INTERIM POLICY FOR THE PROVISION OF BEHAVIORAL HEALTH TREATMENT COVERAGE FOR CHILDREN DIAGNOSED WITH AUTISM SPECTRUM DISORDER

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1 Just the Fax A fax bulletin from Molina Healthcare of California (MHC) September 19, 2014 INTERIM POLICY FOR THE PROVISION OF BEHAVIORAL HEALTH TREATMENT COVERAGE FOR CHILDREN DIAGNOSED WITH AUTISM SPECTRUM DISORDER (DHCS ALL PLAN LETTER ) The purpose of this notification is to provide interim policy guidance to Molina Healthcare of California network providers regarding Behavioral Health Therapy (BHT) for Medi-Cal beneficiaries 0 to 21 years of age diagnosed with Autism Spectrum Disorder (ASD). Molina is providing a summary based on the DHCS APL dated September 15, Please refer to the below DHCS website/link for complete information regarding the Behavioral Health Treatment Interim Policy detailed in All Plan Letter at: Effective September 15, 2014, BHT is a covered benefit provided by Molina Healthcare of California, under 1905(a)(4)(B) of the Social Security Act (the Act) for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening benefit for qualifying beneficiaries age 0 to 21 years old. All children, including children with ASD, must receive EPSDT screenings designed to identify health and developmental issues, including ASD, as early as possible. The comprehensive screening and prevention services must include but not limited to, a health and developmental history, a comprehensive physical examination, appropriate immunizations, lab tests, and lead toxicity screening. When a screening examination indicates the need for further evaluation, the child must be appropriately referred for all medically necessary diagnosis and treatment without delay. The goal of EPSDT is to ensure that all children, including Molina members, receive the right care, in the right setting, at the right time. BACKGROUND The Centers for Disease Control and Prevention estimates that approximately 1 in 68 children are diagnosed with ASD. ASD is a developmental disability that can cause significant social, communication and behavioral challenges. A diagnosis of ASD now includes several conditions that previously were diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified (PDD- NOS), and Asperger syndrome. These conditions are now all called ASD. On July 7, 2014, the Centers for Medicare and Medicaid Services (CMS) released guidance regarding the coverage of BHT services pursuant to section 1905(a)(4)(B) of the Social Security Act (the Act) for Early and Periodic Screening, Diagnostic and Treatment services (EPSDT). Section 1905(r) of the Act defines the EPSDT benefit to include a comprehensive array of preventive, diagnostic, and treatment services for low income infants, children and adolescents under age 21. Coverage to individuals eligible for the EPSDT benefit for any Medicaid covered service listed in section 1905(a) of the Act that is determined to be medically necessary to correct or ameliorate any physical or behavioral condition needs to be provided. The EPSDT benefit is more robust than the Medicaid benefit package required for adults and as indicated above, it is designed to ensure that children receive early detection and preventive care, in addition to medically necessary treatment services. Just the Fax is published by Molina Healthcare of California. Visit us at our web site at: If you believe that you have received this fax in error or would like to be removed from our distribution database, please call toll free at (800) ext: and leave the name of the provider and fax # you would like to have removed. It takes approximately 30 days to be remove from the distribution list.

