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Most children enrolled in Medicaid receive services through a Medicaid health plan, such as an HMO or other insurance company. The state Medicaid agency and the Medicaid health plan determine if treatments are medically necessary and which providers can be reimbursed for services. Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit of Medicaid, beneficiaries under the age of 21 are entitled to all health care services that are found to be medically necessary to treat conditions discovered in a child.
Who is eligible for Medicaid?
Medicaid is most often determined by income, but eligibility varies by state. Visit the Medicaid website or contact your state’s Medicaid program for an overview of each state’s Medicaid program, including income and other eligibility requirements.
Please note that Achieving a Better Life Experience (ABLE) Accounts do not affect Medicaid eligibility.
Some states disregard income for individuals with disabilities (including autism) who require an institutional level of care.
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For example, under TEFRA (the Katie Beckett State Plan Option) a child with a disability qualifies for Medicaid if
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The child is 18 years old or younger.
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The child meets the state’s definition of “institutional level of care”.
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The child has medical needs that can be safely provided outside of an institutional setting.
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The cost of care in the community does not exceed the cost of institutional care.
Coverage for the treatment of autism under EPSDT
The EPSDT program has been around for decades. However, the federal government only recently clarified to state Medicaid agencies that all medically necessary services for autism must be included. This requirement is regardless of whether the service is covered in a state’s Medicaid plan.
Since 2014, state Medicaid agencies have worked to amend their state plans or adopt state regulations that clarify ABA as a covered benefit when medically necessary and provided by qualified Medicaid providers. As of February 2022, all 50 states have implemented their Medicaid autism services benefit.
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EPSDT Toolkit- PROVided by autismspeaks.com
The EPSDT Toolkit helps families who are working to secure Medicaid payment for medically necessary treatments for autism, including Applied Behavior Analysis (ABA).
