The new coverage guidelines apply to children with autism spectrum disorder, a group of developmental conditions including autistic disorder and Asperger syndrome. Roughly 1 in 68 children have the disorder, according to the Centers for Disease Control and Prevention. The Association Of Maternal Child Health Programs estimates that just over a third of them get coverage through Medicaid or CHIP.
In California, to get coverage under the state’s Medicaid waiver program children need to be substantially disabled and have a full autistic disorder diagnosis, says Jacobson.
"It doesn't cover people with Asperger's syndrome or other forms of autism spectrum disorder," she says, leaving children with language or certain functional abilities unable to get services.
Jacobson estimates that up to 6,000 new children in California who are currently ineligible under the waiver program may qualify for autism services under CMS’ new guidance.
"For them it’s going to be a huge deal," she says.
The new coverage rules went into effect July 7 when the CMS guidance was issued, although many states are still setting up procedures. More than a dozen states have contacted him about implementing the new policy, says Unumb.
Advocates across the country in recent years have been working to build support for better insurance coverage of autism services, including Medicaid coverage. The federal government’s announcement followed a number of recent court cases, including federal circuit decisions in Florida and Ohio, affirming that applied behavioral analysis services were required under the Medicaid EPSTD benefit. Those decisions bolstered advocates’ long campaign to get such services covered, Unumb says.
In addition, 37 states and the District of Columbia have passed laws that require private plans to cover autism treatment, according to Autism Speaks. “It reached that boiling point where CMS had to step in and issue this guidance,” says Unumb.
Caring for someone with autism costs more than $3 million over a lifetime, according to a 2007 study published in the Archives of Pediatrics and Adolescent Medicine.
Advocates argue that early intervention, even pricey applied behavioral analysis that may cost more than $50,000 annually, can save money in the long run. Nearly half of children who receive early interventions such as applied behavioral analysis can achieve mainstream status, according to a 2005 study published in the American Journal of Mental Retardation.
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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.
Mon, Aug 25 2014