CMS seeks to clarify coverage for autism treatment under CHIP, Medicaid

The CMS has moved to clarify confusion about a bulletin it released in July on coverage for comprehensive autism treatment under Medicaid and the Children's Health Insurance Program. Uncertainty centered on whether the CMS was mandating coverage for applied-behavior analysis therapy, a costly treatment.

ABA treatment, believed to be the most effective for people with autism, involves behavioral specialists leading patients through drills to help with speaking and social skills.

Annual ABA therapy cost for one patient ranges from $25,000 to $70,000. Experts say demanding ABA for every Medicaid- or CHIP-covered child could cost states and the federal government hundreds of millions of dollars per year.

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 one-third of children with autism are covered by Medicaid or CHIP, according to the Association of Maternal & Child Health Programs.

CMS was mum for several weeks on whether the bulletin mandated ABA, or any specific autism treatments. But Thursday it posted a follow-up FAQ document (PDF) explaining its intent for the initial July document release.

“CMS is not endorsing or requiring any particular treatment modality for [autism],” the agency said in the FAQ. “State Medicaid agencies are responsible for determining what services are medically necessary for eligible individuals.”

It did clarify, however, that there should be some form of covered treatment for children with autism under Medicaid or CHIP. However, it has no immediate plans to assess state compliance with autism treatment coverage for affected children.

“States may not have focused on the application of these requirements in this area,” the CMS said. “As a result, a state may need time to review its current program policies to determine if changes are needed to existing state regulations and/or policy to ensure compliance.”

Follow Virgil Dickson on Twitter: @MHvdickson