Autism Spectrum Disorders—90%

Services and Supplies Must Be Preauthorized With the Trust Office

Benefits are provided for medically necessary physical therapy, speech therapy, occupational therapy, and applied behavior analysis for a child age twelve and under who is diagnosed with autism spectrum disorder by a licensed physician or psychologist. Services must be prescribed by a licensed physician or licensed psychologist and can be provided in the patient's home, the physician's office or clinic, or an outpatient clinic at a hospital. Treatment must be based on a physician's or psychologist's written treatment plan and provided by an autism service provider who is licensed or certified by the state in which the services are provided.

"Autism spectrum disorder" means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified. "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.

There is an annual maximum benefit of 15 visits. If charges for more than 15 visits are submitted, those charges will be denied.

The child's physician must preauthorize treatment with the Trust Office and must periodically review the written treatment plan specifically describing the services provided. Progress notes may be required by the Trust Office. This benefit includes maintenance services for identifiable underlying causes when significant deterioration of the child's condition would result without the service.

Benefits are not provided for:

1. Custodial or maintenance care; nonmedical self-help or related testing; recreational, educational, cognitive, or vocational therapy; feeding therapy; hippotherapy; routine developmental screening exams; or gym or pool therapy.
2. Speech therapy for self-correcting dysfunction such as hoarseness, or language therapy for young children with natural dysfluency; oral myofunctional therapy; stammering and stuttering; or tongue thrust. Developmental articulation errors that are self-correcting are also not covered.
3. State-required medical assessments for specialized educational programs; services or supplies required by law to be provided by any school system; or treatment for learning disabilities. This exclusion applies regardless of the recommendation of the attending physician.
4. Neurodevelopmental therapy and rehabilitation care for the same condition.