Autism Spectrum Disorders (ASD) include any of the pervasive developmental disorders, as defined in the most recent edition and as amended, of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder.

ASD is a group of developmental and neurobiological disorders characterized by atypical development in:

• Communication and language; and 
• Social skills and interaction; and
• Restrictive, repetitive behavior and interests.

Coverage for Autism Services for Policies Subject to Delaware Law

Effective for new plans and those renewing after December 11, 2012, Delaware law now requires coverage for ASD. The application of this mandate is limited to individual and group coverage that is subject to Delaware insurance law (insured business).

• The Delaware Autism Mandate (18 Del. C. Sections 3361 and 3570A) requires coverage for the medically necessary screening, diagnosis and treatment of ASD by autism services providers for individuals less than 21 years of age. Coverage may not be denied on the basis that the treatment is habilitative or non-restorative in nature.
• Coverage shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health benefit plan, except as otherwise provided for regarding Applied Behavioral Analysis (ABA) therapy (discussed below).
• The mandate specifically requires coverage for ABA as described below. 

Autism Services Provider

This includes licensed physicians, psychologists, psychiatrists, speech therapists or their aides, occupational therapists or their aides, physical therapists or their assistants, practitioners with the national certification of board certified behavior analyst or those working under their supervision, or any person, entity, or group meeting the standards set by the Department of Health and Social Services (DHSS). 

The mandate contains its own definition of medically necessary.

Medically necessary means reasonably expected to do the following:

• Prevent the onset of an illness, condition, injury, or disability; or
• Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or
• Assist to achieve or maintain maximum functional capacity in performing daily activities taking into account both the function capacity of the individual and the functional capacities that are appropriate for individuals of the same age.

Treatment for ASD shall include the following care prescribed or ordered for an individual diagnosed with one (1) of the ASD by a licensed physician or licensed psychologist who determines the care to be medically necessary:

• Behavioral health treatment - Behavioral health treatment means professional counseling, guidance services or treatment programs, including applied behavior analysis, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual. This definition also applies to treatment or counseling to improve social skills and function.
• Pharmacy care - Pharmacy care means medications prescribed by a licensed practitioner and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.
• Psychiatric care - Psychiatric care means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
• Psychological care - Psychological care means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 
• Therapeutic care - Therapeutic care means services provided by speech, occupational, or physical therapists or an aide or assistant under their supervision. Items and equipment necessary to provide, receive, or advance in the above listed services (DME), including those necessary for applied behavioral analysis; and
• Any care for individuals with autism spectrum disorders that is determined by the Secretary of the Department of Health and Social Services, based upon their review of best practices and/or evidence-based research, to be medically necessary. The Insurance Commissioner shall issue a bulletin stating that any such care, treatment, intervention, service, or item that was not previously covered shall be included in any health benefit plan delivered, executed, issued, amended, adjusted, or renewed on or after 120 days following the date of such bulletin. 

The definition of medically necessary in the mandate must be used to determine the medical necessity for all screening, diagnosis and treatment services for ASD. Highmark Delaware will determine the application of this definition to all screening and diagnostic services; however, pursuant to the mandate, the treating physician or psychologist will determine medical necessity for those ASD treatments outlined above. Highmark Delaware reserves the right to request medical records or a letter of medical necessity as appropriate. 

ABA

ABA means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. The Delaware law mandates coverage to age 21 and prohibits any limitations on number or location of visits by ABA providers. 

Maximum benefit amounts for ABA were removed effective January 1, 2014. 

ABA Providers

The Department of Health and Social Services (DHSS) promulgated Regulation 1170 to establish standards for certification of qualified ABA providers. Under DHSS Regulation 1170, ABA providers must obtain national certification as a Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst – D (BCBA-D). Behavioral Technicians who work under the supervision of a BCBA or BCBA-D and who meet specific criteria set forth in the Regulation may also provide ABA services. Coverage for ASD services shall be limited to those providers who meet standards set forth in the DHSS Regulation.

Traditional medical management of ASD may include the following common examples. (This is not an all-inclusive list.) Please be sure to check the member's benefit plan to verify.

• Behavioral health evaluation; or
• Behavioral assessment; or  
• Adaptive behavior treatment; or
• Hearing assessment; or
• Medical assessment and evaluation (complete history and physical examination); or 
• EEG or neurological consult  when in the presence of focal signs or clinical findings suggestive of a seizure disorder or a degenerative neurological condition; or 
• Measurement of blood levels for lead or heavy metal exposure; or
• Pharmacotherapies (subject to the member’s specific benefits for drug coverage); or
• Psychological testing  developmental testing, neurobehavioral status exam, neuropsychological; testing and standardized cognitive performance testing ; or
• Psychotherapy; or
• Physical medicine, occupational therapy, and speech therapy services; or
• Vision assessment; or
• Items and equipment necessary to provide, receive, or advance autism; or
• ABA- for individuals and groups subject to Delaware law and those self-insured/non-risk accounts that elect to cover ABA, services provided for purposes of behavior modification and/or training (ABA) which include:
  • Therapeutic behavioral services per 15 minutes;
  • Community based wrap-around services per 15 minutes;
  • Service plan development; 

·        Sensory Integration

Treatment Plan

Treatment of ASD must be identified in a treatment plan and should include all medically necessary behavioral, pharmacy care, psychiatric care, psychological care, and therapeutic care. The treatment plan must also include ABA services if applicable. Highmark Delaware reserves the right to review the treatment plan once every 12 months.

The following services are not covered for ASD. The preponderance of peer-reviewed clinical literature does not support coverage for these services. If the treating physician or psychologist deems a service medically necessary, medical records and a letter of medical necessity must be submitted. 

• Animal or pet assisted therapy; or
• Chelation therapy and detoxification for heavy metals; or
• Craniosacral therapy; or
• Fibroblast growth factor II; or
• Hydrotherapy; or
• Hyperbaric oxygen therapy; or
• Intravenous Immune Globulin (IVIG); or  
• Music, art and activity therapy; or
• Comfort or convenience items or items that would be useful to a person unrelated to illness, injury or condition including but not limited to phones, computers, exercise  and play equipment; or
• Naltrexone therapy; or
• Neurofeedback; or
• Peripheral stem cell transplantation and umbilical cord stem cell transplantation; or
• Secretin therapy; or
• Social therapeutic group; or
• Behavioral health day treatment; or  
• Testing for immunologic; or  
• Vitamin: Laboratory testing; or
• Vitamins, nutritional supplements, or diet-oriented therapy. 

When any of the above mentioned services are not covered, all related services are also not covered (e.g., E/M services, laboratory tests, infusion services, drug administration, etc.)

ASD are typically outpatient procedures which are only eligible for coverage as inpatient procedures in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.