PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MPUP3126
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
Original Date: 08/19/2015
Effective Date: 09/15/2014 vs. DHCS
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 11/18/2016
Last Review Date: 11/18/2015
Applies to:
☒ Medi-Cal
☒ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 11/18/2015
I.
RELATED POLICIES:
A. MCUP3065 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services
B. MPCP2006 - Coordination of Services for Members with Special Health Care Needs
(MSHCNS) and Persons with Developmental Disabilities
C. MCUP3041 - Tar Review Process
D. MCCP2014 - Continuity of Care
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
D. Provider Relations
III.
DEFINITIONS:
A. Autism Spectrum Disorder (ASD) is characterized by varying degrees of difficulty in social
interaction, verbal and non-verbal communication, and manifestation of repetitive behavior and
restricted interests. According to Diagnostic and Statistical Manual (DSM) V, a diagnosis of ASD
includes several conditions including Autistic Disorder, Pervasive Developmental Disorder Not
Otherwise Specified (PDD-NOS) and Asperger Syndrome.
B. Applied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental
modifications to produce socially significant improvement in human behavior. ABA includes the use of
direct observation, measurement, and functional analysis of the relations between environment and
behavior. (BACB Certification Board Guidelines 2012)
C. Behavioral Health Treatment (BHT) means professional services and treatment programs, including
but not limited to Applied Behavior Analysis (ABA) and other evidence-based behavior intervention
programs that develop or restore, to the maximum extent practicable, the functioning of an individual
with ASD. BHT is the design, implementation and evaluation of environmental modification using
behavioral stimuli and consequences to produce significant improvement in human behavior, including
direct observation, measurement, and functional analysis of the relations between environment and
behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or
through prompting to teach each step of targeted behavior. BHT services are services based on reliable
evidence and are not experimental. (Department of Health Care Services [DHCS] All Plan Letter
14-011)
Page 1 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
D. Behavior Analyst Certification Board (BACB) is a corporation established to meet professional
credentialing needs identified by behavior analysts and government agencies. They have defined
requirements for behavior provider certification. They are accredited by the National Commission for
Certifying Agencies. Their 2012 document presents features of ABA, credentialing process and
consensus of standards for acceptable practices by experts in the delivery of ABA services.
E. California Association for Behavioral Analysis (CalABA) is the state association for professional
behavior analysts in California. The association publishes guidelines and offers support and resources
for behavior analysts. It has provided guidelines and recommendations to the Department of
Developmental Services (DDS) and other entities toward ensuring appropriate, cost-effective behavior
services, and utilization of qualified experts in the delivery of services.
F. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services is a
federally mandated Medicaid/ Medi-Cal benefit for Medi-Cal beneficiaries under age 21 for medically
necessary treatment services needed to correct or ameliorate a defect, physical illness, mental illness or a
condition, even if the service or item is not otherwise included in the State’s Medicaid Plan. (Source:
Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532)
G. Parent Training - Service Type refers to instruction, observation and/or modeling behavior techniques
under the direct guidance/ supervision of the behavior therapy agency staff who developed the behavior
treatment plan.
H. Skills Training - Service Type refers to treatment toward development of improvement of adaptive
functioning. Domains of adaptive function may include communication (receptive/ expressive and
pragmatic language); socialization; fine and gross motor development; self-help/ daily living skillseating, toileting, dressing, hygiene; and social emotional functioning. (Source: Autism Spectrum
Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment, California Department of
Developmental Services, pg 51-52.)
I.
Therapeutic Behavior Service - Service Type refers to treatment that seeks to identify the stimulus of
challenging behaviors and then developing a plan that promotes the development of new skills while
reducing the adverse behavior. Challenging behaviors may include tantrums, aggression, self-injury.
(Source: Autism Spectrum Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment,
California Department of Developmental Services, pg 64-65.)
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To define Partnership HealthPlan of California’s (PHC) financial responsibility to provide for Behavioral
Health Treatment (BHT) services to PHC Medi-Cal eligible beneficiaries under age 21 diagnosed with
Autism Spectrum Disorder (ASD) under the Early and Periodic Screening Diagnosis and Treatment
(EPSDT) Supplemental Services benefit. To provide an overview of best practices per California
Association for Behavior Analysis (CalABA March 2011) and Behavior Analyst Certification Board
(BACB report 2012) that meet the expectations of Department of Health Care Services (DHCS) and
Partnership HealthPlan for delivery of quality behavioral services.
Page 2 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
VI.
POLICY / PROCEDURE:
A. General Criteria for BHT Services
In order to be eligible for BHT services, a PHC Medi-Cal beneficiary must meet all of the
following coverage criteria. The recipient must:
1. Be under 21 years of age and have a completed diagnostic evaluation confirming ASD or a
provisional diagnosis of ASD if under the age of 3.
2. Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with
home or community activities (including, but not limited to, aggression, self-injury,
elopement, and/or social interaction, independent living, play and/or communication skills)
requiring behavioral assessment and treatment.
3. Be medically stable and without a need for 24-hour medical/nursing monitoring or
procedures provided in a hospital or intermediate care facility for persons with intellectual
disabilities (ICF/ID)
B. Diagnostic Evaluation
1. Member must have undergone a comprehensive diagnostic evaluation by an appropriately
licensed and/or certified behavior professional that indicates evidence-based BHT services are
medically necessary and recognized as therapeutically appropriate. The diagnostic evaluation
should include clinical history, direct observation, review of available records and standardized
measures including but not limited to ASD features, cognitive abilities and adaptive functioning
using published instruments such as Autism Diagnostic Observation Schedule (ADOS). If a
copy of the diagnostic evaluation is not available and other reports are provided, such as school
reports, those reports will be reviewed. If those reports are not determined to be sufficient, PHC
may obtain/authorize a comprehensive diagnostic evaluation.
2. If member does not have a diagnostic evaluation PHC will authorize up to 8 hours for the
diagnostic evaluation, which is to include the written report. If, due to special circumstances, it
is anticipated that additional time will be needed, the Provider must request the additional time
and it must be pre-approved by PHC. Diagnostic evaluation will include:
a. Clinical history with informed parent/guardian, inclusive of developmental and
psychosocial history
b. Direct observation
c. Review of available records
d. Standardized measures including ASD core features, general psychopathology, cognitive
abilities, and adaptive functioning using published instruments administered by qualified
members of a diagnostic team
C. Covered Services for Behavior Assessment and Behavioral Health Treatment (BHT)
TARS will be required for all BHT services and should be faxed or electronically submitted from the
Provider to the Health Services Department for review based upon medical necessity criteria and
procedures otherwise in compliance with PCH Policy MCUP3041 TAR Review Process.
EPSDT covered BHT services must be:
1. Prescribed by a licensed physician or surgeon or developed by a licensed psychologist.
2. Determined as medically necessary as defined by Welfare & Institutions Code Section 14132(v)
3. Authorized prior to provision of service in accordance with PHC Policy MCUP3065 Section III AE: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services; and
4. Delivered in accordance with the member’s approved treatment plan
Page 3 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
D. Providers of Services
BHT services must be provided and supervised under an approved treatment plan developed by a
“qualified autism service provider” as defined by Health & Safety Code Section 1374.73(c). In
accordance with DHCS, treatment services may be administered by one of the following:
1. A qualified autism service provider as defined by H&S Code section 1374.73(c)(3)
2. A qualified autism service professional as defined by H&S Code section 1374.73(c)(4) who is
supervised and employed by the qualified autism services provider
3. A qualified autism service paraprofessional as defined by H&S Code section 1374.73(c)(5) who is
supervised and employed by a qualified autism service provider
E. Treatment Plan Criteria
1. BHT services in compliance with Health and Safety Code 1374.73 and Welfare and Institution Code
4686.2 shall be rendered in accordance with the beneficiary’s treatment plan. The treatment plan
shall have measureable goals over a specific timeline that is developed and approved by the
qualified autism service provider for the specific member being treated. The treatment plan shall be
reviewed no less than once every six months by the qualified autism provider and modified
whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions
Code pursuant to which the qualified autism service provider does all of the following:
a. Describes the patient’s behavioral health impairments or developmental challenges that are to be
treated
b. Designs an intervention plan that includes the service type, number of hours and parent
participation needed to achieve the plan’s goal and objectives, and the frequency at which the
member’s progress is evaluated and reported
c. Provider’s intervention plans that utilize evidence-based practices, with demonstrated clinical
efficacy in treating pervasive developmental disorder or autism
d. Discontinues intensive behavioral intervention services when the treatment goals and objectives
are achieved or no longer appropriate
2. In compliance with DHCS All Plan Letter 14-011, the treatment plan shall:
a. Be person-centered and based upon individualized goals over a specific timeline
b. Be developed by a qualified autism service provider for the specific beneficiary being treated
c. Delineate both the frequency of baseline behaviors and the treatment planned to address the
behaviors
d. Identify long, intermediate, and short-term goals and objectives that are specific, behaviorally
defined, measurable, and based upon clinical observation
e. Include outcome measurement assessment criteria that will be used to measure achievement of
behavior objectives
f. Utilize evidence-based practices with demonstrated clinical efficacy in treating ASD, and are
tailored to the beneficiary
g. Ensure that interventions are consistent with evidenced-based BHT techniques.
h. Clearly identify the service type, number of hours of direct service and supervision, and parent
or guardian participation needed to achieve the plan’s goals and objectives, the frequency at
which the beneficiary’s progress is reported, and identifies the individual providers responsible
for delivering the services
i. Include care coordination involving the parents or caregiver(s), school, state disability programs,
and others as applicable; and
j. Include parent/caregiver training, support, and participation
Page 4 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
F. BHT Service Limitations
1. Services must give consideration to the child’s age, school attendance requirements, and other daily
activities as documented in the treatment plan.
