Autism Spectrum Disorders
Autism is the most common of a group of conditions collectively referred to as autism spectrum disorders (ASDs). Autism is a developmental disorder that presents in the first few years of life and profoundly interferes with an 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 at provider.healthnet.com and www.mhn.com.
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 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, 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 and MHN websites at provider.healthnet.com and www.mhn.com.
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.
Lovaas therapy, a behavioral treatment model utilizing the principles of applied behavioral analysis (ABA), is covered when medically necessary for Health Net members diagnosed with ASDs when coverage is mandated by the state.
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
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.
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 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 medically necessary ABA services for Health Net PPO members diagnosed with ASDs when coverage is mandated by the state).
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
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 and other services.
- 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