Historic progress in children’s Medicaid coverage of autism services

This month, Texas became the 50^th state to implement its autism services benefit which provides coverage for applied behavior analysis (ABA) therapy when medically appropriate for autistic children enrolled in Medicaid. Texas follows New York’s 2021 implementation and Illinois’s 2020 implementation, making it one of the last three states to make available this often life-changing therapy, which is widely covered within commercial insurance.

ABA is a therapy based on the science of learning and behavior and is provided by a board-certified behavior analyst (BCBA) or state-licensed behavior analyst (LBA) and members of their team. It applies our understanding of how behavior works to real situations, to increase behaviors that are helpful and decrease behaviors that are harmful or negatively affect learning. ABA programs can help increase language and communication skills; improve attention, focus, social skills, memory and academics; and decrease problem behaviors. It is a flexible therapy that can be adapted to meet the needs of each unique person. 

This behavioral health therapy is provided under the federal EPSDT (Early and Periodic Screening, Diagnostic and Treatment) requirement, which mandates a variety of medically necessary services for children under the age of 21. These services include baby and child well check visits at specific ages and stages of development, physical and mental health screenings and evaluations, as well as other preventative services and treatments. The Center for Medicaid and CHIP Services (CMCS) describes the goal of EPSDT: “to assure that children get the right health care they need, when they need it – the right care to the right child at the right time in the right setting.” While there has been progress toward this goal—as evidenced by the rollout of the new ABA benefit—there is still considerable work needed to ensure that children with autism get the “health care they need, when they need it.” Specific to children accessing ABA, many states have an inadequate network of providers due to low reimbursement rates, structural/credentialing issues or other factors.

Autism Speaks staff and volunteers continue to lead in states across the U.S. to see these benefits into implementation and to advocate for steps that improve the adequacy of provider networks. We do this, together with local partners, by working with state Medicaid agency staff and state legislators, sharing best practices and technical assistance as well as voicing the experiences of the autism community. Improved and available autism services within Medicaid is crucial to our organization’s diversity, equity, access and inclusion objectives and vision for a world where all people with autism can reach their full potential.