Autism Spectrum Disorders
- Participating Physician Groups (PPG)
Autism is the most common of a group of conditions collectively called autism spectrum disorders (ASDs). Autism, a severe behavioral illness, is a developmental disorder that presents in the first few years of life and profoundly interferes with the individual's lifelong functioning.
Health Net and MHN, Health Net's behavioral health subsidiary, have developed a medical policy, Autism Spectrum Disorder: Diagnosis and Treatment, which provides more detailed information about the screening, diagnosis and treatment of ASD. This medical policy is available on the Health Net and MHN websites at provider.healthnet.com and www.mhn.com.
The primary care physician (PCP) is usually the first practitioner to see signs of autism, typically characterized by impairment in three core areas:
- Social interactions
- Verbal and nonverbal communication
- Restricted activities or interests and/or unusual, repetitive behaviors
The degree of impairment in these areas varies widely from child to child.
The American Academy of Pediatrics (AAP) has added screening for autism at ages 18 and 24 months to their recommendations for preventive pediatric care. Additional follow-up visits after six months for borderline results are at the discretion of the provider. Screenings may include:
- Assessing vision and hearing
- Directly observing the child in structured and unstructured settings
- Evaluating cognitive functioning (verbal and nonverbal)
- Assessing adaptive functioning
- Discussing with parents any concerns they have and asking specific questions regarding the child's functioning
AAP guidelines are available online at https://brightfutures.aap.org. Additional AAP autism resources are available at www.healthychildren.org/English/health-issues/conditions/Autism/Pages/Autism-Spectrum-Disorder.aspx.
Typically, a team of medical and behavioral specialists that generally includes the child's PCP or a behavioral pediatrician, child psychiatrist, speech and language pathologist, and other ancillary clinical specialists, as needed, provides input for a diagnosis of ASD. A thorough evaluation for ASD may include the following:
- Parents and/or caregiver interview, including siblings of the child with suspected autism
- Comprehensive medical evaluation
- Direct observation of the child
- Evaluation by a speech-language pathologist
- Formal hearing evaluation, including frequency-specific brainstem auditory evoked response
- Evaluation of the child's cognitive and adaptive functioning
- Evaluation of academic achievement for children ages six and older
There are a number of assessment tools that are used by clinicians to assist in the diagnosis of autism. A list of some of the assessment tools is included in the Health Net medical policy on the Health Net and MHN websites at provider.healthnet.com and www.mhn.com.
Health Net arranges for covered medical services for ASD through its participating network of physicians, hospitals and other providers. The PCP provides a medical home for the member with ASD and, as such, provides preventive health screenings and immunizations and routine and urgent medical care, including referrals for specialty care. For members with ASD, medical referrals may include speech and language therapy, physical therapy, occupational therapy, and/or specialty management for seizure disorders and other appropriate services. Health Net has policies for standing referrals, which may be appropriate in some ASD cases, that assist members to obtain needed care without additional authorization approval. PCPs may also refer the member with ASD for any needed behavioral health services.
Behavioral Health Services
When an employer purchases a Health Net plan that includes behavioral health benefits administered by MHN, behavioral health services can be accessed directly by parents or by referral from any treating physician. The MHN participating network of child psychiatrists provides services such as medication management of specific symptoms related to the ASD as well as any comorbid psychiatric conditions. MHN network therapists are available to provide family therapy to help parents and siblings cope with the diagnosis and the member with ASD behaviors, brief psychotherapy to teach behavior modification techniques to parents to assist them in managing their child, and individual psychotherapy for adolescents and young adults with an ASD. This treatment may be designed to help the family better understand how to cope with the disorder or treat a comorbid mood or anxiety disorder. Inpatient hospitalization is also available if the child with ASD becomes an acute danger to self or others or is behaviorally disruptive, requiring intensive intervention to restabilize the individual.
Beginning January 1, 2012, Health Net covers Lovaas therapy, a behavioral treatment model utilizing the principals of applied behavioral analysis (ABA), when medically necessary for Health Net members diagnosed with ASDs. Providers should refer requests for ABA services to MHN.
Health Net members who access behavioral health services through a plan other than MHN should contact their behavioral health plan for details on services and access to treatment.
An important potential source of help for children with autism is the public school system. Under Federal Public Law 94-142 (the Individuals with Disabilities Education Acts of 1990 and 1997), each school is required to provide handicapped children with free, appropriate education through age 21. The school is required to evaluate each child and, with the parents, develop an individual education plan (IEP). The IEP determines the educational setting that is most appropriate for the child, establishing goals for each child that are academic and behavioral/social. The local public school system may provide for or refer the child for educational interventions, such as ABA, intensive behavioral intervention (BI), discrete trials training, early intensive behavioral intervention (EIBI), intensive intervention programs, Picture Exchange Communication Systems (PECS), facilitated communication, Treatment and Education of Autistic and Related Communication of Handicapped Children (TEACCH), or floortime.
The local school system is responsible for education services once the child reaches age three. California's Early Start Program (for children under age three) or the local regional center (for children ages three and up) provides other services, such as in-home services.
Health Net is not responsible for and does not provide coverage for educational services (except for ABA services for Health Net commercial members diagnosed with ASDs when coverage is mandated by the state).
At the request of the provider, Health Net or the delegated participating physician group (PPG) provides a case manager who is knowledgeable about plan benefits to assist in the coordination of health care treatment services. Health Net and MHN have also implemented a comanagement process that encourages better communication and coordination with complex cases. Through this process, medical directors and case/care managers from Health Net or a PPG and MHN are able to work together to further integrate the various elements of the medical and behavioral treatment plan. Comanagement may be initiated by Health Net, the PPG, the provider, or MHN. Refer to the General Guidelines for Referrals for information about referring a member to MHN for services .
Coordination of Care
Health Net and MHN expect all providers involved in the treatment of a member with ASD to coordinate the care and treatment they are providing through appropriate communication. Communication helps prevent duplication of tests and contraindicated medications and treatment, and allows providers the opportunity to modify the member's treatment plan based on more thorough information.
Coordination with the school system, Early Start Program, and regional centers regarding educational services helps ensure the ASD member receives the full range of treatment options.
Nurse Advice Line
Decision Power® offers highly trained registered nurses for condition-specific support, 24 hours a day, seven days a week to members. Refer to the Nurse Advice Line to discuss health concerns of ASD for Health Net members.
The following online resources are available to assist providers in the screening, diagnosis and treatment of ASD.
- AAP recommendations for preventive care - https://brightfutures.aap.org/
- Early Start Program - www.dds.ca.gov/earlystart/
- Health Net national medical policy - provider.healthnet.com or www.mhn.com
- Individuals with Disabilities Education Act - https://sites.ed.gov/idea
- Other AAP resources - www.healthychildren.org/English/health-issues/conditions/Autism/Pages/Autism-Spectrum-Disorder.aspx
- Regional Centers contact information - www.dds.ca.gov/RC/RCList.cfm