Medicaid benefits for Autism Spectrum disorder (ASD) diagnosed individuals vary on a state-by-state basis. In some states service is predicated on a severity basis, some have a waiver program with a cap limit, while others offer no coverage at all. California is now becoming the first state to provide full Medicaid coverage for ASD diagnosed individuals.
At the heart of the matter is treatment known as Applied Behavioral Analysis (ABA), the most effective, non-experimental treatment for ASD available. ABA uses positive reinforcement as well as other techniques to stimulate behavioral change. But a Medicaid issued directive goes beyond the ABA treatment ASD diagnosed children so desperately require. Coverage has been divided into four categories that include behavioral management, dietary, medications and alternative medicines.
The Centers for Medicare and Medicaid Services has identified specific benefit categories that apply to its directive. Eligible services fall under the 905(a) category and includes: 1905(a)(6) services of other licensed practitioners, 1905(a)(13)(c) preventative services and 1905(a)(10) therapy services. In order to select these services and ensure federal financial participation eligibility, states may need to update their State Medicaid plan. States must provide eligible services under 1905(a)(4)(B) for Early and Periodic Screening, Diagnostic and Treatment services.
Other Licensed Practitioner Services – These services include medical and remedial care provided by licensed professionals other than physicians. Services by a non-licensed practitioner, under the supervision of a licensed practitioner, may also be covered. Examples would include physical and occupational therapists.
Preventive Services – Medicaid identifies these benefits, prescribed by a licensed professional, to include the prevention of disease and disability and to “promote physical and mental health efficiency.” Autism, or any ASD disorder, could fall under this category.
Therapy Services – These services include speech, hearing and language therapies provided by a licensed speech pathologist. Also covered are physical and occupational therapies.
The Medicaid directive falls under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provision. EPSDT provides a wide variety of treatment for low-income children under 21 that include preventive and diagnostic services. EPSDT is designed to provide early treatment and diagnostic examinations so that health management can be applied as early as possible. This includes all children, including those diagnosed with ASD. It was federal court decisions in Ohio and Florida that ruled that ABA services were to be provided under the Medicaid EPSDT provision. California, the first state to implement this directive, will open the doors to as many as 75,000 children diagnosed with ASD. This directive includes the all-important ABA analysis for autistic children to the age of 21. It is a landmark for families who have been dealing with medical issues for years with their ASD diagnosed children.
It has been estimated that costs for caring for someone with autism exceeds $3 million over a lifetime. While ABA costs can exceed $50,000 annually, medical cost estimates are reduced over the long-term. Studies have shown that almost half the children who receive early ABA can learn to function in the mainstream of society.
There are, however, 49 additional states that need to implement the federal court directed benefits. Many states still base their Medicaid provided services based on a waiver system that is often capped. Maryland, for example, has a waiver cap of 900 while 4,000 children with autism are on the waiting list. While California is the pioneer, countless families elsewhere are still carrying the fight and are waiting for the federal directive to be implemented in their state.
By Hans Benes