WASHINGTON, DC (July 8, 2014) -- In a major victory for Medicaid coverage of autism, The Department of Health & Human Services, Centers for Medicare & Medicaid Services (CMS) 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).

According to the Center for Disease Control (CDC), about one in 68 children is diagnosed with Autism Spectrum Disorder. An estimated one-third of all children with autism receive primary coverage through Medicaid.

In Pennsylvania, thousands of children with significant disabilities such as Autism Spectrum Disorder are eligible for the states Medical Assistance program. This program is a cost-sharing arrangement under which the federal government reimburses more than half of the expenditures incurred by states that elect to furnish MA to eligible individuals. States are not required to participate in the Medical Assistance program but, if they choose to do so, they must comply with the Social Security Act (Title XIX) and it’s implementing regulations. Pennsylvania has chosen to participate in the program.


The announcement by 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.

"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.


"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.


The Keys for Pennsylvania:

-          CMS recognizes that Medicaid can be used to fund autism treatment services, which specifically includes ABA.

-          Since BCBAs in Pennsylvania can be licensed under Act 62, their services can clearly be covered under Medicaid (without working for an agency with a mental health license!)

-          This guidance does make it clear that there are several provisions available in federal law under which a state can, and under EPSDT, must cover autism treatment services, including ABA under Medicaid.

Support Source: http://www.autismspeaks.org/advocacy/advocacy-news/major-medicaid-breakthrough-announced-autism