Family Voices shares the following bulletin from the Center for Medicaid. It is important to note that ALL children with Medicaid are covered by EPSDT benefits, not just those with ASD. If you have questions, feel free to contact us.
DATE: July 7, 2014
FROM: Cindy Mann, Director
Center for Medicaid and CHIP Services
SUBJECT: Clarification of Medicaid Coverage of Services to Children with Autism
In response to increased interest and activity with respect to services available to children with
autism spectrum disorder (ASD), CMS is providing information on approaches available under
the federal Medicaid program for providing services to eligible individuals with ASD.
EPSDT Benefit Requirements
Section 1905(r) of the Act defines the EPSDT benefit to include a comprehensive array of
preventive, diagnostic, and treatment services for low-income infants, children and adolescents
under age 21. States are required to arrange for and cover for individuals eligible for the EPSDT
benefit any Medicaid coverable service listed in section 1905(a) of the Act that is determined to
be medically necessary to correct or ameliorate any physical or behavioral conditions. The
EPSDT benefit is more robust than the Medicaid benefit package required for adults and is
designed to assure that children receive early detection and preventive care, in addition to
medically necessary treatment services, so that health problems are averted or diagnosed and
treated as early as possible. All children, including children with ASD, must receive EPSDT
screenings designed to identify health and developmental issues, including ASD, as early as
possible. Good clinical practice requires ruling out any additional medical issues and not
assuming that a behavioral manifestation is always attributable to the ASD. 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.
The role of states is to make sure all covered services are available as well as to assure that
families of enrolled children, including children with ASD, are aware of and have access to a
broad range of services to meet the individual child’s needs; that is, all services that can be
covered under section 1905(a), including licensed practitioners’ services; speech, occupational,
and physical therapies; physician services; private duty nursing; personal care services; home
health, medical equipment and supplies; rehabilitative services; and vision, hearing, and dental
services.
If a service, supply or equipment that has been determined to be medically necessary for a child
is not listed as covered (for adults) in a state’s Medicaid State Plan, the state will nonetheless
need to arrange for and cover it for the child as long as the service or supply is included within
the categories of mandatory and optional services listed in section 1905(a) of the Social Security
Act. This longstanding coverage design is intended to ensure a comprehensive, high-quality
health care benefit for eligible individuals under age 21, including for those with ASD, based on
individual determinations of medical necessity.
Read the entire bulletin here: http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf
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