Guidelines for availing treatment under CGHS and CS(MA) Rules 1944 for Occupational Therapy, Speech Therapy and Applied Behavior Analysis (ABA)

Guidelines for availing treatment under CGHS and CS(MA) Rules 1944 for Occupational Therapy, Speech Therapy and Applied Behavior Analysis (ABA) based behavioral therapy in individuals with Autism Spectrum Disorder (ASD)/ Non-autistic person/children with ADHD and specific learning disabilities

File No: S.11030/86/2022-EHS
Government of India
Ministry of Health & Family Welfare
EHS Section

Nirman Bhawan, New Delhi
Dated 01.05.2023

OFFICE MEMORANDUM

Subject: Guidelines for availing treatment under CGHS and CS(MA) Rules, 1944, for Occupational Therapy, Speech Therapy and Applied Behavior Analysis (ABA) based behavioral therapy in individuals with Autism Spectrum Disorder (ASD)/ Non-autistic person/children with ADHD and specific learning disabilities – regarding

The undersigned is directed to enclose herewith the Guidelines for availing treatment under CGHS and CS(MA) Rules, 1944, for Occupational Therapy, Speech Therapy and Applied Behavior Analysis (ABA) based behavioral therapy in individuals with Autism Spectrum Disorder (ASD)/ Non­ autistic person/children with ADHD and specific learning disabilities. These guidelines shall come into force from the date of issue of this O.M. and shall be valid till further revision.

2. These guidelines issues with the concurrence of Integrated Finance Division of Ministry of Health & Family Welfare.

Signed by Hemlata Singh
Date: 01-05-2023 13:52:19

(Hemlata Singh)
Under Secretary to the Government of India
Tel. No. 011-23061778

Encl. As above.

Guidelines for availing treatment under CGHS for Occupational Therapy, Speech Therapy and Applied Behavior Analysis (ABA) based behavioral therapy in individuals with Autism Spectrum Disorder (ASD)/ Non-autistic person/children with ADHD and specific learning disabilities:

I. Aim of Occupational Therapy// Speech therapy / Applied behavior analysis based behavioral therapy (ABA) / Special education in individuals with Autism Spectrum Disorder

The therapies aims towards minimizing the sensory issues; motor & praxis related problems, challenging behaviors, decreased social communication, and difficulties in the activities of daily living (ADL) experienced in home, school and community. This in turn improves the levels of independence in ADL, acquisition of significant life skills, promotes community integration and mainstreaming of individuals with Autism Spectrum Disorders.

II. Who can diagnose ASD for purpose of reimbursement?

Reimbursement for therapies after diagnosis of Autism Spectrum Disorder will be done if prescribed by Pediatrician/ Developmental Pediatrician/ Pediatric Neurologist/ Psychiatrist/ Child and Adolescent Psychiatrist in public or CGHS Empanelled Hospitals.

III. Ceiling rates for the therapy session

The ceiling rates for Occupational Therapy, ABA based therapy, Speech therapy and special education for individuals with autism spectrum disorder under CGHS shall be Rs 400/- per session irrespective of the type of session.

IV. Eligible Centers

Any centre (Empanelled or Non Empanelled) providing therapy services administered by qualified personnel having minimum qualifications (Table-I) as summarized as under :

1. Beneficiaries shall be eligible to receive the proposed therapy if :

1. They have been evaluated and diagnosed to have Autism Spectrum Disorder as per the standard protocoloutlined by the committee.
2. The said therapy has been recommended as a necessary component in the management of the affected individual with Autism Spectrum Disorder.

2. The therapies can be taken at empanelled or non-empanelled centers but reimbursement would be done as per the ceiling rate or as per actual whichever is less subject to the condition that

1. Provision of therapy session notes as per the format (Basic minimum standard guidelines for recording and therapy report) published in the gazette by the central mental health authority as per provisions of the Mental Healthcare Act, 2017. (Annexure-I)
2. The Therapists are recognized by the competent authorities in their respective fields as documented in Table 1 (Para-4 above).

3. The beneficiary has undergone a detailed assessment by the therapist including sensory profile/sensory checklist, level of communication, social interaction, stereotypic and repetitive behavior, impact on the school environment / home, impact on motor/ sensory function, activities of daily living, behavioral issues that need to be addressed, parental perception of problems, family coping, strategies, expected family support/involvement, motivation and expected compliance for the therapy.

4. As autism requires multidisciplinary management, it was proposed that reimbursement should include at least two or more types of therapy including any of ABA based behavioral therapy occupational therapy, speech and language therapy, special education, unless only one type of therapy is available within the reach of the beneficiary.

5. Individualized therapy plan – The therapist has to provide a written individualized therapy Plan (ITP) customized for therapy that specifies the following:

1. Short term goals: those that are expected to be achieved in three months.
2. Long term goals: those that are expected to be achieved within a year.
3. Home based plan
4. The schedule and frequency of sessions required to achieve the short term and long term goals. This will depend upon the severity of the behavioral issues, the phase of therapy, and the compliance of the caregivers to therapy.
5. Therapy record for each session: a specific written plan that details home assignments given to parents/ caregivers – the details of activities, how to administer them, the frequency, the duration, etc.
6. A structured operational system to monitor compliance of caregivers with the home assignments.
7. A structured operational system of regular evaluation of the impact of the therapy on the functioning of the affected individual.

VI. Frequency of therapy sessions-

• Duration of each session should be attest 40 minutes
• It should be based upon the severity of Autism as diagnosed by the referring clinician and as recommended underneath :

VII. Follow-up to be done every 6 months:

• By referring clinician with the treatment plan and severity rating (Any of CARS2/CARS/ ISAA and preferably ATEC)
• Number of sessions per week to be decided based upon the inputs and recommendations from the treating therapist and referring clinicians as per the upper ceiling of recommended sessions in initial phase.
• Parental compliance to therapy to be ensured by a compliance sheet of home – based program, template to given by the treating therapist and produced at the time of review.

VIII. Screening, Diagnosis and Follow up of individuals with Autism Spectrum Disorders

a. Screening

• Moderate to High risk for autism may be determined by Modified Checklist for Autism in Toddlers (M- CHAT­ R/F) from 16-30 months of age.

b. Modified Checklist for Autism in Toddlers (M-CHAT-R/F) for SCORES

1. Total Score 0-2: The score is LOW risk. No Follow-Up needed.
2. Total Score 3-7 : The score is MODERATE risk.
3. Total Score: 8-20: The score is HIGH risk.

c) Severity grading of ASD should be by:

Severity scores is assessed by using CARS2/CARS/ ISAA scales

ANNEXURE-I

1. Basic Minimum Standard Guidelines for Recording of Therapy Report (facilities where persons with ASD are provided with therapy).

2. Minimum Basic Standard Guidelines for Recording of Therapy (Name of the Institute/ Hospital/Centre with address)

Clinic record no __________

THERAPIST SESSION NOTES

• • Short term Goals.
  • Long term
  • Progress.

Therapist observations and reflections :

Plan for next session :                                Date for next session:

Therapist                                                       Supervised by (if applicable)