DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
Medicaid and CHIP FAQs: Services to Address Autism 
September 2014  
 
On July 7, 2014, CMCS issued an Informational Bulletin (CIB) (see 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf) to provide 
information on approaches available under Medicaid for providing services to individuals with 
Autism Spectrum Disorder (ASD).  In this CIB, CMS discussed the various authorities under 
which services to address ASD could be reimbursed including section 1905(a) of the Social 
Security Act (the Act).   Services to address ASD can be covered under three benefit categories: 
Section 1905(a) (6) Other Licensed Practitioner (OLP), section 1905(a) (13) Preventive Services, 
and section 1905(a) (11) Therapies. 
 
The informational bulletin also reviewed state obligations under section 1905(a)(4)(B)  of the 
Act, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit,  where states 
must cover all medically necessary services for children, including services to address ASD.  
 
Q1: Has CMS mandated Applied Behavior Analysis (ABA) services for children under 21 with 
Autism Spectrum Disorder (ASD)?  
 
A1:  No. Applied Behavior Analysis (ABA) is one treatment modality for ASD.  CMS is not 
endorsing or requiring any particular treatment modality for ASD.  State Medicaid agencies 
are responsible for determining what services are medically necessary for eligible 
individuals.  States are expected to adhere to long-standing EPSDT obligations for 
individuals from birth to age 21, including providing medically necessary services available 
for the treatment of ASD.   
 
Q2:When will CMS begin to assess state compliance with coverage requirements for children 
with Autism Spectrum Disorder (ASD)?   
 
A2: There is no specific time frame for CMS review of state practices in this area. The CMCS 
Informational Bulletin released July 7, 2014 (see http://www.medicaid.gov/Federal-Policy-
Guidance/Downloads/CIB-07-07-14.pdf), related to Autism Spectrum Disorder discusses 
the obligations under the Medicaid statute and regulations that are already in effect.  
However, CMS recognizes that states may not have focused on the application of these 
requirements in this area.  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.  States may also want to confer with the stakeholder community for 
public input on the benefit design of autism services for children.  CMS believes states 
should complete this work expeditiously and should not delay or deny provision of 
medically necessary services.  CMS is available to provide technical assistance to states to 
ensure the availability of services that children may need.   
Q3: Do states need to submit a Medicaid state plan amendment (SPA) to offer benefits to 
individuals with Autism Spectrum Disorder (ASD)? 
 
A3: In order to have services reimbursed under the Federal Medicaid program, a service must 
meet the definition of a coverable service under section 1905(a) of the Social Security 
Act.  Treatment for ASD is not specifically referenced as a section 1905(a) service.  
However, some treatment modalities, or components of such treatment modalities, are 
within the scope of the federal Medicaid program under the following service categories: 
section 1905(a)(6) Other Licensed Practitioner (OLP), section 1905(a)(13) Preventive 
Services, and section 1905(a)(11) Therapies :.   States may provide services to address ASD 
under each of these benefit categories.  States will need to determine what, if any, steps 
are needed to implement this policy clarification.  In keeping with the role of the Medicaid 
state plan as a comprehensive written statement of the nature and scope of services 
available under the states Medicaid program, a SPA is strongly encouraged to articulate 
the states menu of services for ASD treatment.  
 
Q4:  How should a state that has a section 1915(c) home and community-based services 
waiver that is limited to EPSDT-age individuals but includes services related to Autism 
Spectrum Disorder (ASD) that are now available through the state plan respond to this 
policy clarification?  
 
A4: The ASD-related services should be provided through the Medicaid state plan for the 
EPSDT-eligible individuals, rather than the 1915(c) waiver.  CMS will work with states to 
ensure that such services are able to be made available under the state plan.  Accordingly, 
CMS with also work with states to remove the service from the 1915(c) home and 
community-based services waiver at the next amendment or renewal, whichever comes 
first. 
 
Q5: How should a state that has a section 1915(c) home and community-based services 
waiver that includes individuals in the EPSDT age group and also individuals beyond their 
21st birthday address the Autism Spectrum Disorder (ASD)-related services that are now 
available through the Medicaid state plan?  
 
A5:  The ASD-related services for EPSDT eligible individuals (under age 21) must be provided 
under the Medicaid state plan and not under the 1915(c) waiver.  When the state submits 
the home and community-based services waiver for renewal or amendment, the state 
should include a restriction under the limits section for that specific service indicating that 
EPSDT-aged individuals are excluded as the services are fully covered in the state plan.  
ASD-related services for individuals over age 21 may continue to be provided under the 
1915(c) waiver. 
 
 
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