Autism Spectrum Disorders
Autism is the most common of a group of conditions collectively called autism spectrum disorders (ASDs). Autism, a behavioral illness that can range on the spectrum from mild to severe, is a developmental disorder. Severe forms of autism present in the first few years of life and profoundly interfere with the individual's lifelong functioning.
Health Net has developed a medical policy, Applied Behavioral Analysis (ABA), which provides more detailed information about the screening, diagnosis and treatment of ASD. This medical policy is available on the Health Net website.
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 for Autism Spectrum Disorders are available online at https://brightfutures.aap.org. Additional AAP autism resources are available at www.healthychildren.org.
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 website.
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
Behavioral health services can be accessed directly by parents or by referral from any treating physician. Health Net's 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. The network of therapists are available to provide family therapy to help parents and siblings as well as the member with ASD; 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.
Qualified Autism Professionals
Every health care service plan subject to Section 1374.73 of the Health and Safety Code shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.
A “qualified autism service professional” is a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. These professionals can be a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor as long as these types meet the criteria for a Behavioral Health Professional as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
A “qualified autism service paraprofessional” is an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider. A qualified autism service paraprofessional can include a behavioral health paraprofessional.
Definitions of qualified autism service providers, professionals and paraprofessionals:
A “qualified autism service provider” means either of the following:
- A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.
- A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.
- Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
A “qualified autism service professiona” means an individual who meets all of the following criteria:
- Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
- Is supervised by a qualified autism service provider.
- Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.
- Is either of the following:
- A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program, or meets the criteria set forth in the regulations adopted pursuant to subdivision (a) of Section 4686.4 of the Welfare and Institutions Code for a behavioral health professional.
- A psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
A “qualified autism service paraprofessional” means an unlicensed and uncertified individual who meets all of the following criteria:
- Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.
- Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.
- Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations for a behavior management technician (paraprofessional) Behavior Management Technician (Paraprofessional) or meets the criteria set forth in the regulations adopted pursuant to subdivision (b) of Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Paraprofessional.
- Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.
- Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
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 (IBI), 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 floor time.
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 provides a case manager who is knowledgeable about plan benefits to assist in the coordination of health care treatment services. Health Net has 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 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 or the provider. Email or fax a completed Care Management Referral Form using the information noted on the form.
Coordination of Care
Health Net expects 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
The Nurse Advice Line 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
- Individuals with Disabilities Education Act - https://sites.ed.gov/idea
- Other AAP resource - www.healthychildren.org/
- Regional centers contact information - www.dds.ca.gov/RC/RCList.cfm