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CMS Guidance Says Autism Therapy Covered as Medicaid Benefit for Kids

Yesterday, CMS officials released federal guidance for states on Medicaid coverage of autism therapy, and that guidance indicates it is covered for beneficiaries under age 21.

“It’s a good day. It’s such a good day,” said Julie Kornack, senior public policy analyst at the Center for Autism and Related Disorders, an advocacy group based in Tarzana. “Whenever you get a decision that we’ve been seeking for years, that is a good day.”

Applied behavior analysis treatment, known as ABA therapy, now is a benefit for those under age 21 under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision of Medicaid — and therefore it also must be covered under Medi-Cal, California’s version of Medicaid, according to Kristin Jacobson, president of Autism Deserves Equal Coverage, an advocacy group based in Burlingame.

“ABA therapy must be covered under EPSDT. It’s very, very clear,” Jacobson said. “Any coverable benefit must be provided under the age of 21. If it’s coverable in any way, then you have to provide it.”

On top of that, CMS’ new guidance says state officials don’t need to file a State Plan Amendment to start coverage of autism therapy. “It doesn’t have to be in your state plan, it says it right there,” Jacobson said.

State officials were a little more careful.

According to Norman Williams, deputy director of public affairs for the Department of Health Care Services, the health policy experts at DHCS need a bit more time to fully review the guidance.

Kornack acknowledged that “lawyers are still dissecting the guidance and [that] there’s some leeway here about how states will implement this.”

“But whether they implement is no longer a question,” she said.

State officials previously have said they were awaiting federal guidance on the question of ABA therapy coverage — and Kornack, for one, can’t wait to hear the official word from the state.

“I don’t think we could ask for better clarification than what we just got,” she said. “There’s some latitude for states in terms of how to augment the waiver, there will be complexities. But there’s no latitude about whether they provide services. The question about whether they provide it is done.”

Jacobson said now it’s just a matter of the time of implementation till Medi-Cal children can access ABA therapy services.

“When I look at as clarification of existing requirements, I don’t know how much you could delay it,” she said. “They have to make it available and accessible, and make families aware that it’s available and accessible. I’d say, if families already have medical necessity established, they should try to pursue coverage right away.”

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