Autism Resource Center

ASD, often known as autism, is a developmental disability. All children with ASD have challenges in their social interactions, verbal and nonverbal communications, and behavior skills. They may repeat their actions or have ultra-sensitive reactions to smells, tastes or textures. There is a broad range of abilities among people with ASD; some are gifted while others are severely cognitively challenged. Some need more structure than others to get through the day. ASD is not characterized by how a person looks. Individuals with ASD exhibit symptoms that typically begin in early childhood.

ASD DSM-5 Checklist

To determine if your child has ASD, a licensed health care professional with special expertise in childhood development will coordinate a comprehensive diagnostic evaluation. An evaluation team often has a physician, psychologist, speech therapist, and occupational therapist component. During the diagnostic evaluation, these qualified professionals will review your child’s developmental and medical history, behavioral and cognitive evaluation, current medical condition, neurological evaluation, autism specific assessments, and other information that may be required by state mandate.

State laws often identify which types of provider can make a diagnosis of ASD for it to be covered as an insurance benefit. Pediatricians, psychiatrists, licensed clinical psychologists, or child neurologists are typically listed. To find a qualified provider who can help with a comprehensive diagnostic evaluation for your child, please call the New Directions Autism Resource Program at 877-563-9347.

Though there are many methods available to treat people with ASD, applied behavior analysis (ABA) is currently the most widely recognized as a safe and generally effective treatment for autism, endorsed by many state and federal agencies, including the U.S. Surgeon General. Clinical research shows that ABA techniques improve communication, social relationships, self-care, play and school.

Behavior analysis is the scientific study of learning and behavior. Behavior analysis focuses on the principles that explain how learning takes places most efficiently and effectively. Applied Behavior Analysis (ABA) is the use of these principles and strategies used to shape, change and improve behavior. The purpose of the treatment is to bridge the gap between a person’s current chronological age and measured developmental age so they can function effectively with others in their natural environment.

Typically, a Board Certified Behavior Analyst (BCBA) oversees ABA treatment. Registered Behavioral Technicians (RBTs) or “Line Therapists” provide the majority of the ABA treatment under the direction and supervision of the BCBA.

For information about the ABA services your health insurance plan covers, refer to your health plan coverage handbook.

If ABA services are covered, they will address ASD core categories. Such services include social communication deficits, social interaction deficits, repetitive behaviors, and restrictive behaviors.

Services that replicate or duplicate federal or state mandated programs available through public education resources are typically not covered by health insurance benefits.

Yes, treatment services need to be pre-authorized by New Directions before your health plan benefits will pay for them.

Your Health Plan’s website has a listing for ASD treatment providers. If you are not in the same state as your Health Plan, please choose the out-of-state provider directory.

We know finding the right provider for your child can be challenging. Your New Directions’ Autism Resource Program care manager is available to help you find providers in your area at 877-563-9347. Your care manager can also tell you if your policy covers non-network ABA providers.

Before your child can begin ABA treatment, New Directions confirms three conditions are met:

1. You have an active benefit.
2. Your child has received a diagnosis of ASD and recommendation for ABA treatment.
3. You have chosen an eligible ABA service provider and notified New Directions of your choice.

New Directions will then issue an authorization to the ABA provider for an initial ABA treatment assessment. An assessment determines the specific learning areas to be targeted and proposes the intensity of treatment services proposed for your child.

To conduct the initial assessment, the ABA provider will meet with you and your child for an in-depth evaluation. This evaluation will include a review of the completed comprehensive diagnostic evaluation, previous treatment attempts, current medical and behavioral treatments, and any academic education- based support plans. Based upon the needs and deficits in function identified, your ABA provider will create a proposed treatment plan. Treatment plans include:

• Baseline information for your child’s current functioning for all the core deficits of ASD
• Short-term goals to be accomplished over the next six months
• Long-term treatment goals to be completed over the course of treatment
• Schedule of treatment hours per day for each day of the week your child is in therapy
• Location your child will receive services (home, clinic, etc.)
• Anticipated barriers to progress and how they will be addressed
• Parent training expectations and goals
• Referrals to appropriate professional and community supports
• Collaboration with other medical and behavioral treatment providers
• Discharge or transition plan that outlines discharge criteria and transitional services once ABA treatment is complete

Your ABA provider will submit the proposed treatment plan to New Directions for a benefit coverage determination. New Directions will review the proposed plan to verify that the requested services are medically necessary. New Directions will complete our review within 15 days of receiving all required information. We then notify your ABA provider of the results of our review by letter or fax. We’ll send you a letter with the same information.

