States must cover all medically necessary autism treatment until your child reaches age 21.
While scientists research causes and, hopefully, find cures for autism spectrum disorder (ASD), available treatments for children with ASD can improve physical and mental development. However, these therapies are often expensive, placing an enormous economic burden on some families, especially those without private insurance coverage for autism.
Fortunately, the Centers for Medicare & Medicaid Services recently announced a change in Medicaid coverage of ASD. Now every state must cover medically necessary care for children with autism, through age 21. In the past, Medicaid coverage for ASD has traditionally varied from state to state.
The importance of this Medicare move is especially significant considering the large number of children and teens in the U.S. with ASD. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 68 has the developmental disorder, up 30 percent from previous estimates. The recent Medicaid decision will make it possible for more autistic children than ever to receive potentially effective available therapies. In fact, Dan Unumb, executive director of Autism Speaks’ Legal Resource Center, believes it will “dramatically increase access to critical, medically necessary care.”
ASD includes several conditions that were once diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Asperger syndrome. All cause varying degrees of significant social, communication, and behavioral challenges.
Educational and behavioral interventions aimed to help specific symptoms can result in substantial improvement, according to the CDC, especially if the treatments meet specific needs of individual children. ASD treatments include intensive skill-oriented training sessions, such as applied behavioral analysis (ABA), that help children develop social and language skills. Medications help treat specific autism-related symptoms, such as anxiety, depression, or obsessive-compulsive disorder.
Medicaid is the primary source of health insurance coverage for one third of all American children with autism. Unfortunately, that doesn’t mean that parents of these Medicaid-covered youngsters can assume the federal program will now automatically cover all ASD treatments a doctor advises.
Congress specifies which benefits are mandatory under Medicaid, but does not mandate specific treatments. It’s left up to each state’s Medicaid to determine what services are medically necessary for eligible individuals. In addition, about 50 percent of all Medicaid-covered children are enrolled in managed care. That means their state has a contract with a private insurance company or HMO to manage their Medicaid program and to act on behalf of the state to decide what treatments are covered.
If your autistic child has Medicaid and is denied coverage for a treatment you and your doctor believe your child needs, don’t be discouraged. Instead, learn about your rights so you can be proactive.
Autism Speaks, an autism science and advocacy organization, points out that your child has the right to any and all medically necessary treatments, regardless of whether or not your state has added a specific therapy, such as ABA, to its Medicaid program. And, as a Medicaid beneficiary, under federal law, you have the right to appeal any benefit denials. Contact your Medicaid health plan or state Medicaid agency to learn how to file an appeal.
June 15, 2015
Christopher Nystuen, MD, MBA