Understanding the EPSDT Medicaid Benefit

January 15, 2019

This article is a part of our
Health Insurance and Autism Series.

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Early and Periodic Screening Diagnosis and Treatment (EPSDT) is a Medicaid benefit for children established in 1967.  It was introduced to ensure that children under age 21 have access to comprehensive high-quality health benefits.  As the title indicates, the benefit was created to ensure that potential health and developmental problems in Medicaid-eligible children can be found early and addressed thoroughly with the goal of preventing issues or reducing their effects. In New Jersey, Medicaid is part of NJ FamilyCare, the state’s publicly funded health insurance program.

The types of treatment that can be covered under EPSDT are broad and can address a range of concerns including physical and mental health, hearing and vision, dental health, immunizations, and more.

According to the federal Centers for Medicare & Medicaid Services (CMS), “the EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual 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.”

How Does the EPSDT Benefit Apply to Identifying and Treating ASD in Children?

In 2014, CMS issued an informational bulletin clarifying Medicaid coverage of services to children with autism and gave states the authority to decide how to implement the guidance.  Importantly, “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 [Social Security] Act that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions.”

While initially only available to a few hundred children through a Medicaid waiver program, NJ FamilyCare now covers autism treatment for all Medicaid-eligible children under ESPDT. Through its Medicaid program, New Jersey must promptly provide all medically necessary services to correct or ameliorate a child’s autism deficits and conditions. Depending on the medical needs of the individual, those services can include:

  • Applied Behavior Analysis
  • Occupational therapy
  • Physical Therapy
  • Speech Therapy

Who Is Responsible for Delivering ABA to New Jersey Children Covered by NJ FamilyCare?

NJ FamilyCare is a joint federal-state program ensuring low-income individuals have access to medical care that is administered by the State of New Jersey. To fulfill its obligations, the state contracts with five Managed Care Organizations (MCOs) who serve as the insurance carriers for individuals with Medicaid coverage.

Those five MCOs – Aetna, Amerigroup, Horizon NJ Health, United Healthcare Community Plan, and Wellcare – maintain their own provider networks. When their beneficiaries (the individuals covered by Medicaid) receive services, the MCOs are the ones who pay the claims.

While the MCOs administer all aspects of coverage, the State of New Jersey remains responsible for ensuring beneficiaries receive services in accordance with all applicable laws, including receiving treatment in a timely manner.

Does the EPSDT Benefit Apply to Adults with Autism?

No, the EPSDT benefit applies only to individuals ages 0-21. Adults who seek ABA therapy are encouraged to call our 800.4.AUTISM Helpline to discuss their options.

What Is Autism New Jersey Doing to Help Families Access this Benefit? 

Most children with autism in New Jersey have healthcare coverage for some type of treatment benefit, whether covered by Medicaid or commercial health insurance. We are happy to help parents understand what coverage is available for their children and troubleshoot any insurance-related issues you may have with a service provider or insurance company. Contact a helpline specialist on weekdays from 8:30 a.m. to 5:00 p.m. by calling 800.4.AUTISM or email us at information@autismnj.org.

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Introduction to Insurance Split Application MedicaidMedicaid and How To Enroll
Self-Funded Plans Child-Only PlansMedicaid: Starting Treatment
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