CMS Clarification about #Medicaid Covered Services for #ASD

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