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 .

Autism is characterized by impairment in three core areas:

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 its recommendations for preventive pediatric care. Additional follow up in six months for borderline development of autism screening results, such as a 30-month visit, are the providers' clinical decision. Moreover, parental concerns about their child's development should lead to a careful assessment of development at any pediatric visit.

Screenings may include:

AAP guidelines for Autism Spectrum Disorders are available online. Additional AAP autism resources are available at healthychildren.org

If a child exhibits the above behavioral impairments and has an abnormal developmental screening, the next step is referral to one or more medical and behavioral specialists who can include a developmental pediatrician, child psychiatrist, speech and language pathologist, and other ancillary clinical specialists, such as physical therapists and occupational therapists, as needed. These specialists provide input to the primary care physician (PCP) or psychologist for a diagnosis of ASD.

A thorough evaluation for ASD may include the following:

There are a number of assessment tools that are used by clinicians to assist in the diagnosis of autism, including:

Upon diagnosis, children often are referred to a provider of Applied Behavioral Analysis for a functional behavioral assessment. If the assessment reveals that the child can benefit from ABA treatment a request for authorization is submitted to Health Net. Upon authorization, children may receive ABA services for a period of time spanning from a few months to a few years, depending on the child’s level of impairment and response to treatment. Additionally referral to a local Regional Center may be appropriate. Children may also receive school-based services based on recommendations in an Individualized Education Plan (IEP).

Medical services for the treatment of ASD may include physical therapy (PT), occupational therapy (OT), speech therapy (ST), and/or specialty management for comorbid disorders, such as seizure disorders.

Health Net covers medical services for the treatment of ASD. Parents or legal guardians of the member with ASD can ask for one physician to lead the care plan and coordinate services with other physicians and specialists. PT and ST are limited benefits under the Medi-Cal program, based on Title 22, California Code of Regulations (CCR), Section 51309 (rehabilitation benefits) states that:

The regional center assesses each referral, and if the member is eligible for regional center programs, outlines a case-specific plan of therapy and other services, taking into account the benefits and availability of services through the health plan and Local Education Authority (school district). The benefit for OT is limited to two visits per month (this limit does not apply to children under age 21). PT and OT services must be coordinated with the regional center or school district for a coordinated approach to maximize benefits.

Behavioral health therapy (BHT) services may include ABA psychiatric services, such as medication management of specific symptoms related to ASD, as well as any comorbid psychiatric conditions; family therapy to help parents and siblings cope with the diagnosis and the member with ASD's 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. Inpatient hospitalization may also be necessary if the child with ASD becomes an acute danger to self or others, or is behaviorally disruptive, requiring intensive intervention to stabilize the individual.

For assistance with specific member referrals, contact the Health Net Provider Services Center, Community Health Plan of Imperial Valley Provider Services Center or CalViva Health Medi-Cal Provider Services Center for Fresno, Kings and Madera counties.

An important potential source of help for educational services 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 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 applied behavioral analysis (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.

At the provider's request, Health Net or Health Net's delegated PPG provides a case manager who is knowledgeable about plan benefits to assist in the coordination of health care treatment services, including behavioral health services.

Health Net expects all providers involved in the treatment of a member with ASD to coordinate the care and treatment they are providing, and maintain appropriate communication. The PCP has primary responsibility for providing and maintaining the medical home for these children. Communication with other providers and the member's caregivers 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, county mental health, and regional centers regarding educational, therapeutic and psychiatric services helps ensure the member with ASD receives the full range of benefits allowed under legislation and regulations in California.

The following online resources are available to assist providers in the screening, diagnosis and treatment of ASD and other services.