2 The Department of Health Care Services (DHCS) also intends to include BHT services, including Applied Behavioral Analysis (ABA) and other evidence-based behavioral intervention services that develop or restore, to the maximum extent practicable, the functioning of a beneficiary with ASD, as a covered Medi- Cal benefit for individuals 0 to 21 years of age with ASD to the extent required by the federal government. BHT means professional services and treatment programs, including but not limited to Applied Behavioral 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. DHCS is seeking federal approval to provide BHT as it is defined by Section of the Health and Safety (H&S) Code. CONTINUITY OF CARE Members 0 to 21 years of age diagnosed with ASD and receiving BHT services through a Regional Center prior to September 15, 2014, will automatically continue to receive all BHT services through the Regional Center until such time that DHCS and the Department of Developmental Services (DDS) develop a plan for transition. Members that present at Regional Centers on or after this date should receive BHT services through Molina. When requested by a parent or guardian, members receiving BHT services out of network and outside of Regional Centers may continue to receive services accordingly for up to 12 months in accordance with existing continuity of care provisions (APL ). BHT services must not be discontinued during a continuity of care evaluation. Molina Healthcare of California and contracted delegated network providers, including Medical Groups/IPAs, must offer continuity of care with an out-of-network provider to beneficiaries if all of the following circumstances exist: 1. The beneficiary has an existing relationship with a qualified autism service provider. An existing relationship means a beneficiary has seen an out-of network provider at least twice during the 12 months prior to September 15, 2014; 2. The provider is willing to accept payment based on the current Medi-Cal fee schedule; and 3. There are no documented quality of care concerns that would cause Molina or contracted delegated network providers to exclude such providers from its network. CRITERIA FOR BHT SERVICES In order to be eligible for BHT services, a Medi-Cal beneficiary must meet all of the following coverage criteria: 1. Be 0 to 21 years of age and have a diagnosis of ASD; 2. Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities (examples include, but are not limited to, aggression, self-injury, elopement, and/or social interaction, independent living, play and/or communication skills, etc.); 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); 4. Have a comprehensive diagnostic evaluation that indicates evidence-based BHT services are medically necessary and recognized as therapeutically appropriate; and 5. Have a prescription for BHT services ordered by a licensed physician or surgeon or developed by a licensed psychologist. BHT CAN BE PROVIDED BY: Services must be provided and supervised under a Molina Healthcare of California approved treatment plan developed by a contracted and credentialed qualified autism service provider as defined by Health & Safety Code Section (c)(3). Treatment services may be administered by one of the following: Just the Fax is published by Molina Healthcare of California. Visit us at our web site at: If you believe that you have received this fax in error or would like to be removed from our distribution database, please call toll free at (800) ext: and leave the name of the provider and fax # you would like to have removed. It takes approximately 30 days to be remove from the distribution list.

3 1. A qualified autism service provider as defined by H&S Code section (c)(3). 2. A qualified autism service professional as defined by H&S Code section (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 (c)(5) who is supervised and employed by a qualified autism service provider. The treatment plan shall: 1. Be person-centered and based upon individualized goals over a specific timeline; 2. Be developed by a qualified autism service provider for the specific beneficiary being treated; 3. Delineate both the frequency of baseline behaviors and the treatment planned to address the behaviors; 4. Identify long, intermediate, and short-term goals and objectives that are specific, behaviorally defined, measurable, and based upon clinical observation; 5. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives; 6. Utilize evidence-based practices with demonstrated clinical efficacy in treating ASD, and are tailored to the beneficiary; 7. Ensure that interventions are consistent with evidenced-based BHT techniques. 8. 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; 9. Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and 10. Include parent/caregiver training, support, and participation. PRIOR AUTHORIZATION AND COORDINATION OF CARE FORMS While the Department of Health Care Services (DHCS) works toward an approved State Plan Amendment outlining the finalized policies for qualifying beneficiaries to receive BHT services, the state s interim policy described here must be followed by Molina Healthcare of California and contracted delegated network providers. Covered benefit and medical necessity requirements must be met as further defined by Welfare & Institutions Code Section 14132(v). Molina Healthcare of California prior authorization request guidelines related to behavioral health services for Molina Medi-Cal members can be found on the Molina Healthcare of California provider website, under frequently used forms, at To refer Molina IPA delegated members for BHT services, please complete the Molina Behavioral Health Coordination of Care Form (attached) and fax requests to (562) To refer Molina direct members for BHT services, please complete the Behavioral Health Outpatient Treatment Request Form (attached) and fax requests to (866) MORE INFORMATION / QUESTIONS If you have additional questions or require further clarification regarding this notification, please contact your respective Molina Provider Services Representative at (888) extension: /127690/120104/127657/121934/114378/ Los Angeles County /126556/126215/127709/ Riverside/San Bernardino Counties / Sacramento County /126236/126225/120098/ San Diego County (760) Imperial County Just the Fax is published by Molina Healthcare of California. Visit us at our web site at: If you believe that you have received this fax in error or would like to be removed from our distribution database, please call toll free at (800) ext: and leave the name of the provider and fax # you would like to have removed. It takes approximately 30 days to be remove from the distribution list.

