Guidance on Medicaid and EPSDT Regarding Autism Treatment

The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees state Medicaid programs, now requires states to cover behavioral services for autism for children under 21, as well as other autism interventions. North Carolina is just starting to implement access to EPSDT for autism, including evidence-based intensive behavioral treatments.

 

What is EPSDT?

It stands for Early and Periodic Screening, Diagnostic and Treatment (EPSDT). EPSDT is a child health program in Medicaid to help the physical, developmental and mental health needs of children under the age of 21. The idea is to find and treat illnesses and developmental conditions early, so that children have the best chance in adulthood. Children who are on Medicaid are automatically qualified for EPSDT services; they and their families do not need to sign up for a separate program.

What is covered?

EPSDT covers screening and diagnostic tests for various illness or conditions, as well as medically necessary treatment. This can include:

  • Preventive screening
  • Comprehensive diagnostic evaluations
  • Behavioral assessment and the development of a treatment plan
  • Delivery of research-based intensive behavioral health treatment(s)*[RBI-BHT]

*There are many research-based treatments for autism. They may include interventions such as ABA (applied behavioral analysis), TEACCH (structured teaching), pivotal response training, “Floortime,” and other interventions that prevent or minimize the adverse effects of Autism Spectrum Disorder (ASD) and promote functioning of the person with ASD.

 

For more information, including how to access these services, please click here. That document can be downloaded and printed for reference.