By Michelle Andrews
Mon, Aug 25 2014
When Yuri Maldonado's 6-year-old son was diagnosed with autism four years ago, she learned that getting him the therapy he needed from California’s Medicaid plan for low-income children was going to be tough.
Medi-Cal, as California's plan is called, does provide coverage of autism services for some children who are severely disabled by the disorder, in contrast to many states which offer no autism coverage. But Maldonado’s son was approved for 30 hours a week of applied behavioral analysis (ABA), a type of behavior modification therapy that has been shown to be effective with autistic children, and she was worried that wasn’t enough.
So she and her husband, neither of whose jobs offered health insurance, bought an individual private policy for their son, with a $900 monthly price tag, to get him more of the comprehensive therapy.
"I don't know any family that can really afford that," says Maldonado. "We made some sacrifices."
That should be changing soon. In July, the Centers for Medicare & Medicaid Services announced that comprehensive autism services must be covered for children under all state Medicaid and Children’s Health Insurance Program plans, another federal-state program that provide health coverage to lower-income children.
Although coverage of applied behavioral analysis, which uses positive reinforcement and other techniques to encourage behavior change, isn't explicitly required, advocates expect it will be covered.
"Since ABA is the most accepted, effective treatment that isn't experimental and investigational, you can't just exclude it entirely," says Daniel Unumb, executive director of Autism Speaks' legal resource center.
"It's going to help a ton," says Maldonado. "We'll be able to pay our rent on time, and we'll be able to pay some bills that we have."
Like California, some states provided limited coverage before to certain age groups, for example, or up to a specified dollar amount. But the new policy is important because it requires mandatory coverage for everybody under 21, says Kristin Jacobson, co-founder and president of Autism Deserves Equal Coverage, a Burlingame, Calif.-based advocacy group.
In a coverage bulletin last month, CMS said that state Medicaid programs must cover a full range of autism services under the "early and periodic screening, diagnostic and treatment services" provision of the law. The EPSDT benefit, as it’s called, covers any services that are medically necessary to correct or ameliorate physical or behavioral conditions in children up to age 21.