4 Molina Healthcare of California Coordination of Care Form Phone Number: (888) ext Fax Number: (562) Member Information Referring Party/County: Member Name: Member ID: Member Address: County: Date of Evaluation: DOB: MediCal ID#: Member Phone: Language: Interpreter Used: Additional Information Primary Guardian Information (Name & Phone): Living Arrangements: Private Home Board & Care Relative Placement Homeless Other Physical Limitations: Hearing Impaired Visually Impaired Wheelchair Dependent Member Signed Release of Information: Yes No (If No, this information will NOT be forwarded to the PCP) Confidentiality Statement Read to Member: Yes No Treatment History Primary Care Physician: Primary Care Physician Phone #: Current BH provider Provider Name Telephone Number Agency Last Appt. Therapist/Program Psychiatrist Other Referral/Service Type Requested Service is For: Physical Health Substance Abuse Mental Health County Referral Mental Health Managed Care (check as many as applicable) Medication Evaluation/Consult Medication Management Individual / Group Therapy Neuropsychological /Psychological Testing Presenting/Current Symptoms Rating of Level of Severity: 1 = Mild; 2 = Moderate; 3 = Severe; or N/A High Risk Factors: (For symptoms rated 2 or 3, please provide specific information under the Additional Information section) n/a Suicidal Ideation Suicide Plan History of Suicide Attempt(s) Homicidal Ideation Homicide Plan History of Homicide Attempt(s) Gravely Disabled Self-Injurious Behaviors Child Runaway 38599CA0214

5 Molina Healthcare of California Coordination of Care Form Phone Number: (888) ext Fax Number: (562) History of Psychiatric Hospitalization: None Within last 30 days Within last 3 months Intervention Provided, if applicable: (check boxes): Crisis Intervention Crisis Response Team Emergency Responder Medications, if known Medication Dosage Days Supplied Date filled Compliant? At risk of running out/ out of meds? Additional Factors: n/a n/a Anxiety Attention Issues Sleep Disturbances Impulsivity Appetite Issues Dizziness/Light Headed Significant Weight Gain/Loss Paranoia Panic Attacks Confusion Mood Lability Depression Cognitive Deficits Dementia Somatic Complaints Isolative Anger Outbursts Substance Use Aggressiveness Hallucinations Member Provider Choice: Additional Information (explanation of any checked symptoms or other information: 38599CA0214

6 Member Information Molina Healthcare of Califonia Behavioral Health Outpatient Treatment Request Form Phone Number: (800) Fax Number: (866) Plan: Molina Medi-Cal Molina Medicare Molina Marketplace Molina DUALS Date of Admission: Request Type: Initial Concurrent Member Name: DOB: Member ID#: Member Phone #: Service Is: Elective/Routine Expedited/Urgent* *Definition of Urgent/Expedited service request designation is when the treatment requested is required to prevent serious deterioration in the member s health or could jeopardize the member s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent. Provider/Facility/Clinic Name: Provider Information Provider NPI/Provider Tax ID#: Requesting Provider: Phone #: Address: Clinician Name: Clinician Licensure/Credential: Provider Phone #: Fax Number: Treatment History Primary Care Physician: Primary Care Physician Phone #: Date of First Visit: Last Clinician/PCP Care Coordination Date: Is treatment being coordinated with the Primary Care Physician? Yes No If Yes, Name: Current BH provider Provider Name Telephone Number Agency Last Appt. Therapist/Program Psychiatrist Service Is For: Mental Health Office Visit/Therapy Medication Management Home Based Services ECT Primary Diagnosis for Treatment (including provisional) Additional Diagnoses Psychosocial Barriers (formerly Axis IV) Level of Functioning (based on a functional assessment - list tool utilized and the score) Referral/Service Type Requested Substance Abuse Neuropsychological / Psychological Testing ACT ICM Foster Care Treatment PSR ABA Tele Health Other Describe: Procedure Code(s) & Description: Number of days/visits authorized to date: Number of days/visits for this request: Number of days/visits used to date: Date(s) of Service for this request: 39308CA0214

