Wednesday, July 9, 2014

CMS Clarification about #Medicaid Covered Services for #ASD

Family Voices shares the following bulletin from the Center for Medicaid. It is important to note that ALL children with Medicaid are covered by EPSDT benefits, not just those with ASD. If you have questions, feel free to contact us.

DATE: July 7, 2014 
FROM: Cindy Mann, Director 
 Center for Medicaid and CHIP Services 
SUBJECT: Clarification of Medicaid Coverage of Services to Children with Autism 
In response to increased interest and activity with respect to services available to children with 
autism spectrum disorder (ASD), CMS is providing information on approaches available under 
the federal Medicaid program for providing services to eligible individuals with ASD.

EPSDT Benefit Requirements 
Section 1905(r) of the Act defines the EPSDT benefit to include a comprehensive array of 
preventive, diagnostic, and treatment services for low-income infants, children and adolescents 
under age 21. States are required to arrange for and cover for individuals eligible for the EPSDT 
benefit any Medicaid coverable service listed in section 1905(a) of the Act that is determined to 
be medically necessary to correct or ameliorate any physical or behavioral conditions. The 
EPSDT benefit is more robust than the Medicaid benefit package required for adults and is 
designed to assure that children receive early detection and preventive care, in addition to 
medically necessary treatment services, so that health problems are averted or diagnosed and 
treated as early as possible. All children, including children with ASD, must receive EPSDT 
screenings designed to identify health and developmental issues, including ASD, as early as 
possible. Good clinical practice requires ruling out any additional medical issues and not 
assuming that a behavioral manifestation is always attributable to the ASD. EPSDT also 
requires medically necessary diagnostic and treatment services. When a screening examination 
indicates the need for further evaluation of a child’s health, the child should be appropriately 
referred for diagnosis and treatment without delay. Ultimately, the goal of EPSDT is to assure 
that children get the health care they need, when they need it – the right care to the right child at 
the right time in the right setting. 
The role of states is to make sure all covered services are available as well as to assure that 
families of enrolled children, including children with ASD, are aware of and have access to a 
broad range of services to meet the individual child’s needs; that is, all services that can be 
covered under section 1905(a), including licensed practitioners’ services; speech, occupational,
and physical therapies; physician services; private duty nursing; personal care services; home 
health, medical equipment and supplies; rehabilitative services; and vision, hearing, and dental 
If a service, supply or equipment that has been determined to be medically necessary for a child 
is not listed as covered (for adults) in a state’s Medicaid State Plan, the state will nonetheless 
need to arrange for and cover it for the child as long as the service or supply is included within 
the categories of mandatory and optional services listed in section 1905(a) of the Social Security 
Act. This longstanding coverage design is intended to ensure a comprehensive, high-quality 
health care benefit for eligible individuals under age 21, including for those with ASD, based on 
individual determinations of medical necessity.

Read the entire bulletin here:

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