State health officials this week said 105 children have received autism therapy since the Medi-Cal benefit was officially launched Sept. 15. Officials said the state would require a comprehensive diagnostic evaluation before those services would be covered.
“We think we are right about on target, we don’t think that’s low,” said Sarah Brooks, chief of the Managed Care Quality and Monitoring Division at the Department of Health Care Services. “It’s only been two months.”
About 75,000 children enrolled in Medi-Cal are estimated to have autism spectrum disorder. Approximately 7,700 of them already receive services at regional centers across the state.
“We expect to see a bigger increase in the next few weeks,” Brooks said, as a number of cases were recently approved.
Advocates questioned the requirement for evaluation and diagnosis before treatment for young patients with autism.
“The standard of care clinically is to treat right away and not wait for a full diagnostic assessment,” said Kristin Jacobson, president of Autism Deserves Equal Coverage, an advocacy group based in Burlingame. “Especially given the hugely long waiting list, that’s a huge, huge barrier for access to care.”
According to autism advocates at Tuesday’s DHCS stakeholder meeting, the waiting list for diagnostic evaluation for autism is six to 12 months.
Children with autism spectrum disorder can’t wait that long, said Abbi Coursolle, staff attorney for the National Health Law Program.
“We would ask you to look at that requirement again,” Coursolle said. “As many people here have said, we’re concerned it’s going to become a barrier to timely access to care.”
“Requiring a diagnosis may violate EPSDT (Medicaid’s Early and Periodic Screening Diagnosis and Treatment program),” Jacobson said at the stakeholder meeting. That’s because under the EPSDT requirement, medically necessary care needs to be provided for all conditions, she said. “The clinical standard for [autism] is that treatment has to start when diagnosis is seriously considered, not confirmed,” Jacobson said. “I think you’re at risk of running contrary to clinical standards.”
“We have been trying to make everyone happy,” said Laurie Weaver, chief of the benefits division at DHCS. “But ultimately we have to make the federal government happy so we can get this SPA (state plan amendment) approved. We will move forward with the [autism] diagnosis to start autism therapy.”