Providing Applied Behavioral Analysis Treatment to Group Health Members With Autism Spectrum Disorder
Group Health 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 Group Health plans cover ABA treatment. Coverage can be verified by having individuals and/or families contact Group Health Customer Service toll-free at 1-888-901-4636. ABA treatment requires a diagnosis of autism spectrum disorder of ASD (DSM-V code) 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).
Requests for ABA treatment need to be reviewed to determine whether they meet Group Health 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 Group Health and/or meet Group Health Credentialing Criteria.
The authorization process is as follows:
Completing the ITP
Note: Specific Group Health clinical criteria are in bold.
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:
Group Health 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:
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).
Functional, objective, and measurable goals should be established. As noted above each goal should include baseline performance, desired performance (imitate, label, list); quality of performance (with assistance, independently); criteria for meeting objective (frequency, duration, accuracy, speed, and intensity) and conditions of performance (location, prompts, audience). Again, goals should be related to areas of deficit/delay identified in developmental assessment. Group Health will cover for assessment of baseline performance in targeted goals. Target for goals should be what child is expected to achieve within six months.
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.
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:
Example ITP Goal
Target behavior: Improve receptive language.
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) with treatment goals identified that can help facilitate generalization of skills learned in school based and/or therapy services to the home environment. While Group Health only covers ABA services provided in the home or clinic, Group Health will cover:
Measurable discharge criteria and a discharge plan.
As part of the ITP, there should be description of what needs to occur in order for the individual to be able to be discharged from ABA treatment. Typically individuals' no longer need ABA services if:
For continued ABA coverage, at least every six months, providers need to submit a progress report that documents the following:
When describing progress towards goals, describe goal and current performance using specific measurable performance as compared to baseline performance. (For example: A goal for percentage of time the individual follows two-step directions during instructional sessions was 80 percent. Baseline performance was 10 percent. Current performance is 60 percent.)
For parent/caregiver goals, give brief summary of progress (focus with parents was on how to address individual's disruptive behaviors during meal time. Parents have been successful in ignoring verbal outbursts and rewarding appropriate meal time behavior).
Include in the progress report 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).
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 Provider Manual is not intended for any use by any party other than as a resource for Group Health Cooperative's contracted providers in fulfilling their obligations under provider contracts. Group Health intends for the manual to be accurate for its intended purpose but doesnt 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.