There will be changes to autism benefit for 2015

Changes to the Blues’ coverage for autism spectrum disorder will become effective Jan, 1, 2015.

This benefit applies to Blue Cross Blue Shield of Michigan and Blue Care Network groups with underwritten plans, and self-funded groups on the Michigan Operating System. It does not apply to self-funded groups that elected to implement the multistate self-funded benefit.

Limitations on direct-line therapy removed
For the Blues’ standard autism treatment benefits, we’ve removed the current limit of 25 hours of direct-line therapy and skill training for applied behavior analysis (per member, per seven calendar days) for codes H2014 and H2019, as well as the three hours of supervision and caregiver training for codes S5108 and S5111.The treatment must be medically necessary and be preauthorized. Members will continue to be covered through the age of 18.

Remember to check member eligibility and benefits before providing services to ensure the member has autism coverage and to determine which of the limits applies for applied behavior analysis treatment.

Evaluations
For ABA treatment to be payable, the member must have an autism spectrum disorder diagnosis made or confirmed by a Blues-approved autism evaluation center (or a multidisciplinary evaluation for out-of-state members). The member must also obtain a treatment plan containing a comprehensive set of treatment recommendations for the member, including a recommendation for ABA, before treatment begins.

At this time, evaluations are only required for ABA services. Members receiving services other than ABA to treat autism spectrum disorder do not need to receive the ASD diagnosis from an approved autism evaluation center  or a multidisciplinary evaluation.

Visit limits
In 2015, all physical therapy, speech therapy and occupational therapy — when billed with ASD as the primary diagnosis — is covered for the treatment of autism. The treatment must be medically necessary, which is typically up to the age of 18. In addition, these visits do not count toward any plan limits.

Billing for ABA services
More information is available in the Applied Behavior Analysis Billing Guidelines and Procedure Codes on web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Under Other Resources, click on Clinical Criteria & Resources.
• Click on Autism.
• Scroll down to Board-Certified Behavior Analysts and click on Applied Behavior Analysis Billing Guidelines and Procedure Codes.