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Autism Massachusetts Laws

ARICA LAW

FREQUENTLY ASKED QUESTIONS

What does it do?

It requires health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder, which currently affects 1 in every 110 individuals. The text of the law can be found at http://www.mass.gov/legis/laws/seslaw10/sl100207.htm

When does it go into effect?

It went into effect January 1, 2011, but implementation will be based on each policy’s specific renewal date. If you have insurance under a policy that is subject to (see below), the coverage must be provided when the policy renews on or after January 1, 2011, meaning it will go into effect the date that your company’s insurance plan renews annually.

What types of policies through arica cover ABA?

The legislation affects only certain types of health care policies, so coverage under ARICA depends on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs are all required�to comply with the mandate. Many employers have ‘self-funded’ plans, which are regulated under a federal law and not subject to ARICA. However, a majority of ‘self-funded’ plans in Massachusetts are covering autism treatments.

How can I find out if I have coverage under the new mandates?

Contact your employer to verify that your policy is subject to the new law, and if so, what annual date your group policy renews. Even if your company is regulated by, they may as practice comply with State laws. In addition, there is language in the recently enacted federal health care reform that will eventually cover autism treatment. If you are covered by a plan, please contact us for additional information and assistance in advocating for coverage with your company.

Are individuals or family members covered for services under Mass Health or Common Health?

These programs are not subject to the new law, but consumers should know the following:

  • Mass Health may cover co-pays and deductibles for some mandated treatments covered by private insurance.
  • The Premium Assistance Program can help subsidize purchase of private insurance policies and policies through Commonwealth Choice that will cover.
  • Families covered by Mass Health with children under age 9, can also apply for the Massachusetts Children’s Autism Medicaid Waiver through. Note – this is a limited program with specific application windows.

Is there a limit to the amount of the coverage?

No. The diagnosis and treatment of Autism Spectrum Disorders will not be subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.

Is there an age limit to this coverage?

There is no age limit.

How are education services affected?

Educational services are not affected and Insurers are not required to pay for in-school services. Conversely, schools may not require parents to access private insurance for services that are part of the IEP.

MassHealth ABA Coverage
Frequently Asked Questions

Applied Behavior Analysis (ABA) is one of the frequently prescribed therapies for people with autism. Private insurance began covering ABA therapy in 2011, under a Massachusetts act,ARICA. Following passage of the Autism Omnibus Bill in 2014, MassHealth began covering ABA in 2015.

Who is eligible?

ABA is available to children diagnosed with autism under 21 enrolled in MassHealth Standard and CommonHealth; and to children under age 19 enrolled in MassHealth Family Assistance.

How does someone access coverage?

The child’s clinician (usually a developmental pediatrician, neurologist, psychologist), recommends ABA. The family then locates an ABA provider in one of the three MassHealth Managed Care Entities they are assigned to:

The provider requests authorization for ABA from MassHealth, performs an initial evaluation, and develops a treatment plan.

How long will this process take?

The length of time to access services is dependent on how long it takes to locate a provider with availability, how long it take them to complete the initial evaluation and receive authorization for the treatment plan. Families should ask specific providers they are thinking of using for an estimate of how long it might take to start services.

Are there limitations on coverage?

Coverage is based on the plan’s medical necessity criteria. There are no annual or lifetime dollar or unit of service limitations on coverage.

Are Social Skills Groups covered?

Yes, subject to medical necessity criteria.

What treatments are covered under the ARICA law & Omnibus Act?

The law covers the following care prescribed, provided, or ordered for an individual diagnosed with one of the Autism Spectrum Disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary:

Habilitative or Rehabilitative Care – this includes professional, counseling and guidance services and treatment programs, including but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.

Pharmacy care – medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.

Psychiatric care – direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

Psychological care – direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

Therapeutic care – services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.

How are education services affected?

Educational services are not affected and Insurers are not required to pay for in-school services. Conversely, schools may not require parents to access private insurance for services that are part of the IEP.

Science of ABA

Applied Behavior Analysis

Applied Behavior Analysis systematically applies behavioral intervention techniques coupled with a functional analysis of environmental factors to determine the relationship between the individual and their environment to develop, maintain or restore the functioning of individuals with Autism Spectrum Disorder (BACB Inc., 2012). Individuals diagnosed with Autism may often experience and display ritualistic or challenging behaviors including self-injurious behaviors that interfere in activities of daily living. ABA techniques are the recommended treatment of choice intended to produce changes in the individual?s behavior with Autism Spectrum Disorders. Challenging behaviors can include aggression, pica, and self-injurious behaviors such as destruction of property, self-harm or harm to others (Matson, 2011).

