Many Steps To Go Before Authorizing Autism Therapy as Benefit, State Says

by David Gorn

State officials on Friday said they have not determined whether or not to offer applied behavior analysis (ABA therapy) as a Medi-Cal benefit to children with autism.

Federal officials earlier this month issued guidance on the subject, saying it is covered for Medicaid beneficiaries under age 21 as part of the Early and Periodic Screening, Diagnosis and Treatment program.

"Under the Medicaid state plan, services to address [autism spectrum disorder] may be covered under several different … benefit categories," the CMS guidance said. For children, it said, "states must cover services that could otherwise be covered at state option under these categories consistent with the provisions … for Early and Periodic Screening, Diagnostic and Treatment services (EPSDT).

According to René Mollow, deputy director of benefits and eligibility at the Department of Health Care Services, there are many steps before determination of coverage can be made.

"We are not changing course on this issue," Mollow said in an email. "Now that we have federal guidance, we are beginning the process of planning and implementing policy based upon that federal guidance and state statutory requirements.  It is a complex process involving the department and control agencies, stakeholders, Legislature, administration and federal government."

Mollow said the steps DHCS still needs to take to determine the state's course in regard to ABA therapy are laid out in law.

"Specifically, the law states that DHCS will implement Behavioral Health Treatment (BHT) to the extent that it is required by the federal government to be covered by Medi-Cal for individuals under 21 years of age," Mollow said.

"DHCS will implement BHT services only if: 1) it receives federal approval to obtain federal financial participation; 2) it seeks an appropriation of state funding required for the fiscal year; 3) statutory authority for the benefit is provided; and 4) it consults with stakeholders."

She said the department will solicit input from stakeholders at least 30 days prior to submitting a state plan amendment or waiver to CMS.

Mollow said she didn't know how long that process might take.

"It is too early in our process to predict a timeline," she said. "There are numerous contingencies ... All of them can have an impact on how we form and implement policy for these services."

The CMS guidance issued July 7 says:

"States are required to arrange for and cover for individuals eligible for the EPSDT benefit any Medicaid coverable service … 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 [autism spectrum disorder], must receive EPSDT screenings designed to identify health and developmental issues, including ASD, as early as possible."


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