§ 10H — Coverage for medically necessary treatments for persons younger than 21 years old diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist

[Text of section added by 2014, 226, Sec. 25. See also, Section 10H added by 2014, 258, Sec. 19.]

Section 10H. Subject to the availability of federal financial participation, the division shall cover medically necessary treatments for persons younger than 21 years old who are receiving medical coverage under this chapter and who are diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist. If federal funds are available to the commonwealth, said coverage shall include, but shall not be limited to, services for applied behavior analysis supervised by a board certified behavior analyst and dedicated and non-dedicated augmentative and alternative communication devices, including, but not limited to medically necessary tablets; provided, however, that the division shall also provide coverage for augmentative and alternative communication devices not eligible for federal funds if the total cost incurred by the division for a device that is not eligible for federal funds is not more than the commonwealth's share of a comparable device that is eligible for federal funds.

[Text of section added by 2014, 258, Sec. 19. See also, Section 10H added by 2014, 226, Sec. 25.]

Section 10H. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:—

''Acute treatment services'', 24–hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility, as defined by the department of public health, that provides evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychoeducational groups and discharge planning.

''Clinical stabilization services'', 24–hour clinically managed post detoxification treatment for adults or adolescents, as defined by the department of public health, usually following acute treatment services for substance abuse, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others and aftercare planning, for individuals beginning to engage in recovery from addiction.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary acute treatment services and shall not require a preauthorization prior to obtaining treatment.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary clinical stabilization services for up to 14 days and shall not require preauthorization prior to obtaining clinical stabilization services; provided that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7; and provided further, that the division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover, without preauthorization, substance use disorder evaluations ordered pursuant to section 511/2 of chapter 111.

Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient's medical record.