After your child’s treatment plan is authorized for health plan benefit coverage, you may make your child’s first appointment.

ABA care is typically authorized for a six-month period. Since ABA services are typically provided for longer than six months, and may proceed for a number of years, your child may need treatment beyond the end date of an ABA authorization. Every six months, your provider will review the previous treatment plan, record current progress, and develop additional goals to be completed over the next six-month review period. A psychological testing instrument called the Vineland Adaptive Behavioral Scale will be requested within 45 days prior to an annual authorization treatment request. Standardized psychological testing like the Vineland is used to help show what developmental progress your child is making compared with peers their same age. Depending on your child’s progress, other psychological testing may also be requested. Once the provider has completed the review, he or she will submit a new authorization for treatment request to New Directions.

Once New Directions receives the new treatment request from your provider, we will review it and approve additional treatment coverage so long as the treatment plan meets medical necessity criteria for ongoing care.

Your New Directions Autism Resource Program care manager will reach out to you periodically between review cycles to assist with the process.

For any further information about the ongoing authorization process or with help finding a contracting psychologist who can administer a Vineland Adaptive Behavioral Scale or other psychological test, please contact your Autism Resource Program care manager at 877-563-9347.

ABA services can be provided in the home, a treatment center, or in the community. Please review your health plan’s coverage handbook because some plans have specific exclusions about where ABA services can be provided.

New Directions’ care management staff reviews each request for services based on the coverage criteria in effect for your health plan. These coverage criteria are located on the New Directions website under Autism. New Directions uses the criteria to determine if further services will be covered under your health plan benefit. Services must be considered “medically necessary” according to the coverage criteria in order to be covered.

New Directions reviews the coverage criteria annually or more often as new findings on ASD treatment are released into the professional community. During quarterly Provider Advisory Committee meetings, New Directions receives input from ABA service providers on any changes proposed to the coverage criteria.

New Directions will work with your provider to determine the appropriate level of care and health care services for your child.

Please note: The treating provider, in collaboration with you, is responsible for any treatment decisions regarding the initiation or continuation of a specific service. New Directions does not make any treatment decisions regarding your child’s care. We make a benefit coverage determination for services that may be reimbursable under your health plan coverage.

Parent training is an integral component of ABA treatment and service delivery. During these training sessions, families meet directly with the BCBA practitioner to review the treatment plan and practice ways to implement the interventions that have been recommended. Practicing ways to implement the treatment plan can occur via role-play with the BCBA followed by direct practice between you and your child. This direct practice allows you to use behavioral strategies in real time with your child. Examples of strategies that can be taught to families may include some of the following:

• increasing your child’s ability to ask for his/her favorite item or activity
• increasing your child’s ability to follow instructions during self-care routines
• teaching ways to manage and effectively respond to challenging behaviors

Parent training helps families understand and consistently implement the BCBA’s recommended treatment interventions. We also recognize that a child’s circle of supports may extend beyond the parents. In these instances, extended family members and any other individuals who provide care to your child are encouraged to participate in training sessions. This ensures everyone who is involved in your child’s care can effectively teach new skills or respond to challenging behaviors consistently. While it is important for your child to learn new skills with the BCBA and RBT, ultimately, parent training ensures your child can demonstrate these skills with you and other caregivers across a variety of settings (e.g., home, grocery stores, restaurants, etc.) outside of treatment sessions.

In the Autism Resource Program, we understand how hectic day-to-day responsibilities can be and recommend that families attend at least 80% of parent training sessions. Families and their BCBA typically schedule parent training sessions based around the family’s availability. If training is missed, the BCBA and family can always coordinate and reschedule the missed parent training session.

Additional ABA services can be approved after a child is discharged so long as he or she falls within the age restrictions outlined in your health insurance plan. If a treatment request is submitted after a child has been discharged, New Directions will review it in accordance with our review process described above.

New Directions’ Autism Resource program provides authorizations for ABA services only. Your Autism Resource Program care manager can help you with referrals to other needed medical and behavioral health services. Should you have questions about medical service coverage, please contact the health plan customer service number on the back of your insurance card.

Your health plan benefit determines any age restrictions on reimbursement of ABA therapy. For coverage guidelines, please refer to the customer service phone number on your insurance card.