Frequently Asked Questions
(Providers-FAQ)

 

SCREENING


SERVICES
 

MEDICAID AND MICHILD AUTISM BENEFIT
 

PAYMENT FOR SERVICE
 

RIGHTS AND ADVOCACY
 

CRISIS SERVICES
  

 

What should a family do if they suspect their child may have Autism Spectrum Disorder (ASD)?

The family should discuss the concerns with their health care provider and ask for diagnostic services to determine if their child has Autism Spectrum Disorder. The American Academy of Pediatrics endorses early identification of developmental disorders as being essential to the well-being of children and their families. Early identification through well-child visits should lead to further evaluation, diagnosis, and treatment.
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Does a child need a medical diagnosis or is a school diagnosis accepted for the Medicaid/MIChild Autism Benefit?

The child will need to have a medical diagnosis of Autism Spectrum Disorder to qualify for the Autism Benefit. It is helpful when families bring all medical assessments and school reports to appointments. 
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Does the screening have to be completed by a medical doctor?

Screening for Autism Spectrum Disorder typically occurs during a well-child visit with the pediatrician or family physician. The screening tool may be completed by the parent and reviewed/verified by the practitioner. The Modified Checklist for Autism in Toddlers (M-CHAT) is one example of a validated screening tool.
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How do providers bill for a validated Autism Spectrum Disorder screening tool such as the M-CHAT?

Providers may bill for administration of an autism screening by using CPT code 96110 with a U5 modifier.
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How can the Autism Benefit Coordinator's contact information be found?

In the Medicaid/MIChild Map, the Autism Benefit Coordinators are can be found by their respective county.
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What diagnostic assessments have to be done to determine Autism Spectrum Disorder (ASD) for the Autism Benefit?

Both an Autism Diagnostic Observation Schedule Second Edition (ADOS-2) and a developmental family history interview, such as the Autism Diagnostic Interview Revised (ADI-R), need to be completed to determine eligibility for reach child.
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What is applied behavior analysis (ABA)?

Applied behavior analysis is the science of analyzing and improving socially significant behavior. 
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What is applied behavior analysis (ABA) service?

Applied behavior analysis treatment can be used to address a number of issues relevant to children with Autism Spectrum Disorders, including language acquisition, peer interactions and social skills, responding to group instruction, academic/cognitive skills, following typical classroom routines, self-help and daily living skills, learning in and from the natural environment, and reducing inappropriate behaviors(s). 
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What other services might be available for children eligible for the Medicaid/MIChild Autism Benefit?

The child may qualify for other services such as occupational therapy, speech therapy, physical therapy, family training, and respite.
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Can a family choose what services they want for their child?

Services are determined upon the child's needs. While the family may decide to obtain supplementary services from other networks or outside agencies, they will need to confirm that the supplementary services are addressing specific needs of the child.
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If a child does qualify for the Medicaid/MIChild Autism Benefit and the family does not want to pursue applied behavior analysis (ABA) services, can they still get other needed services such as occupational or speech therapy?

Yes, a child may qualify for services other than applied behavior analysis. Case managers can help navigate this process with families.
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Generally, how long will it take to get services started for a child?

Generally, the process will take 3 to 8 weeks; however, multiple factors are involved in the application, eligibility, and determination process. Typically the PIHP/CMH has 14 days from the time of intake, to planning, and start of services. When additional assessments or evaluations are needed, the time may be extended. If information confirming diagnosis, cognitive abilities, and adaptive function are readily available, the process may be shortened.
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What are the responsibilities of the Board Certified Behavior Analyst (BCBA)?

  • A Board Certified Behavior Analyst will work with the family and team to develop and implement the applied behavior analysis treatment program. They will focus on goals to increase skills specific to a child's need and/or reduce disruptive or challenging behaviors that may be interfering with learning opportunities of everyday function. The Board Certified Behavior Analyst can also supervise and train staff and family on specific gaols the child is working on.
  • Priorities with applied behavior analysis may be increasing communication, play skills, toileting skills, imitation skills, and other self-care skills to help the child reach their fullest potential.

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Who is eligible to receive the Autism Benefit through Medicaid or MIChild?

Children with Medicaid or MIChild, 18 months through 5 years with an Autism Spectrum Disorder medical diagnosis.
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What is the referral date?

