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Coding Issues and Questions

CMS Bulletin Clarifies Medicaid Autism Services Coverage Requirements

Overview
A July 2014 CMS Bulletin to state Medicaid programs clarifies autism spectrum disorder (ASD) treatment services available to Medicaid enrollees in Medicaid and the statutory authorities under which such services can be covered. With an emphasis on the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guarantee for children, this bulletin explains how ASD services for children must be provided.

While the bulletin does not create new coverage requirements, this bulletin clarification and a subsequent CMS FAQ document may have the effect of requiring your state Medicaid program to provide additional or expanded ASD treatment services for children, which may include applied behavioral analysis (ABA). AAP Chapters are encouraged to contact state Medicaid programs to learn more about those ASD services already covered or how such coverage can be expanded under the authorities outlined in this bulletin and expanded upon in the FAQ document.

Details

This CMS bulletin was issued “in response to increased interest and activity with respect to services available to children with autism spectrum disorder (ASD),” and outlines the various statutory authorities Medicaid programs have to provide coverage of ASD services, including:

  • Section 1905(a) of the Social Security Act
  • Section 1915(c) Home and Community Based Services Waiver Program
  • Section 1115 Research and Demonstration Waiver Program
  • EPSDT

Section 1905(a) of the Social Security Act

Section 1905(a) lists categories of mandatory and optional benefits required to be covered by Medicaid programs. The CMS bulletin indicates that ASD services may be provided under a number of different 1905(a) categories, including those of “services of other licensed practitioners,” “preventive services,” and “therapy services.” Of note, a January 2014 regulatory change discussed in this StateHealth e-update now allows Medicaid coverage of preventive services recommended by a physician, not necessarily only those provided by a physician. The July CMS bulletin details how ASD services may be provided under all of these various 1905(a) authorities.

Section 1915(c) Home and Community Based Services Waiver Program

ASD services can also be provided using 1915(c) waiver authority (commonly known as Katie Beckett waiver authority), which is intended to provide a combination of medical services and long-term care and supports to those who meet an “institutional” level of care but are served in the community. The bulletin notes how 1915(c) authority can be used to supplement services for children transitioning from Medicaid coverage to adult Medicaid coverage without losing important benefits and supports, and how ASD services can be provided under other Medicaid authorities.

Section 1115 Research and Demonstration Waiver Program

Section 1115 waiver authority is also detailed—as these waivers are generally experimental and broad in scope, states have flexibility to use them to provide new or innovative ways of providing ASD services under this authority.

EPSDT

Finally and critically, the bulletin outlines EPSDT requirements for children and how EPSDT applies to ASD services. The bulletin reminds state Medicaid programs that the goal of EPSDT is to provide “the right care to the right child at the right time in the right setting.” To this end, states must provide access to a broad array of all services that can be covered under Section 1905(a) as well as any service deemed medically necessary for a child even if it is not listed as covered in the state’s Medicaid State Plan.

CMS also indicates that this clarification may have implications for existing Section 1915(c), Section 1915(i), and Section 1115 waiver programs that provide ASD services, and that CMS is available to provide technical assistance to states that currently have approved waivers or state plans that may be affected by the bulletin.

 

Questions on coding?  The AAP has a web page where you can submit questions and review resources that provide information on coding.  To access this resource click here, then :

  • The navigation for this link is to click the blue tab at the top left of the AAP website that says “Professional Resources.”
  • From there, click “Practice Support”
  • Then scroll down to the heading that reads, “Financing and Payment.”
  • The third link under this heading says, “Coding Resources.”
  • When you go to that page, you’ll see the “Coding Questions/Coding Hotline Form” link on the right.

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