CMS Bulletin Clarifies Medicaid Funding for ASD Services for Children and Adults

The Centers for Medicare and Medicaid Services (CMS) has released an Informational Bulletin (IB) providing information on approaches available under the federal Medicaid program for providing services to eligible individuals with Autism Spectrum Disorder (ASD), including children. The Bulletin details how ASD services can be reimbursed through the state plan, section 1915(i) state plan Home and Community-Based Services (HCBS), section 1915(c) HCBS waiver programs, and section 1115 research and demonstration programs. The Bulletin also addresses how EPSDT interacts with ASD services. CMS emphasizes that the IB pertains to a broad range of ASD treatments, stating that “while much of the current national discussion focuses on one particular treatment modality called Applied Behavioral Analysis (ABA), there are other recognized and emerging treatment modalities for children with ASD,” and references services described in the “ASD Services, Final Report on Environmental Scan.”

The Bulletin goes into some detail as to how ASD services can be provided through a Medicaid state plan. CMS indicates that services to address ASD may be covered under several different section 1905(a) benefit categories: services of other licensed practitioners; preventive services; and therapy services. Other Licensed Practitioner (OLP) services, defined at 42 CFR 440.60, are “medical or remedial care or services, other than physicians’ services, provided by licensed practitioners within the scope of practice as defined under State law.” CMS states that “if a state licenses practitioners who furnish services to address ASD, the state may elect to cover those providers under this section of their state plan even if the providers are not covered under other sections of the plan.” In addition, services that are furnished by non-licensed practitioners under the supervision of a licensed practitioner could be covered under the OLP benefit if:

• The licensed provider is able to furnish the service being provided;
• The state’s Scope of Practice Act for the licensed practitioners specifically allows the licensed practitioners to supervise the non-licensed practitioners who furnish the service;
• The state’s Scope of Practice Act also requires the licensed practitioners to assume professional responsibility for the patient and the service furnished by the unlicensed practitioner under their supervision; and
• The licensed practitioners bill for the service.

Preventive Services, defined at 42 CFR 440.130(c) are “services recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice under state law to—

(1) Prevent disease, disability, and other health conditions or their progression;

(2) Prolong life; and

(3) Promote physical and mental health and efficiency.” 

Note that a regulatory change that took effect January 1, 2014, permits coverage of preventive services furnished by non-licensed practitioners who meet the qualifications set by the state as long at the services are recommended by a physician or other licensed practitioner. Under the preventive services benefit, in the state plan, the state must:

1)    list the services to be provided to ensure that services meet the definition of preventive services as stated in section 4385 of the State Medicaid Manual (including the requirement for the service to involve direct patient care); 

2) identify the type(s) of non-licensed practitioners who may furnish the services; and 

3)    include a summary of the state’s provider qualifications, including any required education, training, experience, credentialing, supervision, oversight and/ or registration. 

Physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders, may be covered under the Medicaid therapies benefit at 42 CFR 440.110. Physical and occupational therapy must be prescribed by a physician or other licensed practitioner and provided to a beneficiary by or under the direction of a qualified therapist, and the services can include diagnostic, screening, preventive or corrective services.

The IB also discusses state responsibilities under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, defined in Section 1905(r) of the Act 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 provide 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, CMS states, “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 must receive EPSDT screenings designed to identify health and developmental issues, including ASD, as early as possible. 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. States must “make sure all covered services are available” and “assure that families of enrolled children…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.”

CMS points out that 1915 (c) waiver-funded extended state plan services related to section 1905(a) services are not available to individuals under the age of 21 because of the expectation that EPSDT will meet the individual’s needs, meaning that “a limited number of services can be provided to this age group under 1915 (c) waivers, primarily respite, and/or environmental/vehicle modifications.” For states that currently provide waiver services to individuals under age 21 to address ASD, CMS points out, “the ability to provide services under the 1905(a) state plan may have the effect of making these individuals ineligible for the waiver unless another waiver service is provided.” The IB warns that this would have particularly significant implications for individuals with ASD who are eligible for EPSDT but whose Medicaid eligibility rests entirely on eligibility for the (c) waiver.”

CMS clarifies that “individuals age 21 and older may continue to receive services to address ASD through the waiver if a state does not elect to provide these services to adults under its Medicaid state plan.” CMS also mentions that “for individuals under the age of 21 who are eligible for EPSDT services, an HCBS waiver could provide services and supports for ASD that are above and beyond services listed in section 1905(a), such as respite care.” Additionally, CMS points out, “for individuals who are receiving state plan benefits as part of EPSDT that are not available to adults under the state plan, waiver services may be used to help these individuals transition into adulthood and not lose valuable necessary services and supports.”

FMI: The Informational Bulletin is available at http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf. The “Autism Spectrum Disorders (ASDs) Services Final Report on Environmental Scan,” published in 2010, can be found at  http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Downloads/Autism-Spectrum-Disorders.pdf.