AUTISM SPECTRUM DISORDER COVERAGE
Effective January 1, 2015
The University of Utah is pleased
to announce additional coverage for Autism Spectrum Disorder (ASD) in all Employee Health Care Plan Options beginning
January 1, 2015.
The Centers for Disease Control (CDC) states the number of children in the US who have been identified with ASD is significantly higher than previously estimated. The increase is likely the result of rising awareness and access to services. Although the symptoms of ASD can be present within the first two years of life, the average age of diagnosis in the US is 4 ½ years of age. With early diagnosis and intervention, children with ASD can make significant progress. Unfortunately, many families have experienced challenges in obtaining insurance coverage for the needed diagnostic evaluations and behavioral treatments that can help children with ASD reach their potential. With the prevalence of ASD and the advances in treatment protocols now available, we are confident this is the appropriate time to add these benefits to the University's self-funded health plan.
At the University of Utah, we are fortunate to work with leading experts in research, treatment, and intervention programs for individuals with ASD. Our University experts have helped us develop a benefit designed to provide valuable coverage for our members. All health plan members will be eligible to access this coverage for themselves and their enrolled family members beginning January 1, 2015.
The coverage will include diagnostic screening as well as comprehensive diagnostic testing when medically appropriate (prior authorization is required). Health plan members who are diagnosed with ASD will be eligible for coverage for early intervention therapy (health plan members under age 8), behavioral intervention therapy (health plan members age 8 through age 25), and social skills therapy (health plan members of all ages). The intervention therapies will require prior authorization and ongoing periodic review. The current occupational therapy, speech therapy and physical therapy benefits will now also be available for health plan members with ASD, subject only to the age and medically appropriate limits already part of the health plan. The specialized behavioral case management team at University Neuropsychiatric Institute (UNI) is prepared to help members understand and access the new benefits. A summary of covered treatment/services is provided below.
Employees who believe their child qualifies for early or behavioral intervention therapy should contact the UNI case management team through the Employee Assistance Program at (801) 587-9319 or (800) 926-9619 as soon as possible to help us provide you with a referral in time for the coverage to begin on January 1st. The UNI case management team can provide you with a referral to a network provider or determine if coverage for future treatment is available with your current provider. Your case manager can also help you access the other ASD benefits available under the plan.
| THE AMOUNT YOU PAY FOR COVERED MEDICAL SERVICES (Applies toward Medical Out-of-Pocket Maximum): | |||||||
| Diagnostic Screening | |||||||
| Early Intervention Therapy for Individuals Diagnosed with Autism Spectrum Disorder •Children under age 8 •Limited to 20 hours/week |
|||||||
| Behavioral Intervention Therapy for Individuals Diagnosed with Autism Spectrum Disorder •Children age 8 through age 25•Limited to 12 hours/week |
|||||||
Pre-authorization of the treatment plan and ongoing review of goals and progress is required. Members must contact the UNI case management team through the Employee Assistance Program at (801) 587-9319 or (800) 926-9619 to obtain a referral to a network provider. Authorization for treatment is required to have Early Intervention Therapy and Behavioral Intervention Therapy covered as Network Provider Services. Occupational therapy, physical therapy and speech therapy are covered the same for all health plan members, including those with autism spectrum disorder (see Neurodevelopmental Therapy and Rehabilitation Services benefits). The member's co-pay or co-insurance expense for the services covered under the Behavioral Health Services will count toward the member's Behavioral Health and Chemical Dependency Services out-of-pocket maximum for the plan year.
| THE AMOUNT YOU PAY FOR COVERED BEHAVIORAL HEALTH SERVICES | |||
Preferred ValueCare Network and Out-of-Network |
|||
| Diagnostic Testing for Autism Spectrum Disorder | |||
| Social Skills Group Therapy for Individuals with Autism Spectrum Disorder Limited to 15 weeks per plan year |
|||
Pre-authorization of Diagnostic Testing for ASD is required. Members must contact the UNI case management team through the Employee Assistance Program at (801) 587-9319 or (800) 926-9619 to obtain prior authorization for diagnostic testing and/or an EAP referral for Social Skills Group Therapy. The member's co-pay or co-insurance expense for the services covered under the Behavioral Health Services will not count toward the member's medical out-of-pocket maximum for the plan year
* If you use an out-of-network provider, you may be billed for balances beyond any copay or coinsurance. This is sometimes referred to as balance billing.