In July, the Centers for Medicare & Medicaid Services announced that comprehensive autism services must be covered for children under all state Medicaid and Children’s Health Insurance Program plans, another federal-state program that provide health coverage to lower-income children.
Although coverage of applied behavioral analysis, which uses positive reinforcement and other techniques to encourage behavior change, isn't explicitly required, advocates expect it will be covered.
"Since ABA is the most accepted, effective treatment that isn't experimental and investigational, you can't just exclude it entirely," says Daniel Unumb, executive director of Autism Speaks' legal resource center.
Like California, some states provided limited coverage before to certain age groups, for example, or up to a specified dollar amount. But the new policy is important because it requires mandatory coverage for everybody under 21, says Kristin Jacobson, co-founder and president of Autism Deserves Equal Coverage, a Burlingame, Calif.-based advocacy group.
In a coverage bulletin last month, CMS said that state Medicaid programs must cover a full range of autism services under the "early and periodic screening, diagnostic and treatment services" provision of the law. The EPSDT benefit, as it’s called, covers any services that are medically necessary to correct or ameliorate physical or behavioral conditions in children up to age 21.
Some states are concerned about the new requirement, says Matt Salo, executive director of the National Association Of Medicaid Directors.
"The nexus of covering a lot of kids and a fairly unknown condition and treatment for that condition, combined with EPSDT, anytime you get that you get states a bit concerned because there's very little way to control costs in that arena," says Salo.
The new coverage guidelines apply to children with autism spectrum disorder, a group of developmental conditions including autistic disorder and Asperger syndrome. Roughly 1 in 68 children have the disorder, according to the Centers for Disease Control and Prevention. The Association Of Maternal Child Health Programs estimates that just over a third of them get coverage through Medicaid or CHIP.