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It’s Here! Medi-Cal Coverage for Autism Treatment

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As of September 15, 2014, children enrolled in Medi-Cal will be eligible to receive the clinical standard-of-care treatment for autism spectrum disorders, including applied behavior analysis or ABA therapy. The new ruling states that ABA therapy and other treatments for autism must be covered by Medicaid when the treatment is medically necessary. According to the federal Centers for Disease Control and Prevention, roughly 1 in 68 children in the nation have been diagnosed with autism spectrum disorder. Traditionally, therapy has not been covered by healthcare insurance.

The therapy, which can total tens of thousands of dollars annually, involves working closely to improve children’s behavior and learn new tasks. Treatment includes speech, occupational and physical therapy as covered benefits through Medi-Cal, as well as psychiatry, psychology, and counseling services.

Managed by the California Department of Health Care Services (DHCS), Medi-Cal is California’s Medicaid program, providing free or low-cost health insurance for qualified California residents.

The approval for this treatment is California’s action to comply with the recent ruling by the U.S. Centers for Medicare & Medicaid Services that requires the therapy to be covered, when deemed medically necessary, as part of a “comprehensive array of preventive, diagnostic and treatment services” for low-income people 21 and under.

California already has programs in place that cover a percentage of autistic kids through the California Department of Developmental Services and public school districts. Although several states, including Louisiana and Washington have made limited efforts to provide behavioral therapy for autism, others have little or no public coverage for it.

In California, an estimated 75,000 children in the Medi-Cal program likely have an autism spectrum disorder; in 2013, the state Department of Developmental Services spent approximately $88 million on behavioral treatment for about 7,500 children considered to be eligible for Medi-Cal. Health advocates say the new rule on Medi-Cal coverage could add between 4,000 and 6,000 additional children to the program.

How to get Behavioral Intervention Therapy (ABA)

In order to be eligible, children will need to have a diagnostic assessment of autism spectrum disorder, and a prescription for ABA therapy from either a treating physician or psychologist. The prescribing professional will need to explain why ABA therapy is medically necessary for a child. Families on Medi-Cal can contact their health plan and their child’s primary care physician and request an assessment for ABA therapy.

Norman Williams, DHCS deputy director of public affairs, stated payment for ABA therapy will be backdated to July 7, the date the agency was notified that autism therapy was a Medicaid benefit under Early and Periodic Screening, Diagnosis and Treatment provisions.

California will work to keep costs under control by setting fixed rates for care under a managed care model. The federal government will pay for half of the cost of providing autism treatment through Medi-Cal, and the state will pay the rest.

Consumers having difficulty with their health plan and are not sure what their rights include, can contact the Medi-Cal Ombudsman’s office for help.

In addition to checking into Medi-Cal coverage, don’t forget to check out healthcare assistance under the state’s new health insurance plans. You may be eligible for help under Obamacare.

Do you have a child with ASD? Feel free to share your thoughts in the comments section below.

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