Behavioral health treatment for Medi-Cal members under the age of 21

Blue Shield of California Promise Health Plan covers Behavioral Health Treatment (BHT), including Applied Behavior Analysis (ABA) therapy, for Medi-Cal beneficiaries under the age of 21. Blue Shield Promise manages this benefit directly.

Referrals for BHT or ABA treatment for a member should not be sent to the member's medical group or IPA. A primary care physician (PCP) or healthcare provider will follow the screening process below.

If a provider believes the member may have autism spectrum disorder (ASD), based on screening outcomes, the provider should submit a diagnostic evaluation referral for ASD to Blue Shield Promise. If a provider believes a member is likely to benefit from BHT or ABA services, the provider can submit a referral for treatment to Blue Shield Promise.

A diagnosis of autism spectrum disorder is not required for the member to be eligible for BHT or ABA treatment. Please refer to All Plan Letter (APL) 19-014 from Department of Health Care Services (DHCS) for more information.

Steps for referral and evaluation:

Step 1 - Screening

The PCP or healthcare provider completes Early Periodic Screening, Diagnosis, and Treatment (EPSDT), which should include a validated screening tool. The provider then makes a referral to Blue Shield Promise, as appropriate.

Step 2 - Diagnostic evaluation for autism spectrum disorder OR referral for BHT or ABA treatment

• If your screening leads you to believe that the member may have autism spectrum disorder, the Behavioral Health Treatment team at Blue Shield Promise will provide authorization for a diagnostic evaluation with a licensed clinical psychologist.
• If your screening leads you to believe the member is likely to benefit from behavioral health treatment such as ABA, please submit a referral form to the Behavioral Health Treatment team at Blue Shield Promise.

The questions and answers below will help guide you through helping the member to use this benefit.