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Amazon autism spectrum disorder benefits

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Autism spectrum disorder benefits information The autism spectrum disorder (ASD) benefit is for members of the Aetna medical plans.

Please review this guide to understand this benefit and how to use it. You can take this information to appointments so your health care professionals are aware of your coverage.

Tips to get the most from this benefit 1. If you have any questions about your ASD benefits,

claims or processes, call your 24/7 Aetna Concierge at 1-866-574-9124, or log in at aetna.com and click “Contact Us” to send an email.

2. Review this guide for applied behavior analysis (ABA) therapy access. It will help you navigate ABA therapy, from finding health care professionals to filing claims.

3. Complete the Precertification/Preauthorization Nonparticipating Provider Request form if your ASD provider is not in the network. You can find the form at the end of this guide.

Eligibility All enrolled members with an ASD diagnosis are eligible for ASD benefits. Dependents are eligible for coverage until age 26. Coverage may continue beyond age 26 for a dependent child who can’t support himself or herself because of a developmental or physical disability when certain criteria are met. This eligibility is reviewed on a case-by-case basis.

ASD benefit description The ASD benefit covers these services:

• Occupational, speech and physical therapies

• Behavioral health treatment

• Applied behavior analysis (ABA)

Coverage for services is included for eligible members whose primary diagnosis is one of the following:

• Autistic Disorder (ICD-10 code F84.0)

• Other Childhood Disintegrative Disorder (ICD-10 code F84.3)

• Asperger’s Disorder (ICD-10 code F84.5)

• Rett’s Disorder (ICD-10 code F84.2)

• Other Pervasive Developmental Disorder (ICD-10 code F84.8)

• Pervasive Development Disorder Not Otherwise Specified (ICD-10 code F84.9)

Occupational, speech and physical therapies* • Occupational therapy (OT) is a medically prescribed

treatment concerned with improving or restoring functions that have been impaired by illness, injury or disability through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.

• Speech therapy (ST) is the treatment of communication impairment and swallowing disorders.

• Physical therapy (PT) is a medically prescribed treatment concerned with improving or restoring physical function following disease, injury or loss of body part.

*These therapies will be covered under this benefit when billed with a diagnosis of an autism spectrum disorder, and are not subject to visit limits. Any services rendered by professionals for the treatment of illness or injury not related to autism will apply to the standard rehabilitation benefit.

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Behavioral health treatment Mental health and chemical dependency treatment, including psychotherapy and other psychiatric/ psychological treatment services, will also be covered under this benefit when billed with a diagnosis of an autism spectrum disorder (subject to plan provisions and limitations). These services do not have visit limitations.

Applied behavior analysis (ABA) ABA is a treatment for autism that’s made up of techniques designed to help you or your child change behaviors in a positive way. It helps increase quality of life by working on behaviors that are useful and productive. At the same time, it helps reduce harmful ones.

This benefit provides coverage for behavioral interventions through ABA and is available to eligible members covered by an Aetna medical plan.

The benefit covers:

• Initial assessment

• Program development

• Treatment planning

• Supervision of the providers of direct service

Covered health care professionals The following health care professionals are eligible for coverage for ABA services:

Licensed health care professionals — Medical doctors (MDs); doctors of osteopathic medicine (DOs); nurse practitioners (NPs, ANPs, ARNPs, etc.); master’s-level mental health clinicians; occupational, physical and speech therapists when providing ABA services and practicing within their scope of practice.

Board Certified Behavior Analysts — Board Certified Behavior Analysts (BCBAs) are certified by the Behavior Analyst Certification Board. These professionals have master’s or doctoral degrees. Some are also licensed in a master’s- or doctoral-level mental health field; however, most are not licensed professionals. For ABA, either a licensed provider or a BCBA can function as a program manager. The program manager conducts behavioral assessments, including functional analyses, and provides behavior analytic interpretations of the results. The program manager designs and periodically reviews behavior analytic interventions (program development and treatment planning). For ABA programs that use unlicensed therapy assistants, the program manager also supervises the therapy assistants.

Therapy assistants — These are professionals who are not licensed or certified. They are trained by a licensed professional or a BCBA and then deliver direct treatment to individuals and their families. Although some ABA programs use licensed professionals or BCBAs for direct treatment services, many ABA programs use therapy assistants. Therapy assistants receive direction and supervision from a licensed professional or a BCBA (program manager). The program manager is responsible for signing off on the time billed for therapy assistant services.

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Limitations and exclusions There are no visit limits for ABA therapy; occupational, speech and physical therapies; or behavioral health therapies that are rendered for treatment of ASD. Occupational, speech and physical therapies billed with a diagnosis other than ASD will apply to the outpatient rehabilitation benefit on your plan and are subject to the 60-visit-per-plan-year limit.

This benefit does not cover:

• Accompanying children or family members to health care appointments that are not part of the direct provision of ABA services

• Services provided in a home school, or public/private school environment that are part of a child’s schooling as distinct from specific ABA treatment services (e.g., acting as the “teacher’s aide” or helping a child with homework)

• Time spent doing housework or chores

• Travel time

• Transporting parents or family members

• Babysitting

• Respite for parents/family members

• Training of therapy assistants and family members (as distinct from supervision)

• Services for a child who has not been diagnosed as having one of the autism spectrum disorders

• Parent training or classes, except for one-on-one or one-on-two direct training of the parents of one identified patient

• Equestrian therapy

Coverage for other neurodevelopmental disorders Your plan covers other neurodevelopmental disorders; however, there may be different cost shares or coverage limitations based on your medical plan selection. The neurodevelopmental benefit is generally combined with the outpatient rehabilitation visit maximum of 60 visits per plan year, except when used to treat a mental health condition. This visit maximum includes cognitive, physical, occupational and speech therapy. Neurodevelopmental services for members under age 7 are not subject to this limit.