The functional analysis of ABA explicitly identifies the antecedent stimuli and the consequence associated with the relationship between the environment and the individual?s behavior. ABA applies positive reinforcement techniques to teach and train adaptive and desirable behaviors. The goal of ABA is to specifically target behaviors and to apply specific behavioral techniques to eliminate severe behaviors (e.g., self-injurious behaviors, violent behaviors), teach new skills and maintain adaptive behaviors in his/her natural settings (e.g., home, school). ABA programs are intensive and tailored programs for the individual receiving treatment which is why the treatment format is one-to-one and face-to-face.

ABA is a behavioral treatment and should not be considered the Early Intervention Program for developmental delays. Early Intervention Programs may have a behavioral component and members may receive behavioral consultations within these programs however, these programs are not considered Applied Behavior Analysis.

Discrete Trial Training

Discrete Trial Training (DTT) is a specific method of teaching based on the principles of ABA. DTT breaks down skills into discrete steps and provides multiple opportunities to practice each skill. Through the use of prompting and reinforcement, children learn individual skills and then the ability to combine these skills into more complex repertoires. Research has proven that DTT is an effective method in teaching various skills to children with autism and related disorders.

Picture Exchange Communication Systems (PECS)

Children with autism and related disorders often have delays in their ability to communicate and develop expressive language. Picture Exchange Communication System (PECS) offers an alternative means of communication through the use of visuals. Parents and children are taught in stages how to initiate requests and develop more complex language. PECS is often used with children that have a limited vocal repertoire and helps children increase interest in initiating communication and develop the means to communicate with others.

Visual Strategies

Research has shown that children with autism have difficulty processing auditory information. In a world that communicates so much information verbally, it is important to utilize the strengths of the children we work with. ATC utilizes visual strategies to promote a child’s understanding and success in addition to reducing frustration when teaching new skills and addressing behavioral excesses.

Pivotal Response Training

Pivotal Response Training (PRT) is a behavioral intervention based on the principles of ABA. By focusing on the two pivotal behaviors such as motivation and responsivity through PRT, we are able to address a larger range of behaviors affecting communication, play, and social skills. PRT is a child directed, naturalistic approach, allowing ATC staff and parents to effectively teach children in a comfortable, less structured format.

Social Skills Training

For children and adults with autism and related disorders, social interaction is often a challenge. ATC utilizes a social skills curriculum that is based on typical development. This curriculum includes social skills such as joint attention (e.g. referencing others to share enjoyment, pointing to show others something of interest), play skills (e.g. turn taking, pretend play), conversation (e.g. initiating and responding) and understanding social rules (e.g. how to be a good sport). The implementation of this curriculum utilizes ABA methods in the clinic, home, school and community settings. Skills are initially taught in a 1:1 Setting and are generalized to peer dyads and eventually social skills groups.

ABA Training-FAQ

My child has PDD/Asperger’s/Hyperlexia, not autism. Does he really need all this ABA stuff??

The different labels used to describe the pervasive developmental disorders (PDDs) have little use other than to confuse parents and muddy their children’s legal rights. There are occasionally reasons why a qualified diagnostician may use one term rather than another, but for the most part the label really doesn’t matter. What counts is effective treatment.

The term “autistic spectrum disorder,” while not ‘official,’ does make the situation clearer. Individuals with PDDs vary widely in their degree of disability. The greatest mistake you can make is to believe (or not challenge the opinion) that because your child “just” has PDD then he or she does not need a high-quality, intensive program to help him or her “catch up” as quickly as possible. It is true that more severely disabled children will typically require more hours than those on the less severe end of the autism spectrum, but that is a judgment to be made by a qualified professional. The range is likely to be from 10 to 40 hours per week.

My son, for example, fits the published criteria for “the syndrome of hyperlexia.” This really means that while he has autism he also has above average ability (and motivation) to work with letters and numbers. But if we had stuck with the available literature on “hyperlexia” we would never have found the intensive ABA approach that has helped him so much.

What is an ABA program?

There are three components that all have to work together: people, programming, and practice. And they have to work together for quite a while – at least 4 years, usually longer.

The people include a behavior analyst ‘therapists,’ you and other significant family members, and usually (although perhaps not at first) your school staff. The behavior analyst (usually just called the ‘consultant’) is responsible for the other components, programming and practice. He will help train the therapists and you in the practice of ABA, and give you (your team) the curriculum (‘programming’) that tells you exactly what and how to teach. He will also periodically evaluate results and adjust the program as your child learns.

