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Autism-Related Services in NC

Table of Contents

Autism and Medicaid

In July 2014, the Centers for Medicare and Medicaid Services (CMS) issued guidance clarifying its position on Medicaid coverage of services to children with Autism Spectrum Disorder (ASD). ASD includes 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 with Medicaid, even if the services are not covered for adults under the State Medicaid Plan 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.

CMS’s bulletin discussed three benefit categories that could be used by states to fund ASD services through Medicaid, Section 1905(a) of the Social Security Act : 1905(a)(6) Other Licensed Practitioner; Section 1905(a)(13) Preventive Services; and Section 1905(a)(11) Therapies.

Early and periodic screening, diagnostic and treatment benefit (EPSDT)

The bulletin also explained the State’s obligation to cover ASD services under Section 1905(a)(4)(B) of the Act, known as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which requires states to cover all medically necessary services for children who are Medicaid eligible under the age of 21, including services and treatments for ASD. NC has covered ASD-related services under this benefit.

Section 1905(r) of the Act defines EPSDT broadly. The CMS Informational Bulletin (page 4-5) states as follows:

EPSDT Benefit Requirements

Section 1905(r) of the Act defines the EPSDT benefit to include a comprehensive array of preventive, diagnostic, and treatment services for low-income infants, children and adolescents under age 21. States are required to arrange for and cover for individuals eligible for the EPSDT benefit any Medicaid coverable service listed in section 1905(a) of the Act 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 ASD, must receive EPSDT screenings designed to identify health and developmental issues, including ASD, as early as possible. Good clinical practice requires ruling out any additional medical issues and not assuming that a behavioral manifestation is always attributable to the ASD.

EPSDT also requires medically necessary diagnostic and treatment services. When a screening examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnosis and treatment without delay. Ultimately, the goal of EPSDT is to assure that children get the health care they need, when they need it – the right care to the right child at the right time in the right setting.

The role of states is to make sure all covered services are available as well as to assure that families of enrolled children, including children with ASD, are aware of and have access to a broad range of services to meet the individual child’s needs; that is, all services that can be covered under section 1905(a), including licensed practitioners’ services; speech, occupational, and physical therapies; physician services; private duty nursing; personal care services; home health, medical equipment and supplies; rehabilitative services; and vision, hearing, and dental services.

If a service, supply or equipment that has been determined to be medically necessary for a child is not listed as covered (for adults) in a state’s Medicaid State Plan, the state will nonetheless need to arrange for and cover it for the child as long as the service or supply is included within the categories of mandatory and optional services listed in section 1905(a) of the Social Security Act. This longstanding coverage design is intended to ensure a comprehensive, high-quality health care benefit for eligible individuals under age 21, including for those with ASD, based on individual determinations of medical necessity.

View the Centers for Medicare and Medicaid Services, Clarification of Medicaid Coverage of Services to Children with Autism, July 7, 2014.

How Do I Request Autism-Related Services?

Requests for services for children up to age 3 should be made to the Division of Medical Assistance (DMA) within the NC Department of Health and Human Services.

Requests for Autism-related services for children aged 3 to 21are made as EPSDT requests to the child’s LME/MCO. 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/MCOs have this form on their websites.

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 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’s decision to the Office of Administrative Hearings.

Autism Services and CAP Waivers

Note that children who already receive services through a CAP 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 Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP/MR-DD), prior approval must be obtained to exceed the waiver cost limit” (EPSDT Policy Instructions Update, July 31, 2007, REV. 1/11/2010).

CAP services include CAP/C (Community Alternatives Program for Children – providing home and community based services to medically fragile children under age 21), CAP/DA (Community Alternatives Program for Disabled Adults – allowing elderly and disabled adults, ages 18 and up, to receive support services in their own home, as an alternative to nursing home placement) and the Innovations Waiver program (formerly CAP/MR-DD).

Autism and Private Health Insurance Coverage (Senate Bill 676)

Some private insurance plans already include coverage for Autism-related services on a voluntary basis. Others may add it as a result of the recent legislation, SB 676 (2015). As of July 2016, Autism health insurance coverage must be included in some but not all private insurance policies (with coverage for services up to $40,000/year). This new requirement will become effective at the time a policy renews after July 2016. Group insurance plans renew on a quarterly basis. Plans that renew on July 1, 2016, will start Autism coverage then. Plans that renew after July 1 will offer the benefit starting with the renewal date: October 1, 2016, January 1, 2017, and April 1, 2017, depending on the plan/employer renewal date.

This legislation only requires coverage for ASD services ”to individuals 18 years of age or younger” (so a 19-year-old that had received ASD services through a parent’s private insurance would not automatically be entitled to continue receiving those services – it would depend on the specific policy) . However, individuals who become eligible for SSI upon turning 18 would also automatically qualify for Medicaid. In that case, they would then be able to receive Autism-related services through age 21 as part of the EPSDT benefit.

The new insurance benefit requires coverage for medically necessary treatments such as occupational therapy, speech therapy and physical therapy, as well as psychiatric, psychological, and pharmacy care. You can expect co-pays, co-insurance, and deductibles just like there is for other insurance benefits. These will differ based on the specific plan.

The only way to know how your insurance plan works is to ask the company what benefit they will offer and what the required co-pays, deductibles and co-insurance will be.

Determining which employers are required to provide Autism-related services can be confusing. Disability Rights NC recommends that you contact your insurance carrier and/or employer to determine if they are required to provide coverage. If your employer does not know (and sometimes your insurance company may not know or give you incorrect information), you can call the NC Insurance Commissioner at 1-855-408-1212.

Finally, if you have employer-based health coverage but your child is not currently on that plan, you should determine if it’s worth paying for the cost of family coverage to get the added Autism benefit. Below are some examples of plans that are required and not required to cover the ASD benefit under the new law. This is complicated – so check with your employer or insurance company for a definitive answer.

What plans that are covered by SB 676?

  • SB 676 requires Autism coverage in group health plans of larger employers (those with more than 50 employees), which are based in and operate only in North Carolina.

What Plans are Not Covered by SB 676?

  • Large employers that operate in more than one state or internationally are not required to follow state law, but operate under federal ERISA (Employee Retirement Income Security Act) laws. These employers will be more likely to offer coverage to employees living in North Carolina now that the bill has passed, but are not required to do so.
  • Individual plans sold under the Affordable Care Act on the health-care
  • Federal plans such as Tricare are not required to cover Autism
  • Medicare is not required to cover Autism
  • North Carolina’s Health Choice benefit for kids does not include coverage for Autism
  • The State Employee Health Plan was not included in the law because they began offering ABA/autism behavioral treatment benefits on July 1.