Autism Spectrum Disorders
Provider Type
- Physicians
- Ancillary
Autism is the most common of a group of conditions collectively referred to as 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.
Screening
Autism is 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 in six months for borderline development of autism screening results, such as a 30-month visit, is the clinical decision 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/English/health-issues/conditions/Autism/Pages/Autism-Spectrum-Disorder.aspx.
Diagnostic Evaluation
Typically, the child's medical services provider or a behavioral pediatrician, a child psychiatrist, a speech and language pathologist, and other ancillary clinical specialists, as needed, provide 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, including the Health Net Diagnostic Evaluation/Assessment Form (PDF) . A list of some of the assessment tools is included in the Health Net medical policy on the Health Net website.
Medical and Behavioral Health Services
Health Net provides coverage for medical and behavioral health services, subject to limitations, copayments, coinsurance, and deductibles of the member's benefit plan. Members may access services through Health Net's participating providers or through out-of-network providers if out-of-network provider services are covered under the member's benefit plan. Some covered expenses are subject to precertification. A provider or member should request precertification, when required, before services are rendered to verify benefit coverage and ensure that the member receives full benefits. All precertifications are performed by Health Net.
Medical services for the treatment of ASD may include speech and language therapy, physical therapy, occupational therapy, and specialty management for seizure disorders and other appropriate services. Parents (or legal guardians) of the member with ASD can request a medical home with one provider or ask one provider to lead the care plan and coordinate medical services with other providers and specialists.
Behavioral health services may include psychiatric services, such as medication management of specific symptoms related to ASD and any comorbid psychiatric conditions; 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. 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 restabilize the individual. Inpatient services do require precertification.
Prescribed Treatment Plan
The behavioral health treatment plan encompasses the professional services and treatment program. This includes ABA and other evidence-based behavioral intervention programs that develop or restore, to the maximum extent possible, the member's functioning with ASD.
A qualified autism service provider (QASP) must develop the treatment plan and review it once every six months and modify it whenever appropriate. When the treatment goals and objectives are achieved or no longer appropriate, intensive behavioral intervention services should be discontinued. The QASP must make the treatment plan available to Health Net upon request.
Health Net's participating providers are available to treat pervasive developmental disorders (PDD) or ASD. The participating provider network includes the following qualified autism service providers, who are either:
- Certified by a national entity, such as the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, to design, supervise or provide the treatment for PDD or ASD that is within the experience and competence of that provider's national certification.
- Licensed physicians, physical therapists, occupational therapists, psychologists, marriage and family therapists, educational psychologists, clinical social workers, professional clinical counselors, speech-language pathologists, or audiologists who design, supervise or provide treatment for PDD or ASD that is within the scope of that licensee's experience and competence.
PDD or ASD treatment is provided according to a treatment plan prescribed by a qualified autism service provider and administered by one of the following:
- A QASP
- A qualified autism service professional who is employed and supervised by the QASP
- A qualified autism service paraprofessional who is employed and supervised by the QASP
Notification Submission
Providers must include a completed Diagnostic Evaluation/Assessment Form and a copy of the initial prescribed treatment plan when notifying Health Net of behavioral health treatment for ASD. Submit notifications to the Health Net Medical Management Department.
For ongoing care after the initial six months of service or notification period, Health Net requires the treating provider to submit an authorization request for continued services. Upon receipt of this request, Health Net conducts a medical necessity review based on the initial treatment plan, and the treating provider's updated treatment plan analysis.
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.
Educational Services
Health Net is not responsible for and does not provide coverage for educational services. 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 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 Lovaas therapy, 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 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 medically necessary ABA services for Health Net PPO members diagnosed with ASDs when coverage is mandated by the state).
Case Management/Comanagement
At the provider's request, Health Net 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 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 service 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.
Resources
The following online resources are available to assist providers in the screening, diagnosis and treatment of ASD and other services.
ABA Forms
- Applied Behavioral Analysis (ABA) Prior Authorization Request Form (PDF) – ABA treating practitioners are required to submit a prior authorization request form along with an updated treatment plan to Health Net prior to delivering ABA services.
- Confirmation of Diagnosis: Autism Spectrum Diagnosis (ASD) Form (PDF) – This form must be completed by a licensed physician or licensed psychologist to establish a diagnosis of autism and recommend ABA services. Attach a copy of the member’s most recent face-to-face evaluation and any additional supporting documentation (e.g., comprehensive diagnostic evaluation, prescription, physician letter, etc.)