2. Services must be delivered in a home or community-based settings, including clinics.
3. Services will be discontinued when the treatment goals and objectives are achieved or are no longer
medically necessary.
4. PHC will comply with requirements related to coordination with Local Education Agencies.
5. PHC may cease to authorize continued services that do not meet medical necessity criteria, nor
qualify for covered BHT services for reimbursement, including:
a. Therapy services rendered when continued clinical benefit is not expected
b. Services that are primarily respite, daycare or educational in nature and are used to reimburse a
parent for participating in the treatment program
c. Treatment whose purpose is vocationally or recreationally-based
d. Custodial care defined as provided primarily to assist in the activities of daily living (ADLs),
such as bathing, dressing, eating, and maintaining personal hygiene and safety; care that is
provided primarily for maintaining the recipient’s or anyone else’s safety; and care that could be
provided by persons without professional skills or training.
e. Services, supplies, or procedures performed in a non-conventional setting including but not
limited to resorts spas or camp
f. Services rendered by a parent, legal guardian, or legally responsible person
G. Transition of Members Receiving Services from Regional Centers
1. Effective on or after the transition date and phased in approach (to be determined by DHCS), PHC
will assume financial responsibility for BHT service for children under the age of 21 who had
previously received BHT under a Regional Center. All Regional Center services, other than BHT
services for children diagnosed on the Autism Spectrum disorder, will remain the responsibility of
the Regional Center.
2. PHC and the member’s local Regional Center will work together to ensure that the needs of the
member are met. A Memorandum of Understanding (MOU) that clearly defines roles and
responsibilities will be executed between the Regional Centers and PHC.
3. The member and responsible party (parent, guardian) will receive notice of the transition at 60 and
30 days prior to transition implementation. PHC’s Special Program Case Managers and Member
Services staff will also attempt outreach to each member’s parent/guardian via telephone to discuss
the transition, answer any questions, and to assure them that the transition should not interrupt
treatment.
4. Continuity of Care
a. If the member is receiving services from an out of network provider, PHC will enter into a
continuity of care agreement for up to 12 months when:
1) The beneficiary has a pre-existing relationship with the provider as defined by DHCS
2) The plan and the provider can agree to a minimum of the Medi-Cal FFS rate
3) The provider meets professional standards and has no identified quality of care issues
4) The provider is a State Plan approved provider as defined in the Health & Safety Code
1374.73 and
5) Documents (ie. assessment and treatment plan) are provided to PHC by the provider to
facilitate continuity of care
b. If PHC and the existing member’s provider are unable to reach a continuity of care agreement,
PHC will reach out to the member to transition through a warm handoff to an in-network BHT
provider to ensure no gaps in services will apply.
Page 5 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
VII.
REFERENCES:
A. Behavior Analyst Certification Board, Inc (BCBA): Guidelines—Health Plan Coverage of Applied
Behavior Analysis Treatment for Autism Spectrum Disorder (2012)
B. California Association for Behavior Analysis (CalABA): Report of the Task Force of California
Association for Behavior Analysis—Guidelines for Applied Behavior Analysis (ABA) Services and
Recommendations for Best Practices for Regional Center Consumers (March 2011)
C. California Department of Developmental Services, Autism Spectrum Disorders- Best Practice
Guidelines Screening, Diagnosis and Assessment, (2002)
D. Department of Health Care Services All Plan Letter 14-011: Interim Policy for the Provision of
Behavioral Health Treatment Coverage for Children Diagnosed with Autism Spectrum Disorder
(9/15/14)
E. Diagnostic and Statistical Manual (DSM) V
F. Health & Safety Code Section 1374.73(c)
G. Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532
H. Welfare & Institutions Code Section 14132(v) and 4686.2
I.
Department of Health Care Services All Plan Letter 15-019: Continuity of Care for Medi-Cal
Beneficiaries Who Transition Into Medi-Cal Managed Care
VIII.
DISTRIBUTION:
A. Department Directors
B. Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES: 08/19/15 effective 09/15/14 per DHCS; 11/18/15
PREVIOUSLY APPLIED TO:
N/A
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
Page 6 of 7
Policy/Procedure Number: MPUP3126
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Autism Spectrum Disorder (ASD)
Behavioral Health Treatment (BHT)
☐ Internal Policy
Original Date: 08/19/2015
Next Review Date: 11/18/2016
Effective Date: 09/15/2014 vs. DHCS
Last Review Date: 11/18/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
Page 7 of 7