Autism and pervasive developmental disorder (PDD) are the most common of a group of conditions collectively referred to as autism spectrum disorders (ASDs). Signs of ASD appear early in a child's life. Autism is typically characterized by impairments in social interactions, verbal and nonverbal communication, and restricted activities or interest and/or unusual, repetitive behavior. The degree of impairment varies widely in severity and will present in each individual child differently.
Some of the different types of autism spectrum disorders include:
The Centers for Disease Control and Prevention (CDC) currently estimates that one in every 88 children has an ASD, and the number of diagnosed children is growing. The risk of ASD is nearly five times higher in males than in females. While there is no cure for autism, it is treatable. In general, the younger the child is at the time of diagnosis and implementation of treatment, the better the outcome.
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 30-month visit, are the clinical decision of the provider.
Screening may include:
Normally, the child's medical services provider, pediatrician, or a psychologist provides input for a diagnosis of ASD. A thorough evaluation for ASD is required to insure a proper diagnosis. Health Net has developed a Diagnostic Evaluation/Assessment Form for use in properly diagnosing ASD.
Health Net arranges for covered services for ASD through its participating network of physicians, hospitals and other providers. Refer to your plan document for specified information.
Medical Services include, but are not limited to:
Behavioral Health Services include, but are not limited to:
"Behavioral health treatment," as defined by the State of California (SB 946 (2011)) means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with ASD.
Beginning January 1, 2012 behavioral health treatment services (including ABA) are covered when medically necessary for Health Net commercial members diagnosed with autism spectrum disorders (ASDs). Effective July 1, 2012, California's Legislature enacted SB 946, which further defined provisions for required coverage of behavioral health treatment for PDD or ASD, including the establishment of a network of qualified autism service providers.
Health Net provides medically necessary behavioral health benefits, including Applied Behavioral Analysis (ABA), and other medical benefits for the treatment of PDD and ASD. Behavioral health benefits are administered by UBH.
Treatment Plan Prescribed
If the diagnosis of ASD is confirmed, the child's treatment is to be prescribed by a physician or is to be developed by a psychologist. The treatment is to be provided under a treatment plan prescribed by a qualified autism service provider, as defined below, and is to be administered by one of the following:
The treatment plan is then to be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate. Intensive behavioral intervention services should be discontinued when the treatment goals and objectives are achieved or are no longer appropriate. Health Net may not cover certain services if the primary purpose of the treatment plan is to provide respite, day care or educational services or to reimburse the parent for participating in the treatment program.
Requests regarding treatment plans should be directed to UBH.
Health Net enrollees have access to a provider network available for the treatment of PDD or ASD through UBH. Their network includes the following types of providers:
"Qualified Autism Provider": A person who is certified by the Behavior Analyst Certification Board as a BCBA or BCBA-D and who designs, supervises, or provides treatment for PDD or ASD that is within the experience and competence of the person's certification. This individual must have completed at a minimum a Bachelors Degree from an accredited school as required by the Behavioral Analyst Certification Board, and maintain professional liability insurance covering the services that are provided. A Qualified Autism Provider may also be licensed as a physician, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist or audiologist.
"Qualified Autism Service Professional": A person who is certified by the Behavior Analyst Certification Board as a BCaBA and has training and experience in providing services for PDD or ASD. This individual must have completed at a minimum a Bachelors Degree from an accredited school as required by the Behavioral Analyst Certification Board, and maintain professional liability insurance covering the services that are provided. Qualified Autism Service Professionals must be employed by and supervised by a Qualified Autism Provider and must provide treatment pursuant to a treatment plan developed and approved by the Qualified Autism Service Provider.
Contracted Qualified Autism Service Providers must attest and certify that any and all Paraprofessionals they employ and supervise meet specific requirements, including but not limited to requirements of SB 946 (2011).
At the request of a provider, a case manager who is knowledgeable about plan benefits may assist in the coordination of health care treatment services in managing PDD and ASD.
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