States question whether new CMS policy requires autism coverage
States, insurers and patient advocates are debating the meaning and scope of a new CMS bulletin on coverage for comprehensive autism treatment under Medicaid and the Children’s Health Insurance Program.
Some states and insurers argue that the policy is optional and that narrower state programs for children with the most severe cases of autism are allowed. But some legal experts and patient advocates say the CMS coverage policy is a requirement for all qualifying children and young adults up to age 21.
“I don’t see anything that mandates that service,” said Joe Fairbanks, policy development coordinator at the Oklahoma State Department of Health. An Oregon Medicaid official also said the bulletin does not require coverage.
“Our understanding is the bulletin did not mandate coverage of these services,” said Jamie Kelly, a spokeswoman for Tufts Health Plan, which has members in Massachusetts and Rhode Island.
But others sharply disagreed. “This makes clear that a state has no discretion to avoid providing to any child autism-related services, including (applied behavior analysis therapy), which are medically necessary,” said Sheldon Toubman, a staff attorney and Medicaid specialist at the New Haven (Conn.) Legal Assistance Association.
State Medicaid agencies in Delaware, Illinois, Nebraska, Utah and Wisconsin said they are still trying to understand the bulletin and its financial impact. Some states and insurers expressed alarm about the costs involved, while others noted they already were covering some treatment. There are no official estimates of the cost of the CMS coverage policy. But some say it could boost costs by hundreds of millions of dollars a year.
The CMS did not respond to requests for comment by deadline.
In a little-noticed move on July 7, the CMS posted an information bulletin about coverage for autism services under the Medicaid law’s provision for early and periodic screening, and diagnostic and treatment services. “In response to increased interest and activity with respect to services available to children with autism spectrum disorder (ASD), CMS is providing information on approaches available under the federal Medicaid program for providing services to eligible individuals with ASD,” the agency wrote. In the document, the CMS said it was interpreting current Medicaid regulations.
Following the announcement, patient advocates said thousands of children in low-income families who currently are not receiving any treatment could begin to get it. State Medicaid and CHIP programs have had widely varying coverage policies for comprehensive autism services. For example, Oklahoma hasn’t covered applied-behavior analysis therapy at all and has no plans to, while Oregon will begin offering it Jan. 1, but only for children up to age 12.
Oklahoma officials questioned whether applied-behavior analysis therapy specifically was being mandated. ABA treatment involves behavioral specialists leading autism patients through drills to help with speaking and social skills. The annual cost of the therapy ranges from $25,000 to $70,000.
Officials in the District of Columbia, Florida, Idaho, Maine, New Jersey, Ohio, Washington and West Virginia said they are already covering the services discussed in the CMS bulletin.
The Centers for Disease Control and Prevention reported this year that autism rates in children have increased from 1 in 88 children in 2012 to 1 in 68 children in 2014. More than a third of children with autism are covered by Medicaid or CHIP, according to the Association of Maternal and Child Health Programs.
A Maryland official expressed concern about the scope of the CMS policy. Maryland has a waiver to cover ABA therapy for only about 900 children and young adults with the most severe cases.
South Carolina also has a waiver, allowing it to cover about 600 autistic children who are receiving ABA therapy. Officials there interpret the CMS bulletin to mean the state will have to cover services for all autistic children. “CMS doesn’t send things out as friendly reminders,” said Tony Keck, director of the South Carolina Department of Health and Human Services. He predicted his state’s Medicaid expenses will increase from $12 million to more than $100 million as a result.
Toubman said states with limited coverage waivers are not in compliance with the CMS bulletin. “The fact that a state may have a very limited waiver to cover medically necessary ABA services for a small group of children in narrow circumstances cannot be used to deny medically necessary ABA services to those children,” he argued.
California has told Medicaid managed-care plans that they must cover autism-related services by Sept. 1, even though the state has not yet announced how much it will pay the plans to cover these services, said Patricia Tanquary, CEO for Contra Costa Health Plan. “Many plans are having to develop a new network and utilization criteria.”
Some states fear the CMS policy on autism treatment will require therapy costing up to $70,000 a year per child.