On July 7, 2014, the Centers for Medicare and Medicaid Services (“CMS”), the Federal office responsible for overseeing Medicaid programs, issued an informational bulletin to Medicaid agencies and constituents. This important communication affirms the availability of Medicaid funding for Applied Behavioral Analysis (“ABA”) services if federal requirements are met.
CMS affirmed the following points:
- Autism spectrum disorder (“ASD”) is a developmental disability that can cause significant social, communication, and behavioral challenges.
- Treatments for children with ASD can improve physical and mental development.
- The federal Medicaid program may reimburse for services, including, but not limited to, ABA to address ASD.
- States are required to arrange for and cover individuals eligible for the EPSDT benefit any Medicaid coverable service listed in section 1905(a) of the Act that is determined to be medically necessary to correct or ameliorate any physical or behavioral conditions.
- Under EPSDT, if a service, supply, or equipment that has been determined to be medically necessary for a child is not listed as covered (for adults) in a state’s Medicaid State Plan, the state will nonetheless need to arrange for and cover it for the child, as long as the service or supply is included within the categories of mandatory and optional services listed in section 1905(a) of the Social Security Act.
What is EPSDT?
EPSDT stands for Early and Periodic Screening, Diagnosis, and Treatment.
EPSDT is a mandatory Medicaid program; if a state elects to participate in Medicaid, it must provide EPSDT services. EPSDT covers diagnostic and treatment services for both physical and mental conditions. The definition of treatment services is broad and it includes access to all services that Medicaid covers, whether or not the service is included in a Medicaid state plan.
Ohio’s version of EPSDT is called Healthchek. It provides a group of services to children and teens (birth through age 20) which include prevention, diagnosis, and treatment. The purpose of Healthchek is to discover and treat health problems early. These services are marketed as Healthchek to parents as a set of preventive health screenings with follow-up diagnosis and treatment.
Court Cases on EPSDT in Ohio
Three cases have affirmed the importance of EPSDT services and ruled that applied behavior analysis (ABA) programs for children with autism are covered by EPSDT.
In Hummel v. ODJFS, 164 Ohio App. 3d 776 (Lucas App. 2005), the Ohio state court held that ABA services were covered by EPSDT for a child with autism. The court found substantial evidence that ABA is medically necessary for the child and that that ABA is a medical service covered by Medicaid.
In PLEAS v. Jones-Kelley U.S. District Court of Ohio, Southern District Case No. 2:08-cv-421 decided on June 30, 2008 (revised July 1, 2008), the Court issued a preliminary injunction prohibiting changes in rules which affected ABA services. The Court relied primarily on the EPSDT requirements. The Sixth Circuit affirmed the grant of preliminary injunction. PLEAS v. Jones-Kelley 339 Fed. Appx. 542; 2009 U.S. App. LEXIS 16637 (July 29, 2009).
In G.D. v. Riley, U.S. District Court of Ohio, Southern District Case No. 2:05-cv-00980, the parties entered into a consent decree which addressed methods of ensuring adequate notice of Healthchek benefits. The court is still reviewing the definition of medical necessity.
How to Access EPSDT Services
The child must be Medicaid eligible. If the family does not qualify for Medicaid directly, the child may become eligible by getting a waiver, such as a Home Care, Level One, or Individual Options waiver.
A qualified physician or other qualified professional must evaluate the child and define what services are medically necessary. The Ohio definition of medical necessity can be found at OAC 5101:3-1-01; there are some differences between the Ohio and Federal definitions which are being reviewed by the Federal Court in G.D. v. Riley.
If a service or group of services is identified as medically necessary, you, your case manager, or service and support administrator should explore all reasonably available alternatives to see if the child’s needs can be met with existing Medicaid services, either locally or somewhere in Ohio. It is prudent to seek assistance from the Family and Children First Council, local school district, and other resources. Be sure to document all contacts and communications in the process of trying to obtain local suitable services.
If the identified needs cannot be met with local or state-wide resources, or if the services are denied, it is possible to seek a prior authorization for necessary services (procedures are at OAC 5101:3-1-31). This process allows the Department of Job and Family Services (DJFS) to review individual cases and decide that additional services are necessary. If the DJFS denies additional services, you can file an appeal under section 5101.35 of the Ohio Revised Code. If services were denied you may file an appeal directly, without going through the prior authorization process. Whenever a service has been changed, terminated or denied, DJFS must give you notice of denial and a summary of the appeal process.