California Implements Medi-Cal Coverage for Autism Treatment

Beginning September 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, theKaiser Health News/Los Angeles Daily News reports.

Medi-Cal is California’s Medicaid program.


Under a recent rule, CMS said that ABA therapy and other treatments for autism must be covered by Medicaid when the treatment is medically necessary (Hernandez, Kaiser Health News/Los Angeles Daily News, 9/15).

In California, an estimated 75,000 children in the Medi-Cal program likely have an autism spectrum disorder, according to KQED’s “State of Health” (Gorn, “State of Health,” KQED, 9/15).

Details of Calif. Autism Coverage

California in late August issued a final draft letter to managed care health insurers implementing the policy beginning on Sept. 15.

Norman Williams, deputy director of public affairs for DHCS, has said payment for ABA therapy will be retroactive to July 7, the day the agency received federal guidance that autism therapy was a Medicaid benefit under Early and Periodic Screening, Diagnosis and Treatment provisions (Gorn,California Healthline, 9/3).

State officials said rates for autism treatment will have fixed 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, according to the KHN/Daily News.

Dylan Roby, a health care economist at UCLA’s Fielding School of Public Health, said the state will pay for the coverage through the general fund. However, the state might end up needing to cut existing programs or obtain additional funding through appropriations if the general fund money runs out, Roby said.

Challenges Remain

Kristin Jacobson, with Burlingame-based Autism Deserves Equal Coverage, said the additional coverage will give Medi-Cal beneficiaries “access to this treatment that can help these children reach their potential” (Kaiser Health News/Los Angeles Daily News, 9/15). However, she added, “If Medi-Cal doesn’t make sure to contract with the vast majority of current existing providers, they will not have enough providers. They will not be able to actually provide the benefit that they’re saying” (“State of Health,” KQED, 9/15).

In addition, Daniel Unumb, executive director of the Autism Legal Resource Center at Autism Speaks, said it will be critical that states offer adequate reimbursement rates, adding, “Otherwise, they will not attract sufficient providers and there will be huge problems with access.”

Meanwhile, some observers say states should be cautious of providers who might try to garner greater profits by misdiagnosing or over-prescribing autism treatment.

Matt Salo, executive director of the National Association of Medicaid Directors, said many clinicians do not understand autism or treatment for the illness (Kaiser Health News/Los Angeles Daily News, 9/15).

Courtesy California Healthline, Sept. 19, 2014