Children of Duke employees covered under a Duke medical plan (Duke Select, Duke Basic, Blue Care, Duke Options, or Duke USA) may seek treatment for Autism Spectrum Disorder with Applied Behavior Analysis.
Applied Behavior Analysis (ABA) is an evidence-based behavioral intervention that is used to diminish substantial deficits in a child's adaptive functioning or significant behavioral challenges due to autism spectrum disorder. The interventions address three areas of behavioral functioning: deficits in developmentally appropriate skills and behaviors, impairments in social communicative adaptive skills, and prevention of harm to self or others. Coverage of ABA to treat Autism Spectrum Disorder is provided subject to prior authorization, medical necessity, utilization review, and discharge from care criteria.
A copay of $20 (or $25 on Duke Basic/Duke USA) is required per visit for In-Network providers. Out-of-Network providers will be subject to the $650 deductible and the 30% coinsurance (40% coinsurance on Duke USA). The supervising professional is responsible for billing for all ABA services, and obtaining prior authorization.
ABA must be provided or supervised by one of the following licensed professionals:
- Licensed Psychologist or psychological associate
- Licensed Psychiatrist or developmental pediatrician
- Licensed Clinical Social Worker
ABA treatment may be provided by a paraprofessional who meets the following requirements:
- Is supervised by one of the licensed professionals listed in #1-3 above, AND
- Is currently certified by the Behavior Analyst Certification Board with one of the following certifications:
- Board Certified Behavior Analyst - Doctoral
- Board Certified Behavior Analyst
- Board Certified Assistant Behavior Analyst
- Registered Behavior Technician, AND
- As attested by the supervising licensed professional, meets all of the following criteria:
- Has documented coursework and/or didactic training pertinent to the ABA being delivered, and
- Is receiving documented ongoing supervision by the licensed professional during any period in which the unlicensed individual provides ABA services.
All services performed must be within the scope of license and ethical boundaries of the licensed professional to be eligible for reimbursement. Board Certified Behavior Analysts or Board Certified Assistant Behavior Analysts with no other current behavioral health license must be supervised by a licensed behavioral health provider, including but not limited to a psychiatrist or a licensed developmental pediatrician. The licensed behavioral health provider must submit both the request for authorization and the claims for payment. A provider in any state who ONLY holds a certification from the national Behavior Analyst Certification Board is not eligible for reimbursement even though they may be eligible for reimbursement in the state in which they practice.
Applied Behavior Analysis Exclusions
Treatment for the following is not covered:
- Members with medical conditions or impairments that would prevent beneficial utilization of services
- Members requiring 24-hour medical/nursing monitoring or procedures provided in a hospital setting
ABA treatment will not be certified for the following services:
- Vocational rehabilitation
- Supportive respite care
- Recreational therapy
- Orientation and mobility
- Respite care
- Equine therapy
- Dolphin therapy or similar animal related therapy
- Service animals
- Other educational services