Providing Applied Behavioral Analysis Treatment to Kaiser Permanente Members With Autism Spectrum Disorder

Background

Kaiser Permanente provides coverage for applied behavioral analysis (ABA) treatment to individuals with autism spectrum disorder (ASD). The intent of this document is to provide guidance to providers on the process for accessing the benefit, what type of documentation is needed, and what is the scope of ABA services.

Coverage and Referral

Not all Kaiser Permanente plans cover ABA treatment. Coverage can be verified by having individuals and/or families contact Kaiser Permanente of Washington Customer Service toll-free at 1-888-901-4636. ABA treatment requires a diagnosis of autism spectrum disorder and there must be a referral for ABA treatment from a licensed health, mental health, or allied health provider (e.g., physician, psychologist, or speech-language pathologist).

Authorization Process

Requests for ABA treatment need to be reviewed to determine whether they meet Kaiser Permanente Clinical Review Criteria (PDF). Prior authorization is needed for development of initial treatment plan and ongoing ABA treatment. ABA treatment can only be delivered by providers who are contracted with Kaiser Permanente and/or meet Kaiser Permanente Credentialing Criteria.

The authorization process is as follows:

  • There is an initial review of a referral to determine whether the individual meets eligibility criteria for referral for ABA treatments that is as follows:
    1. Diagnosis of ABA by qualified using DSM 5 criteria and severity level
    2. How behavior is interfering with patients ability to adequately participate in home, school, or community activities
    3. How lower levels of care (school, speech therapy) either have been tried and/or not considered effective to address member’s behaviors.
  • If individual meets criteria for ABA services, then initial authorization is for development of an individualized treatment plan (ITP).
  • Once the ITP is completed, it is reviewed and if it meets Kaiser Permanente Clinical Review Criteria, authorization is typically given for six months of ABA therapy.
  • After six months, a progress report needs to be submitted to determine whether the member continues to meet criteria for ABA therapy and if so, an additional six months of ABA therapy is authorized.

Initial Treatment and Progress Plans (Word) should be sent to:
Kaiser Permanente of Washington
Review Services
Kaiser Permanente Renton Campus
2715 Naches Ave SW, Mail Stop GSW-A3S05
Renton, WA 98057

  • Fax: 1-800-377-8853
  • Phone: 1-206-630-1854

Completing the ITP

The ITP must be based on a diagnostic assessment within no more than 12 months of initiating treatment.

A diagnostic assessment is an individual's performance on standardized developmental assessment, checklists, or rating scales. Example assessments include:

  • Self-help skills: Vineland Adaptive Behavior Scales
  • Communication skills: Preschool Language Scale-5 (PLS-5), Clinical Evaluation of Language Fundamentals-5 (CELF-5), Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP)
  • Social skills: Social Skills Rating Scales (SSRS), Assessment of Basic Language and Learning Skills (ABBLS), Achenbach System of Empirically Based Assessment (ASEBA)
  • Behavior rating scales: ASEBA, Behavior Assessment System for Children Second Edition (BASC-2)

Kaiser Permanente recommends that ITP goals be based upon where there is the most significant developmental and/or standardized gap in the diagnostic assessment.

The ITP should address autistic symptoms in one or more of the following areas:

  • Social Communication and Social Interaction Behavior (to include restricted, repetitive, and/or stereotypical patterns of behavior, interests, and/or activities)
  • Restrictive/Repetitive/Stereotypical patterns of Behavior (i.e. stereotyped/repetitive motor movements, insistence on sameness, inflexible adherence to routines, highly fixated interests, hyper/hyporeactivity to sensory input)

Coverage of ABA treatment is for behaviors and/or symptoms related to the core symptoms of autism as noted above.

ABA treatment is not covered for symptoms and/or behaviors that are not part of core symptoms of autism (i.e. impulsivity due to ADHD, reading difficulty due to learning disability, excessive worry due to anxiety disorder).

