WASHINGTON, DC (July 8, 2014) -- In a major victory for Medicaid coverage of autism, a federal agency has directed the states to cover medically necessary treatments for autism for children and young adults, including behavioral health treatments such as Applied Behavior Analysis (ABA). An estimated one-third of all children with autism receive primary coverage through Medicaid.
The announcement by the Centers for Medicare & Medicaid Services (CMS) makes clear that autism treatment must be addressed under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services which cover Medicaid-eligible children up to the age of 21.
Dan Unumb, the executive director of the Autism Speaks Legal Resource Center, said the new CMS guidance "is extremely useful in providing a road map for Medicaid coverage of autism treatments, including ABA, and admonishing the states that their obligation to provide all necessary medical care under EPSDT applies with full force to children with ASD.”
Because Medicaid is a joint state/federal program, benefits can vary widely from state to state. EPSDT, however, is mandatory.
"The time for walling off EPSDT from autism is over," said Melissa Harris, a CMS official who briefed the Interagency Autism Coordinating Committee on the changes today.
"All children, including children with ASD, must receive EPSDT screenings designed to identify health and developmental issues, including ASD, as early as possible," the CMS guidance directs. "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," according to CMS.
Among the autism treatments referenced were speech, occupational and physical therapies.
“Public health insurance programs like Medicaid are critical to the healthcare of children with autism," said Stuart Spielman, Autism Speaks' senior policy advisor and counsel. "The bulletin provides assurance that these programs will provide the kinds of medically necessary services families are seeking.”
According to Unumb, the guidance also makes clear that services can be delivered by licensed practitioners as well as appropriately credentialed non-licensed practitioners. This is important for states that do not license providers such as behavior analysts, but instead rely on national certification for credentialing.