Autism Spectrum Disorders
- Participating Physician Groups (PPG)
Autism, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger's syndrome comprise a group of conditions collectively called autism spectrum disorders (ASDs). Autism 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 division, 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.
Autism is 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 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:
- 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.
If a child exhibits the above behavioral impairments and has an abnormal developmental screening, the next step is referral to a team of medical and behavioral specialists that generally includes a developmental pediatrician, a child psychiatrist, a 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) for a diagnosis of ASD. Upon diagnosis, referral to a regional center may be appropriate. Additionally, for children over age three, a referral to the local school district for an individual education plan (IEP) may be appropriate.
The PCP serves as the medical home and coordinates follow-up referrals to the appropriate regional center and school district for additional testing and treatment.
A thorough evaluation for ASD may include the following:
- Parents and/or caregiver interview, including interviews of 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, including:
- Pervasive Developmental Disorders Screening Test-II (PDDST-II) for children from birth to age three
- Checklist of Autism in Toddlers (CHAT) for children age 18 months
- Modified Checklist for Autism in Toddlers (M-CHAT™) for children starting at age 16 months. (Spanish, Turkish, Chinese, and Japanese versions are available.) A revised version, M-CHAT-R,™ is also available.
- Screening Test for Autism in Two-Year-Olds (STAT)
- Social Communication Questionnaire (SCQ) for children ages four and older
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:
- Physical therapy services shall include physical therapy evaluation, treatment planning, treatment, instruction, consultative services, and application of topical medications. Services do not include the use of Roentgen rays or radioactive materials or the use of electricity for surgical purposes including cauterization. Services are limited to treatment immediately necessary to prevent or to reduce anticipated hospitalization or to continue a necessary plan of treatment after discharge from the hospital
- Such services, except physical therapy, are subject to the limitations set forth in Section 51304(a): Program coverage of services is limited to a maximum of two services from among those services set forth in those sections in any one calendar month.
- Members under age 21 have access to additional medically necessary therapy visits, subject to prior authorization
- Provision of the services is with the expectation that the beneficiary will improve significantly in a reasonable and generally predictable period of time or to establish an effective maintenance program in connection with a specific disease state
- The service is reasonable and medically necessary for the treatment of the beneficiary's condition
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. PT and OT services must be coordinated with the regional center or school district for a coordinated approach to maximize benefits.
Behavioral Health Therapy Services
Behavioral health therapy (BHT) services may include 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.
BHT services are administered by MHN, Health Net's behavioral health subsidiary. Providers may submit treatment referrals to MHN.
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.
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, 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.
- Health Net and MHN websites
- AAP recommendations for preventive care - https://brightfutures.aap.org
- 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/listings/
- Early Start Program - www.dds.ca.gov/services/early-start/early-start-publications-resources-and-program-guidance/program-guidance-materials/
- Individual with Disabilities Education Act - https://sites.ed.gov/idea