News » Medicaid Coverage for Autism Treatment

Medicaid Coverage for Autism Treatment

January 17, 2019

Toddler and mother playing together

The state is preparing to have Medicaid coverage available for autism treatment for youth within the next few months.

Read the official notice

Approval is being sought from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, for an amendment to the New Jersey Medicaid (Title XIX) State Plan to include Autism Spectrum Disorder-related services for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) eligible individuals (ages birth to 21).

According to the state’s notice, “If approved, individuals with autism will have access to a multidisciplinary array of services that are individually planned and coordinated. Services are identified in a plan of care that is inclusive of parent/caregiver and youth choice, and best practice decisions between formal and informal supports/services and families that yield sustainable growth for the youth and family across life domains.”

The state’s notice continues, “Subject to approval by CMS, a multidisciplinary array of services for youth with autism, to prevent and manage complications, and ultimately to maximize beneficiary quality of life may be provided by approved New Jersey Medicaid in home providers, out of home providers, clinic, physician or other qualified professional healthcare providers.” Read the official notice for the 30-day public comment period.

 

Autism New Jersey is both enthusiastically supportive of and concerned with some components of the proposed plan and has submitted comments outlining those areas. For your convenience, here is a summary of our thoughts.

What Autism New Jersey agrees EPSDT-covered treatment should include:

  • Behavioral support services

  • Augmentative and alternative communication (AAC)

  • Speech therapy

  • Eating and feeding evaluation and treatment

What Autism New Jersey recommends changing for EPSDT-covered treatment:

  • Name of and provider qualifications for “behavioral support services”

Consistent with the American Medical Association’s CPT codes, re-name this “Applied Behavior Analysis” to link it to the CPT codes for “Adaptive Behavior Services” and include only professionals with the requisite training and credentialing to offer this medical service (e.g., Board Certified Behavior Analysts, psychologists)

What Autism New Jersey recommends removing from EPSDT-covered treatment because there is no scientific consensus that they meet the medical necessity criteria for the treatment of autism:

  • DIR/Floortime

  • Sensory integration

  • Music, art, play, movement, and equine therapies

Public Comments

Autism New Jersey’s recommendations include three main areas:

WHAT

Evidence-based Treatment

AGREEMENT:

We firmly believe that children with autism deserve access to the best available treatments that have been tested through research and have the consensus of the scientific community. Decades of well-controlled research and parents across the state have repeatedly demonstrated that the abilities and quality of life of children with autism improve with Applied Behavior Analysis (ABA) and related services. The inclusion of “Behavioral Support Services” is a wise investment that will change children’s lives and lower the long-term costs for families and the state.

CONCERN:

Children’s lives should not be gambled with nor should medically necessary treatment be delayed in favor of interventions that have not been proven effective by medical treatment standards. Without effective treatment, the symptoms of autism can worsen over time and cause greater harm.

WHO

Provider Qualifications

AGREEMENT:

Autism New Jersey agrees with many of the provider qualifications included in the proposed plan and recommends that all medically necessary treatment is provided by professionals who are licensed in the State of New Jersey or certified by a nationally accredited credentialing body.

CONCERN:

We are concerned with the wide variety of professionals who could provide “Behavior Support Services.” Many of these professionals do not have “Behavior Support Services” or, as it is more formally known, “Applied Behavior Analysis,” in their scope of practice and are not qualified or competent to deliver such services. This decreases the likelihood that these services will ameliorate the symptoms of autism.

HOW

Process to Access Treatment

COMMENT:

Given the urgent and tremendous unmet treatment needs of children with autism across the state, Autism New Jersey recommends that the administrative home for these services be able to facilitate timely and streamlined access to screening, assessment, treatment, and reimbursement with no improper limitations or delays such as age limits, CSOC DD eligibility, CSOC CMO eligibility, acute behavioral challenges, provider choice, etc.

Additional Information