The therapists provide the actual instruction (usually one-on-one, but not always). Why the quotes above? The term therapist has a medical or professional implication: it implies training and certification in a specialty. Training and good practice are important in an ABA program too, but there is no specific degree, coursework, or internship required. In theory, anyone can learn to become an effective ABA instructor-college students, retired persons, freelance musicians, even exceptional high school students. A degree or specialized education may be helpful, but what counts most is reliability, enthusiasm, creativity, ability to follow directions, and just plain “being good with kids.”

Parents can be therapists too, if they have the time and the inclination, but this is very much a personal decision. It can be a way to save money, keep the hours up, and it certainly gives you better knowledge of your child’s program and progress.

School staff do not provide one-on-one service (except for specialists, who may or may not be working with the ABA program), but they are still very important-they are part of the environment in which your child will either learn or fail. This is a complex topic, but it’s certainly true that cooperation is critical; if they “don’t believe” in what you’re doing, or think they’re doing something better (but the evidence shows otherwise), then your child may not benefit from that environment.

The programming is, in my mind at least, the most distinguishing feature of an ABA program. Bits and pieces of the practice show up in other “methods” or therapeutic approaches. To my knowledge, there is no other program which puts so much care and thought into planning exactly what your child should be learning, how the material is paced, how it is reviewed, and how it is practiced across multiple settings. It is this tremendous discipline and attention to detail that makes it possible for some children to become truly indistinguishable from their peers in ‘just’ a few years.

Programming centers on discrete trial drills, the exercises that your child does one-on-one with a therapist to learn language, play, and social skills. These drills are completely individualized to your child; while there is a substantial core curriculum that all children must complete, which programs are introduced when, and what items are used for teaching, are carefully tailored to your child’s abilities and interests.

The pace of the drills is important too. It is quite possible to go too quickly, leading to superficial progress but not a solid, useful repertoire of skills. A good consultant will plan how often new items are acquired (taught), how often know (mastered) items are reviewed (maintained), and when it might be time even to hold off on new items and just spend a couple of weeks practicing mastered items.

Skills must be mastered across multiple settings (home, school) and with multiple people (therapists, parents, peers). This ‘generalization’ is done systematically with the goal of giving your child skills that he can use independently in any setting.

Finally, it is practice. How skills are taught, at first seems the most unusual feature of ABA. This is because the discrete trial format looks so very different from ‘natural’ teaching methods. But DT teaching is really only one result of applying ABA-the functional analysis of behavior-to the problem of helping your learning disabled child to progress to his maximum potential. A lot happens in those one-on-one sessions, but there are things that you and others can do at other times and in other settings to help your child learn. Again, a consultant will help you learn how to reinforce appropriate behaviors, to help your child, as he learns new skills, to discriminate desirable behaviors from undesirable “autistic” traits.

What kind of progress can I expect??

The amount of progress your child will make depends on two things: his innate ability to learn, and the quality of his instructional program. How much a child can learn given the best possible program is something no one can really predict, although there are indications from research that a higher developmental age (Lovaas 1987) and a younger chronological age (Fenske 1985) at intake are predictors of greater eventual progress. More recent experience suggests that the child’s progress in the first few months-a measure of his ability to learn-is related to long-term success, rather than his initial degree of disability. Above all, understand that this is a very poorly understood subject: there really are no reliable markers in a young child that predict what he/she will be like as an adult. (Note too that some children benefit from other interventions, such as diet or drugs that increase their ability to learn.)

Program quality is something you can influence. The number of hours per week is one obvious measure: since your child has a lengthy curriculum to get through, it is to his benefit to do it as quickly as possible. (This is one thing that many school administrators really do not understand; they believe that they can save money by doing fewer hours of programming each week, or fewer weeks each year. Yet the research suggests exactly the opposite: an intensive program is likely to be over sooner, while a lower intensity program may go on for years and years, costing much more in the long run.) Not only do more hours mean more learning, but if your child is not yet able to initiate appropriate activity, every hour spent learning is one fewer hour spent practicing undesirable activities. In the battle for your child’s future, every hour falls on one side of the ledger or the other; you want to tip the balance towards productive, quality time.

Instructional quality is just as important. As one administrator assured us, “Any idiot can do ABA.” This is true, but to do it well and actually help children takes a lot of training, attention to detail, and plain hard work. Children with autism are not often the best customers for good intentions; simply sitting down and trying to teach on instinct may lead to a wide array of unwanted behaviors, but little useful learning. The principle of providing positive reinforcement seems simple, but it’s rarely enough just to give a child a piece of candy every time he gives a right answer; there are many, many details and strategies which a good ABA teacher must master to really move your child through the curriculum as quickly as possible.