If academic or adaptive deficits are included in the ITP, then the focus should be on addressing autistic symptoms that are impeding these deficits in the home environment (i.e. reduce frequency of self-stimulatory behavior to allow child to be able to complete mathematics sorting task and/or following through on toilet training instruction), rather than on the academic and/or adaptive skill targets (i.e. child will read paragraph level information at grade level or be able to dress self independently).

Goals in the ITP should be described as follows:

  • Objective, baseline measurement levels for each target behavior/symptoms in terms of frequency, intensity and duration, including use of standardized autism measures; and
  • A comprehensive description of treatment interventions and techniques specific to each of the targeted behaviors/symptoms, including documentation of the number of service hours, in terms of frequency and duration for each intervention; and
  • Establishment of treatment goals and objective measures of progress for each intervention specified.
  • Anticipated time for mastery: How long it is anticipated (typically in months) a goal will be mastered

Example ITP Goal

Target area: Improve receptive language as noted by standard score of 75 which is greater than 1.5 standard deviations form mean on receptive factor of preschool language scale.
Target behavior: Individual's performance indicates they are unable to follow two-step directions.
Baseline: Twenty percent accuracy following two-step directions.
Goal: In order to improve receptive language skills due to a diagnosis of autism spectrum disorder, patient will follow simple two-step directions when provided with gesture cues across 80 percent of opportunities when presented with age appropriate instructional material across three treatment sessions.

  • Strategies for generalized learning skills; and
  • A description of parental education, goals, training, and support services.

Strategies for generalization of learning skills (for example having the individual respond to 2-step direction given by parents) should also have specific measurable goals and objectives.

Parent education should include the following:

  • Role of parent for each target established in the ITP.
  • How the parent will integrate goals to promote generalization in home and other environments.
  • Parent training goals need to be functional, objective, measurable, and specific.

Example ITP Goal

Target behavior: Improve receptive language.
Parent goal: In order to promote generalization of receptive language skills, parents will provide simple two-step directions, with gesture cue during structured homework activities.
Target: Patient is able to follow two-step directions with gesture cue with 80 percent accuracy across one week.

Strategies for coordinating ABA treatment with school-based special education programs and other treatment programs.

Targets should be developed in coordination with other services (SLP, BHS, IEP team). There should be awareness of what specific goals is being worked by a speech and language pathologist and the school (i.e. IEP). ABA treatment goals should not overlap with skills learned in school based and/or therapy services. While Kaiser Permanente does not cover ABA services either in school or during regular school hours, Kaiser Permanente will cover:

  • Time needed to review IEP and/or other specialty service goals and/or
  • Meeting with school and/or other treatment providers to coordinate care.

Measurable discharge criteria and a discharge plan.

As part of the ITP, discharge criteria should include specific behavior goals that when reached will indicate the patient is adequately participating in home, school, or community activities and/or is no longer present a safety risk to self or others as well as plans for transition through a continuum of less intensive treatments such that patient’s symptoms can be effectively managed at a lower level of care.

Typically individuals' no longer need ABA services if:

  • Their behaviors and/or symptoms do not prevent them from adequately participating in home, school, or community activities and/or no longer present a safety risk to self or others.
  • Their behaviors and/or symptoms can be adequately addressed through alternative methods (i.e. school, developmental disability services, parent training), or
  • Functional and measurable progress toward treatment goals is not occurring (majority of goals are not being met, there is not significant progress on behaviors and/or symptoms that prevent them from adequately participating in home, school, or community activities and/or no longer present a safety risk to self or others), improvement is not durable over time, and generalizable outside the treatment setting, and there is no reasonable expectation of further progress.
  • Parents have not been active participants in ABA treatment.