The date the child was referred for family inquired about mental health services (i.e. the date a pediatrician referred a child to the PIHP/CMH for an additional ASD diagnostic evaluation after screening at a well-child visit OR a family calls/walks into the PIHP/CMH to inquire about services for their child that may have a delay in development or possible ASD.) For existing children receiving services, this date would be when they were referred or inquired about Autism ABA Benefit.
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What is the evaluation date?

The date the initial evaluation, ADOS-2, or re-evaluation, Vineland, was administered. This date must be on or before the current date. If more than one day was needed to complete the evaluation, enter the first date. (i.e. if the evaluation was done on 3/2/14 and 3/3/14, you would enter 3/2/14 into the system.
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What services are offered under the Autism Benefit?

Applied behavior analysis
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What qualifications are needed to supervise the delivery of applied behavior analysis? (ABA)?

Supervision of the applied behavior analysis service is provided by a Board Certified Behavior Analyst; however, to increase the service delivery capacity of applied behavior analysis, a provision has been passed to permit Licensed Psychologist, Limited Licensed Psychologist, and Child Mental Health Professionals who are enrolled and scheduled to be a BCBA by September 30, 2016 to supervise applied behavior analysis.

Following September 30, 2016, only Board Certified Behavior Analyst will be allowed to supervise the delivery of applied behavior analysis. 
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For the annual re-evaluation, what scores of the Vineland Adaptive Behavior Scales, 2nd edition, should be entered in the WSA?

The adaptive behavior composite and domain standard scores.
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What is cost settled within the Autism Benefit for Medicaid/MIChild recipients?

Cost settlement is limited to the assessment of a child to diagnose and determine eligibility for the 1915(i) State Plan Amendment, provision of applied behavior analysis services and supervision of those services, and the required intermittent, re-assessment of skills related to the applied behavior analysis service only.

  • The U5 modifier should only be used for the codes that are cost-settled, not to other services like OT, PT, etc., while the child is eligible for the Autism Benefit but will not be cost-settled.
  • A cost settled process is being developed. Once finalized, additional information will be provided.

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When will payments for Medicaid and MIChild ABA services go from a manual to automated process?

The payment process will transition to an automated process in October 2013.

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Starting October 2013, what will need to be reported to receive an automated payment for ABA services under the Medicaid and MIChild Benefit?

There are three requirements:

  • The child is enrolled in the Autism Benefit on the WSA Autism Benefit Waiver
  • The individual plan of service (IPOS) is current and uploaded onto the WSA Autism Benefit Waiver
  • At least one valid H2019 with U5 modifier encounter is reported in the datawarehouse

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Can families use choice vouchers for the Medicaid or MIChild Autism Benefit?

No, families cannot use choice vouchers for the Medicaid or MIChild Autism ABA Benefit.

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If a child has private insurance providing applied behavioral analysis, can the child also utilize the Medicaid Autism Benefit to assist with deductibles and co-pays??

Private insurance is always the payor of first resort and all the private insurance rules must be followed and families must access and use all available private insurance benefits first. Medicaid is always the payor of last resort. If the child has an available benefit through private insurance, as with other services, the family needs to complete the prior authorization process (including any insurance required assessment) for the requested service from both sources (private insurance and Medicaid) and use a provider that is approved by both the insurer and one that is Medicaid enrolled. The provider would bill the insurer and if there is an amount owing then the provider would balance bill Medicaid. If the provider agrees to accept the specific insurance plus Medicaid as payment in full for the service, and the individual is eligible for the specific service through both resources, the family may not have to satisfy the deductible or co-pay for private insurance for those specific services.

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If a child is determined "not qualified" or denied the Autism Benefit, what is the appeal process?

If a family feels the child should be reconsidered for additional diagnostic, the family may file a Medical Fair Hearing request with the PIHP.
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Are advocacy and support groups available to families and persons with developmental disabilities and Autism Spectrum Disorders?

There are numerous advocacy groups and support groups. Since the availability of these groups may vary from one region to another, it is best to check with a case manager and/or CMHSP to receive information about groups that would best meet the needs of the child/family. 
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If a family is in crisis, what should they do?

Urge the family to call 911. Each PIHP/CMH maintains employees who respond to crisis situations. Please refer to the map and contact information listed on the PIHP/CMH's website.
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Updated 10/6/2014