American Speech-Language-Hearing Association

CMS Issues Clarification of Medicaid Coverage of Services to Children With Autism

(July 17, 2014)

Centers for Medicare & Medicaid Services officials released federal guidance for states on Medicaid coverage of therapies for autism, and that guidance indicates such treatments are covered for beneficiaries under age 21. While the guidance focuses on the provision of applied behavior analysis (ABA) therapy, it also acknowledges other treatments.

The Center for Medicaid and CHIP (Children's Health Insurance Plan) Services, a division of CMS, released an informational bulletin to clarify Medicaid coverage of services to children with autism. The bulletin was issued in response to increased interest in this topic—specifically, the provision of ABA therapy. Although the bulletin was written to address services for children with autism under the Medicaid program, it also serves to clarify services that speech-language pathologists and audiologists may provide to individuals diagnosed with other conditions.

Melissa Harris, director, Division of Benefits and Coverage, Disabled and Elderly Health Program Group at CMS, addressed the meeting of the Interagency Autism Coordinating Committee (IACC) regarding this bulletin and emphasized that Medicaid covers ABA and similar services for children with autism. Ms. Harris noted that Medicaid and programs such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requirements do not name a specific treatment, but instead address the service needs of the individual. As noted in the bulletin, "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." For children, states must cover services consistent with the EPSDT provision. Ms. Harris also discussed the application of habilitative and rehabilitative services as defined in the Affordable Care Act (ACA) as extended to the Medicaid population and reminded the group of the definitions of those services as developed by the National Association of Insurance Commissioners (NAIC).

The bulletin outlines four major categories of treatment that are beneficial for children with autism spectrum disorder (ASD)-specifically, services available to individuals with ASD through the federal Medicaid program. The categories are (1) behavioral and communication approaches, (2) dietary approaches, (3) medications, and (4) complementary and alternative medicine. ABA therapy is recognized as one treatment for the child with autism, but the bulletin also identifies other treatments that are available to the ASD population and to others in need of those services.

Medicaid funding for services to children with ASD and other conditions may be reimbursed through a variety of authorities, such as specific sections of the Social Security Act, including Section 1915(c) Home and Community-Based Services and Section 1115 Waiver and State Plan Authorities. States are required to submit a state plan amendment (SPA) to address how all services are addressed, with inclusion of therapy services covered under the Medicaid therapies benefit at 42 Code of Federal Regulations (CFR) 440.110 as relating to qualified provider, referral, scope of services, and supervision/direction of services.

Background

About 1 in 68 children has been identified with autism spectrum disorder (ASD), according to estimates from Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring (ADDM) Network. The number of individuals with ASD has increased in the past several years, along with interest in associated treatments and resources to cover payment for those services.

Resources

For more information, please contact Laurie Alban Havens, ASHA's director of private health plan and Medicaid advocacy, at lalbanhavens@asha.org


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