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Guide to Medicaid for autism

Guide to Medicaid for autism

Having a child with autism can mean additional expenses for a family. There may be costs connected to insurance, therapy, special equipment, caregiving, and so on. Medicaid is one of several programs that exist to ease the financial burden on families and make it easier for them to obtain care for their children. In this guide, we’ll look at how Medicaid works for autism.

The basics of Medicaid

Before we look at how Medicaid works with autism, it's important to understand the basics of this system. Here’s all you need to know:

  • What is Medicaid? - In simple terms, Medicaid is a federal and state program designed to assist low or limited-income people with the cost of their healthcare. 
  • How many people use it? - It is the biggest source of funding and financial aid for medical and health services in the United States, with over 70 million people, or close to a quarter of the population, being assisted by Medicaid in some way.
  • Stats and figures - Medicaid helps to cover the costs of around 50% of all births in the US and assists with healthcare costs for more than 28 million children, according to the latest statistics. It can also offer assistance with certain autism-related services.

Medicaid coverage of autism-related health services

Many people with autism, including both children and adults, are covered by Medicaid and can receive financial assistance with different autism-related health services. 

It's important to note, however, that even though Medicaid is funded at a federal level, each state has its own specific Medicaid program and individual state approaches and laws can vary.

Requirements for Medicaid assistance with autism

In order to receive assistance via Medicaid with autism-related health services, individuals need to meet a certain set of criteria. 

The following individuals are typically eligible for Medicaid:

  • Children who come from families that earn under a specific income, varying from state to state 
  • Children and adults who qualify for Supplemental Security Income, or SSI, because of their disabilities 
  • Those who pay for Medicaid via buy-in programs 
  • Adults earning less than 138% of the federal poverty level (FPL) - these individuals are classed as part of the 'Medicaid Expansion Population' and may qualify for alternative benefits via the Alternate Benefit Program (ABP)

Which autism-related health services are covered by Medicaid?

A wide range of autism-related health services can be covered by your Medicaid plan. The list below covers some of these services. However, it is important to remember that plans vary from state to state and case to case, so certain services may or may not be harder to obtain for certain families.

  • Diagnostic testing 
  • Neuropsychological evaluation 
  • Habilitative services 
  • Applied Behavior Analysis (ABA) therapy 
  • Physical therapy 
  • Communication therapy
  • Social therapy
  • Home healthcare services 
  • Prescription medications

Important laws regarding Medicaid

The specifics of Medicaid and your rights to claim autism-related services can be confusing to many. It's important to be aware of certain key laws, both at the federal and state level, in order to better understand how the system works, including the following:

  • The Federal Medicaid Law
  • The Affordable Care Act
  • The Mental Health Parity Act
  • State Plans

Below, we’ll go into deeper depth regarding each of these laws and how they work.

The federal Medicaid law

  • What is it? - The Federal Medicaid Law states that all individuals under the age of 21 who meet the requirements of Medicaid are entitled to EPSDT services, which stands for Early Periodic Screening, Diagnosis, and Treatment. 
  • What does it do? - Thanks to this law, states must cover all of the necessary autism-related services and interventions that qualify under the term "medical assistance", even if they are not included in the usual State Plan list. This provides a lot of opportunities for children with autism to get the care they need.
  • Additional aid for autism - The federal law also states that children with autism should be provided with an adequate network of care providers. If such a network cannot be provided by the state, families should be allowed to go out of the network and seek care elsewhere, while still having Medicaid coverage.

The affordable care act

  • What is it? -The Affordable Care Act was introduced in 2010 and is commonly referred to as "Obamacare". This law obliges various health care plans and systems, including Medicaid and the Medicaid Alternate Benefit Programs, to cover all "Essential Health Benefits''. 
  • What does it do? -This broad term includes mental health benefits and services for individuals living with autism, including speech therapy and social therapy for children with autism.

The mental health parity act

  • What is it? - There's also the Mental Health Parity Act, otherwise known as the Mental Health Parity and Addiction Equity Act of 2008, which may apply in situations involving individuals with autism. This act ensures that all health plans treat coverage of mental health conditions with the same level of care and fairness as they treat coverage for physical health conditions. 
  • What does it do? - Thanks to this act, people cannot be asked to pay more for mental health care services than they would for physical services, and restrictions cannot be imposed on mental services that would not be equally imposed on physical services. 
  • Aid for autism - This can be relevant to people with autism, as some plans could try to offer certain services, like physical therapy or occupational therapy, to those who have suffered physical injuries, but won't offer the same services for those who have autism. 
  • Equal rights - The act ensures that patients are treated equally and those with autism have the same rights as those who require similar services for other reasons. It can therefore be very valuable for individuals with autism who have been denied access to certain treatments or interventions that were deemed "not medically necessary" without a sufficient explication or justification.

State plans and mandates

  • What is it? - As stated above, Medicaid is regulated at both the federal level and at the state level. This can lead to complications, but more and more states are moving in the same direction regarding coverage for autism-related health services. In recent years, many states have even introduced their own laws and mandates, demanding that insurance companies and state Medicaid plans cover autism-related services. This is providing even more protection and coverage for families living with autism.
  • Caveats - However, there are some caveats to be aware of. Every state is different, with its own specific rules and approaches to autism-related health services, and some are more supportive of families living with autism than others.
  • Conditions vary - States like California and New York, for example, are very supportive and make autism-related interventions easy to obtain through Medicaid. They even offer grants and other benefits to families. Other states can be more controlling and strict, with specific age limits or caps on autism coverage.
  • Find out more - It’s important to contact authorities in your state, as well as speaking with your insurance provider and healthcare provider to find out more about what you and your family are entitled to through Medicaid, as well as other benefits that may be available for you.

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