Monday, September 8, 2014

#Medicaid Coverage Of #Autism Treatment Services

Family Voices Policy Update 
POLICY UPDATE: Medicaid Coverage Of Autism Treatment Services 
by Lynda Honberg, Brooke Lehmann and Janis Guerney
The On July 7, 2014, the Center for Medicaid and CHIP Services (CMSC) issued an Informational Bulletin titled "Clarification of Medicaid Coverage of Services to Children with Autism," (  It is estimated that about one-third of children with autism spectrum disorder (ASD) are covered by Medicaid or CHIP and CMSC was responding to increased questions regarding services for these children.

Medically necessary treatment required.  The Bulletin clarifies that state Medicaid programs must provide treatment services to children with ASD.  Although it does not specifically require that any particular treatment type, such as Applied Behavioral Analysis (ABA) be covered, the directive could result in such coverage if the State decides to include it under its State Medicaid plan.

The agency based its clarification on the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) provision of the Medicaid law.  Under the EPSDT provision Medicaid-enrolled children under age 21 are entitled to all services that are medically necessary to correct or ameliorate any physical or behavioral conditions.  The state must provide any such services for which federal cost-sharing is available, whether or not the state normally covers that service in its Medicaid program.

Non-licensed practitioners.  Significantly, the Bulletin also clarifies that Medicaid may pay for the services of practitioners who are not state-licensed, as long as they are under the supervision of licensed providers and certain other conditions are met.  Many individuals who provide ABA therapy are not licensed under state laws.  In most cases, states will have to submit Medicaid State Plan Amendments to provide such coverage.

Impact on those receiving waiver services.  It is important to note that the July Bulletin may result in some children with ASD losing eligibility for services they now receive under a "waiver" program, since state waivers will no longer be available for the ASD services that are now required pursuant to the Bulletin (see page 5).  Those who may be affected are primarily children whose family incomes are too high to qualify for Medicaid without a waiver.  Eligibility can be maintained if some of the services received would not be covered under EPSDT.  Such services might include respite care or other non-medical services. The Bulletin also states that "Individuals age 21 and older may continue to receive services to address ASD through the waiver if a state does not elect to provide these services to adults under its Medicaid state plan."

State advocacy needed.   States will have to figure out how to ensure required coverage of services for children with ASD, providing a good opportunity for family leaders to get involved in the process.  In fact, CMS is encouraging Medicaid Directors to reach out and involve providers, families and advocates as the states review their options and consider any changes that will impact children currently receiving autism services through waivers.

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