Autism Spectrum Disorder (ASD), as defined by the American Psychiatric Association, is a complex condition that involves varying degrees of impairment in function related to atypical developmental in the following areas: 

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

Applied Behavior Analysis (ABA) is defined by the American Psychological Association (APA)  as a method of behavior modification that involves the study of an individual’s functional challenges and utilizes evidenced-based teaching techniques to increase helpful behaviors and reduce behaviors that are harmful.  

Act 62 – 2008 (Autism Spectrum Disorders Coverage Mandate): Effective July 1, 2009. Act 62 applies to: Group contracts offered, issued or renewed on or after July 1, 2009 to fully insured-employers of 51 or more employees; and CHIP programs with respect to contracts executed on or after July 1, 2009. 

• Act 62-2008 (Autism Spectrum Disorders Coverage Mandate) requires coverage for individuals  for the diagnostic assessment and treatment of ASD.
• Treatment of ASD must be identified in a treatment plan and should include any medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, including applied behavioral analysis (ABA), and therapeutic care that is:
  • Prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner; or
  • Provided by an autism service provider; or
  • Provided by a person, entity or group that works under the direction of an autism service provider.
• The treatment plan must be developed by a physician or psychologist, following a comprehensive evaluation consistent with the most recent clinical report or recommendations of the American Academy of Pediatrics. 
  • The treatment plan may be reviewed once every six (6) months, subject to the Plan’s utilization review requirements, including case management, concurrent review and other managed care provisions; or
  • A more or less frequent review can be agreed upon by the Plan and the physician or psychologist developing the treatment plan; and
  • The provider is responsible for maintaining a copy of the autism assessment and treatment plan to be made available upon request.
• Coverage is subject to copayment, deductible and coinsurance provisions, as well as any other general exclusions or limitations set forth in the member’s contract.

Traditional medical management of ASD may include the following common examples and is covered in accordance with the member’s benefit contract (this is not an all-inclusive list):

• Adaptive behavior treatment; or
• Augmentative and alternative communication device; or
• Behavioral health evaluation; or
• Behavioral assessment; or
• Developmental testing; 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
• Genetic testing; or
• Hearing assessment; or
• Medical assessment and evaluation (complete history and physical examination); or
• Measurement of blood levels for lead or heavy metal exposure; or
• Neurobehavioral status exam; or
• Neuropsychological testing;  or
• Pharmacotherapies; or
• Physical medicine, occupational therapy, and speech therapy services; or
• Psychological testing; or
• Psychotherapy; or
• Standardized cognitive performance testing; or
• Vision assessment.

Services beyond traditional medical management of ASD include the following covered services for groups, CHIP, and Adult Basic members whose coverage is impacted by the ASD mandate under Act 62; or in accordance with the member's benefit contract.

• Applied behavior analysis services, provided for purposes of behavior modification, habilitation of functional and adaptive skills and/or training:
  • Community based / wrap around behavioral treatment; or
  • Service plan development, or
  • Therapeutic behavioral services; or
• Sensory Integration.

The following services are not covered for ASD (this list applies to all Plan members, including those whose coverage is impacted by the ASD mandate under Act 62-2008, defined below). The preponderance of peer-reviewed clinical literature does not support coverage for these services. 

• Animal or pet assisted therapy; or
• Art therapy; or
• Chelation therapy and detoxification for heavy metals; or
• Craniosacral therapy; or
• Fibroblast growth factor 2; or
• Hydrotherapy; or
• Hyperbaric oxygen therapy; or
• Intravenous Immune Globulin (IVIG); or
• Music therapy; or  
• Naltrexone therapy; or
• Neurofeedback; or   
• Peripheral stem cell transplantation and umbilical cord stem cell transplantation; or
• Secretin therapy; or
• School based education therapy and/or educational services.  These services are not considered standard ABA therapy. These services are the responsiblity of the school district and should be provided by school staff; or
• Social therapeutic group and behavioral health day treatment. These services are not a standard benefit under the member’s benefit contract; or
• Testing for immunologic abnormalities; 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.