For continued ABA coverage, at least every six months, providers need to submit a progress report that documents the following:

  • Provide descriptive overall summary of how patient is making functional and measurable progress as pertains to social communication and/or social interaction, restrictive/repetitive/stereotypical patterns of behavior or other adaptive behaviors.
  • Provide descriptive overall summary of functional and measurable progress is occurring as it pertains to parent goals particularly as it pertains to transferring interventions from the individual to the parent. Include description of level of participation of parent/legal guardian in treatment.
  • How many patient goals were met, how many patient goals were improved, how many goals patient goals were not met, how many patient goals did patient regress.
  • How many parent goals were met, how many parent goals were improved, how many parent goals were not met, how many goals did parent regress.
  • For goals that have not been met or where there is regression in member’s behavior, describe reason for not meeting goals, how goals are being adjusted and how interventions are being revised to meet goals
  • Any new goals that have been identified (if new goals are identified, include baseline and targeted performance and anticipated time line for mastery). New goals should be geared towards progress or transition to less intensive interventions
  • How the patient is progressing towards discharge and/or plans for discharging from care and/or reducing intensity of intervention based upon patient progress and/or the implementation of less intensive behavioral interventions
  • A brief description of what was done during past six months to coordinate treatment with school and/or health care providers (i.e. phone call was made to speech therapist to make sure there is common picture communication system, conference held with school to coordinate behavioral intervention for self-injurious behavior)
  • If functional progress is not occurring (i.e. every six months patient is not meeting majority of goals and not making significant progress towards increased participation, home school, or community activities and/or is not less of a safety risk to self or others) and there is not a reasonable expectation of further progress, then continued ABA services are not considered to be medically necessary

Every 12 months, developmental assessment should be re-administered to assess whether patient continues to be making functional and measurable progress.

As previously noted, it is expected that goals identified on the ITP should be achieved within six months. It is recognized that there needs to be some experience in working with an individual to determine rate of progress and thus there will be some individuals where a number of goals identified in the ITP are not met after six months. If the goals are not met, it is important to develop a functional analysis to determine the reason for lack of progress (i.e. individual continuing to have difficulty maintaining eye contact, individual continues to engage in self-stimulatory behaviors that prevent follow through with discrete learning) as well as then how intervention will be modified to address lack of progress.

If an individual is unable to demonstrate progress towards meeting the majority of goals after two six month periods of ABA treatment, then consideration will be made as to whether there is a reasonable expectation that child is capable of making progress with ABA therapy. If so, then the individual no longer meets criteria for continued ABA therapy.

The following are not considered to be medically necessary ABA services:

  • More than one program manager/lead behavioral therapist for a member/identified patient at any one time.
  • More than one agency/organization providing ABA services for a member/identified patient at any one time.
  • If the school has determined that a child is eligible to receive services under an IEP which would overlap with ABA services and the school services are declined or discontinued by the parent.
  • Activities and therapy modalities that do not constitute application of applied behavioral analysis techniques for treatment of autism. Examples include (but are not limited to):
    • Taking the member/identified patient to appointments or activities outside of the home (e.g. recreational activities, eating out, shopping, play activities, medical appointments), except when the member/identified patient has demonstrated a pattern of significant behavioral difficulties during specific activities
    • Assisting the member/identified patient with academic work or functioning as a tutor, educational or other aide for the member/identified patient in school
    • Provision of services that are part of an IEP and therefore should be provided by school personnel, or other services that schools are obligated to provide
    • Doing house work or chores, or assisting the member/identified patient with house work or chores, except when the member has demonstrated a pattern of significant behavioral difficulties during specific house work or chores, or acquiring the skills to do specific house work or chores is part of the ABA treatment plan for the member/identified patient
    • travel time
    • residing in the member’s home and functioning as live-in help (e.g. in an au-pair role)

All ABA visits with patient and/or family should be documented to include:

  • Who was present at the visit
  • Duration of the visit
  • What was the targeted behavior during the visit
  • What was procedure/activity/intervention during visit
  • What was response to procedure/activity/intervention
  • Intervention format (individual, group, supervision, parent training)
  • Graphical or numerical data to track progress/participation
  • Signature title, credentials of person completing documentation
Reviewed 2/1/2017

The Provider Manual is not intended for any use by any party other than as a resource for Kaiser Foundation Health Plan of Washington's contracted providers in fulfilling their obligations under provider contracts. Kaiser Permanente intends for the manual to be accurate for its intended purpose but doesn’t guarantee accuracy. Providers should comply with the terms of their provider contracts and any legal requirements in the event of an inconsistency between the manual and a requirement in their provider contracts or the law.