7 Molina Healthcare of Califonia Behavioral Health Outpatient Treatment Request Form Phone Number: (800) Fax Number: (866) Presenting/Current Symptoms that may delay or prevent discharge or lower level of care: Suicidal ideations Appetite issues Homicidal ideations Significant weight gain/loss Suicidal/homicidal plan Panic attacks Suicidal/homicidal attempt Poor motivation HX of Suicidal/ Homicidal actions Cognitive deficits Psychosis Somatic complaints Mood lability Anger outbursts/aggressiveness Anxiety Attention issues Sleep disturbances Impulsivity Legal Issues Problems with performing ADL s Problems with treatment compliance Social Support Problems Learning/School/Work issues Substance Use (include results of Tox Screens below) Medication Dosage New/Change from admit? Compliant? Therapeutic Lab Level? Additional information (explanation of any checked symptoms or other pertinent information): See Following Page for further explanation of clinical information needed. Note: LOC coverage is subject to State Contract Specific Covered Services. Please refer to State Specific Provider handbook for list of covered levels of care. Authorization for services does not guarantee payment. Payment for services are pending eligibility at the time of service and benefit coverage. Below For Molina Use Only: 39308CA0214

8 Clinical Information/Treatment Plan Please provide the following information with the fax: Outpatient Sessions after Initial Evaluation (including home based treatment and Tele Health): *as covered per benefit package Current treatment plan Summary of progress neccesitating additional sessions Neuropsychological/Psychological Testing: *as covered per benefit package Diagnoses and neurological condition and/or cognitive impairment (suspected or demonstrated) Description of symptoms and impairment Member and Family psych /medical history Documentation that medications/substance use have been ruled out as contributing factor Test to be administered and # of hours requested, over how many visits and any past psych testing results What question will testing answer and what action will be taken/how will treatment plan be affected by results Enhanced Outpatient Services (including ACT, PSR, ABA ICM, Foster Care Treatment)*as covered per benefit package: Initial: Diagnosis (suspected or demonstrated) Acute symptoms that warrant ECT (specific symptoms of depression, acute mania, psychosis, etc.) Personal and family psychiatric medical history (comprehensive assessment/history and Physical are acceptable) Medication review Known barriers to treatment and other psychosocial needs identified Treatment plan including ELOS and discharge plan Concurrent: Current treatment plan/goals Progress notes from last 5 visits/sessions (therapy and medication reviews) Review/Updated history of personal and family psychiatric and medical history ELOS and Discharge Plan Additional supports needed to implement discharge plan ECT Acute/Short-Term: *as covered per benefit package Acute symptoms that warrant ECT (specific symptoms of depression, acute mania, psychosis, etc.) ECT indications (acute symptoms refractory to medication or medication contraindication) Informed consent from patient/guardian (needed for both Acute and Continuation) Personal and family medical history (update needed for Continuation) Personal and family psychiatric history (update needed for Continuation) Medication review (update needed for Continuation) Review of systems (update needed for Continuation) Baseline BP Evaluation by anesthesia provider (update needed for Continuation) Evaluation by ECT-privileged psychiatrist (update within last month needed for Continuation) Any additional workups completed due to potential medical complications Continuation/Maintenance: *as covered per benefit package Information updates as indicated above Documentation of positive response to acute/short-term ECT Indications for continuation/maintenance 39308CA0214