You will share in the costs Here’s what you pay for ASD services:

• In-network: 10 percent, after deductible

• Out-of-network: 30 percent of allowable charges, after deductible

Out-of-network health care professionals usually cost more That’s because health care professionals who do not participate in the Aetna network set their own rates to charge you. It may be higher — sometimes much higher — than what your Aetna plan recognizes or allows. Your health care professional may bill you for the dollar amount the plan doesn’t recognize. You’ll also pay a higher coinsurance percentage and a higher deductible than for professionals in the network. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket limits. This means you are fully responsible for paying everything above the amount the plan allows for a service or procedure.

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Programs and resources The following programs are available to you and your covered family members at no extra cost.

Autism advocate program If you need help navigating the process, call 1-866-724-0604, extension 5, to connect with an Aetna autism advocate. This is someone trained in autism spectrum disorders.

Your advocate can:

• Help you understand your benefits

• Link you to community resources for support

• Help you find network providers

• Help you coordinate care with your providers

• Review requests for ABA from your providers

Rethink Benefits Rethink Benefits* is a program that helps families with children who have autism and/or other developmental disabilities build the skills they need to reach their fullest potential. Families can access a variety of resources and support at no cost, including:

• Three hours of live clinical support

• An innovative online library of over 1,500 video-based lessons based on proven ABA teaching techniques

• Research-based assessments, which help guide parents and service providers in building unique treatment plans individualized for the particular needs of their child

• Rethink’s Training Center, which helps train parents and service providers in ABA teaching techniques and strategies for implementing lessons

• Data collection tools to help monitor your child’s progress and guide instruction

These comprehensive resources have been developed by a team of experienced, caring clinicians and are continually updated to offer you the latest treatment techniques and research. To access Rethink Benefits, register online at amazon.rethinkbenefits.com or call 1-877-988-8871.

*Rethink, an independent provider of autism curriculum and support, does not provide Aetna products or services. Rethink is solely responsible for its products and services.

Employee Assistance Program (EAP) The EAP provides free, confidential support, resources and referrals for every aspect of your work and personal life. It is available 24/7 for you and family members living with you.

Call the EAP for resources and referrals for counseling services related to marital issues, depression, anxiety or stress. Additionally, the EAP can help with moving and other personal needs, answer your legal and financial questions, find child or elder care, and more. Up to three counseling sessions are available for each issue.

Call 1-855-435-4333 or visit guidanceresources.com. Use Company ID “AmazonEAP” when registering online for the first time.

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Medical Advice/24-Hour Nurse Line Get answers right away with the Medical Advice/24-Hour Nurse Line at 1-888-434-9473. This confidential service is available to you and your covered family members.

Talk to a registered nurse who can help you understand a specific condition or decide what to do for a symptom. Your nurse may suggest you go to your primary care doctor, a local urgent care center or the emergency room. You can also get tips for home treatment to use until your doctor appointment.

If appropriate, the nurse can connect you for a phone consult with a doctor, who can diagnose and send a prescription for treatment to your pharmacy of choice. Office visit fees will apply for the phone consult.

How to find health care professionals Use our online search tool

1. Log in at aetna.com. If this is your first visit, complete the one-time registration process to get your user name and password.

2. Click “Find Care” from your secure member website home page.

3. Follow the prompts to complete your search.

Call us for help Call your 24/7 Aetna concierge at 1-866-574-9124.

More resources are available at bacb.com You can find more resources on the Behavior Analyst Certification Board (BACB) website.

How to file a claim for payment In-network: Your network doctor or specialist will submit any claims for you. Just pay the applicable copayment at the time of service. After we process the claim, we will send you an explanation of benefits (EOB) statement. Your doctor may also send you confirmation of our payment along with any outstanding amount due from you, such as your deductible.

Out-of-network: Out-of-network doctors are not obligated to submit a claim for you, so you may have to do so yourself. After we process the claim, we will send you an explanation of benefits (EOB) statement. Your doctor may also send you confirmation of our payment along with any outstanding amount due from you, such as your deductible, your percent share of the costs, and the difference between the plan’s allowed or recognized amount and the provider’s actual charge.

If you need to submit the claim yourself, you can download a claim form from your secure member website:

1. Log in at aetna.com.

2. Click on “Forms” at the top of the page to access the claim form.

3. Download, print and complete the form. Or call your Aetna Concierge at 1-866-574-9124. The representative can mail you a claim form.

We accept claim forms by mail, fax and email: • Mail: If there is no mailing address on the form itself,

you can send it to us at the address shown on your Aetna ID card.

• Fax: Use the fax number shown on the form.

• Email:

- Scan the completed claim form and save to your computer.

- Log in to your secure member website at aetna.com.

- Click “Contact Us” in the upper right corner to begin an email.

- Attach the claim form to the email.

Call your Aetna Concierge at 1-866-574-9124 if you need help submitting your claim.

Benefits offered through the Amazon.com Services, Inc. Group Health & Welfare Plan are subject to review by Amazon and may be modified or terminated at any time for any reason. Benefits are administered by Aetna Life Insurance Company (Aetna). Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to aetna.com.

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