Understanding Autism

UNDERSTANDING AUTISM SPECTRUM DISORDER

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that emerges in early childhood. At this time, no physical tests are available to diagnose ASD. Diagnoses may be provided by licensed psychologists or medical doctors and are based on a child’s developmental history and observable behavior. While ASD can be reliably diagnosed as early as 18 to 24 months, most children, unfortunately, are not diagnosed until after 4-years-old.

The Diagnostic and Statistical Manual of Mental Disorders is the most widely accepted reference used for the classification and diagnosis of ASD. The most recent edition (DSM-5; American Psychiatric Association, 2013), redefined the diagnostic criteria for ASD, which was previously regarded as three distinct diagnoses (i.e., autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s disorder). The DSM-5, however, classifies ASD as a single disorder characterized by persistent deficits in social communication and social interaction, in addition to restricted, repetitive patterns of behavior, interests, or activities.

  • Avoids making eye contact
  • Does not respond appropriately to greetings
  • Has trouble initiating and maintaining conversations with others
  • Does not respond appropriately to others’ gestures and facial expressions
  • Has difficulty using gestures and facial expressions appropriately
  • Appears to be unaware of others’ feelings
  • Does not engage in pretend play
  • Prefers playing alone
  • Repeats sounds, words, or phrases out of context
  • Becomes distressed by minor changes in routines
  • Performs repetitive movements, such as hand flapping or rocking
  • Plays with toys in unusual ways, for instance spinning them or lining them up
  • Has unusually strong attachments to particular objects
  • Limits conversations to very specific topics
  • Exhibits over-sensitivity to sounds or textures
  • Appears to be indifferent to pain
  • Has delays or plateaus in skill development
  • Has lost previously acquired skills
  • Displays challenging behaviors, such as aggression, tantrums, and self-injury

 

The Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) is a free, validated screening tool that assesses a child’s risk for ASD. If you have concerns about your child’s development, express your concerns immediately to your child’s pediatrician and request a referral to a specialist who can perform more thorough assessments.

 

PREVALENCE

The Centers for Disease Control and Prevention (CDC)estimates that 1 in 68 children are diagnosed with ASD in the United States. That is about 30% higher than the previously estimated rate of 1 in 88 reported in 2012. The factors contributing to increases in reported rates of ASD are not fully understood. While increased rates may be partially explained by improved screening and diagnostic practices, researchers are also exploring the roles of various environmental and genetic risk factors. CDC statistics reveal that ASD is present across all races, ethnicities, and socioeconomic groups. In addition, boys are nearly 5 times more likely to develop ASD than girls.

 

RISK FACTORS

There is no single known cause for ASD. Rather, evidence suggests that there are many factors involved in the development of ASD. Researchers are actively exploring the roles of various genetic and environmental risk factors.

Genetics have been found to play a significant role in the development of ASD. Evidence indicates that siblings of children with ASD are at an increased risk of developing ASD themselves.Research conducted on twins has found genetics to play a sizable role in the development of ASD. Additionally, rates of ASD are higher among children with various genetic disorders, including fragile X syndrome and tuberous sclerosis. Numerous gene mutations have been found to increase the risk of developing ASD by varying degrees. Sometimes gene mutations are inherited from a parent who carries the same gene mutation while other times gene mutations occur spontaneously.Advanced parental age, another risk factor for ASD, may increase the chance of genetic mutations that occur spontaneously as genetic material is copied over from parent to offspring.

In addition to genetic factors, a number of environmental factors have been found to increase the risk of developing ASD. Many environmental risk factors consist of prenatal exposures, including maternal contact with high levels of air pollution, maternal viral and bacterial infections, and maternal ingestion of some prescription drugs including selective serotonin reuptake inhibitors, a type of antidepressant. On the other hand,prenatal vitamins ingested during pregnancy and the months preceding pregnancy have been found to reduce the risk of ASD. Birth complications involving oxygen deprivation are also associated with an increased risk of ASD.

 

TREATMENT

Intensive behavioral intervention (IBI) is the only empirically validated treatment for ASD. Based on the principles of applied behavior analysis (ABA), IBI is conducted at a high intensity, typically between 20 and 40 hours per week, for multiple years. Evidence suggests that greater treatment intensity leads to superior outcomes. Evidence also indicates that IBI is more effective if initiated in early development; however, services initiated at any age are beneficial for the acquisition of valuable skills.