Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan are expanding coverage for the diagnosis and treatment of autism spectrum disorders.
The coverage became effective Oct. 15, 2012.
BCBSM and BCN coverage for autism spectrum disorder will include benefits for:
- Applied behavior analysis, a specialized treatment for autism
- Physical therapy/speech therapy/occupational therapy as part of ASD treatment
- Nutritional counseling as part of ASD treatment
- Other mental health benefits to diagnose and treat autism
- Other medical services used to diagnose and treat autism
There’s been a change in the services that apply toward the $50,000 annual benefit limit for autism services. Physical therapy, occupational therapy, speech therapy and nutritional counseling won’t be applied to the annual benefit limit. The Blues will continue to apply a limit of $50,000 per year for applied behavior analysis services through age 18.
Services beyond the age or dollar limit will be reviewed for medical appropriateness and may be covered if medically necessary.
NOTE: Benefits at a Glance charts obtained through the quoting tools that include ASD benefits effective Oct. 15, 2012, don’t currently reflect the proper information regarding what’s included in the $50,000 annual maximum. We’ll keep you informed as further details emerge.
Here’s what must occur for applied behavior analysis treatment to be payable:
- A Blues-approved autism evaluation center, or AAEC, participating with the member’s health plan, must confirm a diagnosis of autism spectrum disorder for the member.
- The treatment plan recommendations prepared by the AAEC must include a recommendation for applied behavior analysis.
- The member must seek care with a board-certified behavior analyst. For BCN coverage, the BCBSA must participate with the member’s health plan, unless plan design allows out-of-network benefits.
- The board-certified behavior analyst must obtain approval from BCBSM or BCN before providing applied behavior analysis services.
- BCBSM, For approval, the BCBSA must call Magellan at 800-762-2382 for ABA therapy. Magellan will verify member and provider eligibility, review for medical necessity and make an authorization decision.
- BCN, For approval, the BCBSA must contact BCN behavioral health for ABA prior authorization.
- Authorization decision letters are sent to the member and provider
BCBSM members receiving services other than applied behavior analysis to treat ASD need not receive theASD diagnosis from an AAEC. BCN members must go to a provider in the BCN network unless plan design allows out-of-network benefits.
At this time for BCBSM, prior approval is only required for applied behavior analysis treatment.
Autism providers
- Approved autism evaluation centers, To help ensure access to appropriate care, BCBSM and BCN are working to expand the number of AAECs in the state. We’ve contacted all hospitals in Michigan to inform them of the opportunity to apply for AAEC designation.
- Board-certified behavior analysts, We’ve contacted the certified behavior analysts we’re aware of in the state that currently treat children with autism and have invited them to apply to be a network provider.
Mandated coverage for autism treatment is new to all insurers and health care providers in the state and it may take some time to build the appropriate networks to meet the need in the community.
Information about facilities and specialists that can provide autism treatment services to members with a diagnosis of ASD will appear on bcbsm.com and mibcn.com by Oct. 15.
Out-of-state residents
For the mandated autism benefit, we’ll handle out-of-state claims as they normally are through Blue Card, with the exception of applied behavior analysis treatment. ABA services will only be covered in Michigan.
Here are the services covered at the applicable cost share when provided outside the of Michigan:
- Physical therapy/speech therapy/occupational therapy are provided as part of the treatment of ASD
- Nutritional counseling is provided as part of the treatment of ASD
- Other mental health benefits for the diagnosis and treatment of autism
- Other medical services used to diagnose and treat autism
ASC opt-in process
The autism mandate applies to underwritten and individual business regardless of renewal dates or plan years; self-funded groups aren’t included.
ASC groups can choose to opt in for an effective date of Jan. 1, 2013 or after. You can read more information about ASC group opt-in in this Blue Alert September 26, 2012 Opt-in autism benefit available for Blues ASC customers
NOTE: Benefit requests can’t be submitted before Oct. 15, 2012, because benefits won’t be loaded into the system.
The Blues aren’t charging any fees to administer the benefit program.
NOTE:This doesn’t include the Michigan Autism Coverage Reimbursement Program to reimburse plans for claims paid for autism spectrum disorders services provided in Michigan.
State reimbursement program
The Michigan Autism Coverage Reimbursement Program will reimburse plans for claims paid for autism spectrum disorder services provided in Michigan to Michigan residents. We’ll provide more information on the reimbursement program when the state issues its final guidance.
For more details, see the Frequently Asked Questions document (PDF), which has also been posted on the Group Business and Corporate Marketing section of MISource under”Implementation Guidelines.”
From Blues Alert Volume 5, issue 10, October 10,2012
