHSC stated that Board Certified Behavioral Analysts just obtained state licensure. The model we have set up is that the BCBA or BCBAD would be the Licensed Behavioral Analysts, and would enroll in Texas Medicaid. They would supervise assistant behavioral analysts – who would also be expected to have state licensure – and registered behavioral technicians. We don’t have state licensure for these paraprofessionals, but we are going to require national certification. The numbers currently available indicate that there are not enough LBAs.

Q: Can you discuss the training and assistance available to develop a meaningful benefit? HHSC stated that there will be guidelines to assist health plans. The benefit goals will be functional (health, safety, and independence). The literature review indicates that younger children benefit from 20+ hours/week of IBI. It is going to take excellent documentation by the LBA. There will be a requirement that the treatment plan is in agreement with the family commitment. We don’t want there to be a mismatch between the hours recommended and the hours a family is able to do.

Q: You alluded that the telehealth options would be a carve-in later on. Is there any more you can say about that? HHSC stated that there is some good research specific to ABA and telemedicine/health. Only the LBA would be permitted to deliver the service remotely, and the technician or assistant would deliver face-to-face. Good clinical judgement will have to be applied when determining the use of telemedicine/health. HHSC is hoping that this will address some of the access issues. HHSC stated the benefit will go live in 2020. This is a tight timeframe for implementation and stakeholder input is critical. The draft policy will need input and editing.

Q: Will the payment rate will be enough compared to commercial insurance? HHSC stated that rate analysis takes this into consideration when rates are set.

The Chair inquired about incorporation into existing models. HHSC stated that children with ASD are able to access some services already (speech, OT, etc.). The new benefit adds a (billing) code for interdisciplinary team meetings. This model is very helpful. Clinicians have to have the ability to meet with others. The meeting is not required, but is highly recommended. The meeting is approved for remote delivery, allowing the family to be at home. HHSC stated that they want the interdisciplinary team to involve the service coordinator.

Q: Therapy is provided under STAR Kids and therefore, this would fall under STAR Kids and not the waiver, correct? HHSC said they will come back with a concrete answer, but they believe that is correct. C: I believe the Health Plans would be concerned about the impending uptake in services – people have been waiting a long time for this benefit – and you have a proposed rate hearing coming up. However, normally, Health Plans have their rates set earlier, well in advance of the proposed rate hearing. The rates established for the Health Plans should reflect this new service. HHSC stated they will take that back to the team for consideration.

The Chair inquired about the funding for the rider. HHSC replied that the rider said, “From funds already appropriated”. There was no specific, separate dollar amount.

Q: Are other diagnoses eligible for this benefit or just ASD? HHSC stated that the provision of ABA is tied to Autism Disorder, but this is an EPSDT benefit that falls under the medical necessity rules. Therefore, any child demonstrating medical necessity would be eligible. Q: Will eligibility be on a tiered system? HHSC replied that the draft policy has rules for getting the ABA assessment and there are guidelines for frequency and duration.

Q: Can you comment on the process for monitoring utilization and ensuring it is appropriate? HHSC stated that that is part of the policy process.

C: The Council has recommended this before. The Council felt all along that it should have been implemented because CMS guidelines had told states to move forward. HHSC stated that they are in consultation with CMS.

C: As a parent who has sat in on multiple hours of therapy, I’m very curious about how remote therapy would work. HHSC stated that there is language in the draft, but more research must still be done, including looking at other states. Only the licensed personnel will be eligible for remote delivery. Others will have to be face-to-face.



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