What are Autism-Related Services?
While people diagnosed with autism may benefit from services such as speech and language therapy, occupational therapy, physical therapy, psychology, etc. depending on their individual needs, Autism related services can also refer to autism specific services. Two well-known examples of Autism specific services are applied behavioral analysis (ABA therapy) https://www.autismspeaks.org/applied-behavior-analysis and TEACCH https://teacch.com/ .
Who is eligible to receive these service?
Autism is a lifelong condition, and services can start at a very young age. For children up to age 3, that may take the form of evaluation or assessment and early intervention programs. Autism specific treatments such as ABA and TEACCH are most often offered until age 18 or 20 years of age. However, in July 2021, the NC DHHS began offering Research Based – Behavioral Health Treatment for Autism Spectrum Disorder for those 21 and over. Research Based – Behavioral Health Treatment for Autism Spectrum Disorder | NC Medicaid (ncdhhs.gov)
Are Autism services covered by Medicaid or my health insurance plan?
Autism services are covered by Medicaid and by many, but not all, health insurance plans.
Autism services and private insurance:
Any major insurer in North Carolina that is governed by the NC Department of Insurance must follow the state law, § 58-3-192 Coverage for autism spectrum disorder.
https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3-192.html
This statute requires coverage for autism services for those 18 years of age or younger. In 2017, autism services through private insurance were capped at $40,000 annually; this limit is to be adjusted every March based on the consumer price index. Coverage is also subject to co-pays, deductibles, etc. Not all insurance companies are covered under this state statute. If you are unsure if your insurance plan is covered by this statute, you may contact the NC Department of Insurance (DOI) and ask for assistance 855-408-1212. If the DOI does not have jurisdiction over the plan (cannot intervene), they may be able to direct you to where you can reach out for help.
Self-funded health insurance plans offered by employers are regulated under the US Department of Labor (DOL). You can reach out to the DOL if you want to know if your plan is wrongly denying a claim for services. DOL/ERISA covered insurance plans: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/what-we-do . For technical assistance and complaints, you should call EBSA’s toll free number at 1-866-444-3272. You may contact DOL electronically at www.askebsa.dol.gov.
State of North Carolina Health Plan (State employees and teachers): covers autism services up to $36,000 annually.
Tricare: offers Autism services: https://www.tricare.mil/CoveredServices/IsItCovered/AutismSpectrumDisorder#:~:text=TRICARE%20covers%20many%20services%20for,Physician%20services
Affordable Care Act Marketplace Plans: https://www.hhs.gov/programs/topic-sites/autism/aca-and-autism/index.html
Federal Employee Health Benefit Plans are required to cover ABA for children with ASD https://www.opm.gov/policy-data-oversight/worklife/news-attachments/aba-coverage-in-fehb-for-2017-questions-answers.pdf
Autism Services and Medicaid
In July 2014, the Centers for Medicare and Medicaid Services (CMS) issued guidance [CMS’s bulletin] on Medicaid coverage of services to children with Autism Spectrum Disorder (ASD). ASD includes older diagnoses such as autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s Syndrome.
All states, including North Carolina, must cover therapies that treat ASD for children under 21 who have Medicaid through the EPSDT benefit, as long as the services are medically necessary. While Applied Behavioral Analysis (ABA) is often mentioned as treatment for ASD, there are other recognized treatments as well (some developed by TEACCH in NC) that might be as effective or more so, depending on the individual need.
Early and periodic screening, diagnostic and treatment benefit (EPSDT)
The State is obligated to cover ASD services under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which is Medicaid for kids*. EPSDT requires states to cover all medically necessary services for children who receive Medicaid and are under the age of 21, including services and treatments for ASD.
Please see DRNC’s EPSDT fact sheets for more information: https://disabilityrightsnc.org/resources/epsdt-brochures/ . View the Centers for Medicare and Medicaid Services, Clarification of Medicaid Coverage of Services to Children with Autism, July 7, 2014.
*Please note that North Carolina Health Choice recipients will be covered under EPSDT starting April 1, 2023.
How Do I Request Autism-Related Services Under Medicaid?
Children up to age 3:
Requests for services for children up to age 3 should be made to the Division of Child and Family Wellbeing within the NC Department of Health and Human Services.
North Carolina Infant-Toddler Program 919-707-5520
Children Ages 3-20:
Requests for Autism-related services for children aged 3 to 21 are made as EPSDT requests to the child’s LME/MCO/Tailored Plan or Standard Health Plan. A clinician (not necessarily the provider of the services) must make the request using the “Non-Covered State Medicaid Plan Services Request form for Recipients under 21 Years Old” (“Non-Covered” does not mean that the service is not covered – it means the service is not listed in North Carolina’s State Medicaid Plan). All of the LME/MCO/Tailored Plans and Standard Plans have this form on their websites. For those in Medicaid Direct, the clinician can access the form on NC TRACKS http://www.nctracks.gov/ .
Requests should focus on medical necessity, meaning that the clinician must justify the need for the services. Any information that documents the need for the service should be included. The form explains how and/or where to submit the request. The LME/MCO/Tailored Plan or Standard Plan has 14 days from the date it receives the request to either approve or deny the service. All denials or partial denials must allow the recipient to appeal the LME/MCO/Tailored Plan or Standard Plan’s decision to the Office of Administrative Hearings.
Autism Services and Innovations and CAP (CAP-C/DA) Waivers
Note that children who already receive services through a Waiver program are entitled to receive additional Autism-related services under EPSDT:
“ANY child enrolled in a CAP program can receive BOTH waiver services and EPSDT services. However, if enrolled in CAP/C or CAP/DA, the cost of the recipient’s care must not exceed the waiver cost limit. Should the recipient be enrolled in the [Innovations Waiver], prior approval must be obtained to exceed the waiver cost limit.” (EPSDT Policy Instructions Update, July 31, 2007, REV. 1/11/2010)
Autism Services for Adults:
NC Medicaid received approval from the Centers for Medicare & Medicaid Services (CMS) for Research Based – Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD) services for beneficiaries over the age of 21, effective July 1, 2021, when the intervention provided is supported by credible scientific or clinical evidence, as appropriate for the beneficiary’s age range. Updates are being made to Clinical Coverage Policy 8F to reflect this change.
Request for RB-BHT for beneficiaries over the age of 21 should be made through the applicable LME/MCO/Tailored Plan or Standard Health Plan.