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Medicaid: States Cannot 'Delay Or Deny' Autism Treatment

September 29, 2014

WASHINGTON, DC (September 29, 2014) -- The federal government has issued guidance to states emphasizing that they can neither delay nor deny medically necessary autism treatments, such as ABA, through their Medicaid programs for individuals up to age 21.

The message was delivered in FAQs posted September 24 regarding the July 7 Informational Bulletin issued by the federal Centers for Medicare & Medicaid Services (CMS) concerning autism benefits states must provide through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. While no specific deadline is set forth in the FAQs, "CMS believes states should complete this work expeditiously and should not delay or deny provision of medically necessary services."

In addition to questions on timing, there was confusion among some states because the July Bulletin did not explicitly state that ABA, the most well-accepted and efficacious therapy for individuals with autism, was a required treatment.  In the FAQ’s, "CMS made clear that while it did not single out ABA as a mandated treatment, just as it does not mandate other specific treatments, like chemotherapy for children with cancer, all care that is medically necessary for an individual must be provided," said Dan Unumb, executive director of the Autism Speaks Legal Resource Center.

According to the FAQs, this obligation to provide all medically necessary services that can be covered under Medicaid is part of the states’ “long-standing EPSDT obligations” to children from birth to 21.  Additional information about the states’ EPSDT obligations is available HERE.

In the case of autism, medically necessary care includes ABA, which CMS has already indicated is a coverable service observed Unumb.  "As indicated in professional literature and as held by numerous court cases, there is no question that ABA is medically necessary for many children with autism and therefore it must be made available based on individual determinations of medical necessity," he said.

Some states have also raised concerns over the cost of providing Medicaid coverage of ABA.  “This is not a new issue,” said Unumb.  “In almost all of the three dozen states that have mandated coverage for private insurance, nearly every state initially over-estimated the cost of providing ABA, sometimes by more than 1,000 percent.” 

Unumb also said it is important to keep in mind the cost-savings of providing ABA.  "Studies have shown that providing treatment to children ultimately saves the states taxpayer money by reducing the need for special education and other services and lowering long-term care costs when children reach adulthood."

The FAQs further spell out that while Medicaid State Plan Amendments are not a prerequisite to implement additional mandatory EPSDT coverage, they are strongly encouraged as a means to include the menu of services for ASD treatment as part of the State Plan’s comprehensive written statement of services. The FAQs also discuss the relationship between EPSDT services and waiver services and the transition of medically necessary services from limited waiver coverage to broad state plan coverage for EPSDT-eligible individuals.