DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
CMCS Informational Bulletin 
 
 
DATE:  July 7, 2014 
 
FROM:  Cindy Mann, Director 
    Center for Medicaid and CHIP Services 
 
SUBJECT:  Clarification of Medicaid Coverage of Services to Children with Autism 
 
In response to increased interest and activity with respect to services available to children with 
autism spectrum disorder (ASD), CMS is providing information on approaches available under 
the federal Medicaid program for providing services to eligible individuals with ASD. 
  
Background 
Autism spectrum disorder is a developmental disability that can cause significant social, 
communication and behavioral challenges.  A diagnosis of ASD now includes several conditions 
that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not 
otherwise specified (PDD-NOS), and Asperger syndrome. These conditions are now all called 
autism spectrum disorder.  Currently, the Center for Disease Control and Prevention (CDC) 
estimates that approximately 1 in 68 children has been identified with ASD. 1  
 
Treatments for children with ASD can improve physical and mental development.  Generally 
these treatments can be categorized in four categories:  1) behavioral and communication 
approaches; 2) dietary approaches; 3) medications; and 4) complementary and alternative 
medicine. 2  While much of the current national discussion focuses on one particular treatment 
modality called Applied Behavioral Analysis (ABA), there are other recognized and emerging 
treatment modalities for children with ASD, including those described in the ASD Services, 
Final Report on Environmental Scan (see link below)3.  This bulletin provides information 
related to services available to individuals with ASD through the federal Medicaid program. 
 
The federal Medicaid program may reimburse for services to address ASD through a variety of 
authorities.  Services can be reimbursed through section 1905(a) of the Social Security Act (the 
Act), section 1915(i) state plan Home and Community-Based Services, section 1915(c) Home 
                                                            
1 http://www.cdc.gov/ncbddd/autism/facts.html 
2 http://www.cdc.gov/ncbddd/autism/treatment.html 
3  http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-
Supports/Downloads/Autism-Spectrum-Disorders.pdf 
   Page 2-CMCS Informational Bulletin 
and Community-Based Services (HCBS) waiver programs and section 1115 research and 
demonstration programs. 
 
State Plan Authorities  
Under the Medicaid state plan, services to address ASD may be covered under several different 
section 1905(a) benefit categories.  Those categories include:  section 1905(a)(6) - services of 
other licensed practitioners; section 1905(a)(13)(c) - preventive services; and section 1905(a)(10) 
- therapy services.  States electing these services may need to update the Medicaid state plan in 
order to ensure federal financial participation (FFP) is available for expenditures for these 
services.  In addition, for children, as discussed below, states must cover services that could 
otherwise be covered at state option under these categories consistent with the provisions  at 
1905(a)(4)(B) for Early and Periodic Screening, Diagnostic and Treatment services (EPSDT).  
Below is information on these coverage categories for services to address ASD.  Under these 
section 1905(a) benefit categories all other state Medicaid plan requirements such state-wideness 
and comparability must also be met. 
 
Other Licensed Practitioner Services  
Other Licensed Practitioner services (OLP) services, defined at 42 CFR 440.60, are medical or 
remedial care or services, other than physicians services, provided by licensed practitioners 
within the scope of practice as defined under State law.  If a state licenses practitioners who 
furnish services to address ASD, the state may elect to cover those providers under this section 
of their state plan even if the providers are not covered under other sections of the plan (e.g., 
physical therapist, occupational therapist, etc.).  A state would need to submit a state plan 
amendment (SPA) to add the new licensed provider to their Medicaid plan.  The SPA must 
describe the providers qualifications and include a reimbursement methodology for paying the 
provider. 
 
In addition, services that are furnished by non-licensed practitioners under the supervision of a 
licensed practitioner could be covered under the OLP benefit if the criteria below are met:   
  Services are furnished directly by non-licensed practitioners who work under the 
supervision of the licensed practitioners;  
  The licensed provider is able to furnish the service being provided;  
  The states Scope of Practice Act for the licensed practitioners specifically allows the 
licensed practitioners to supervise the non-licensed practitioners who furnish the service;  
  The states Scope of Practice Act also requires the licensed practitioners to assume 
professional responsibility for the patient and the service furnished by the unlicensed 
practitioner under their supervision; and  
  The licensed practitioners bill for the service; 
Preventive Services 
Preventive Services, defined at 42 CFR 440.130(c) are services recommended by a physician or 
other licensed practitioner of the healing arts within the scope of his practice under state law to 
(1) Prevent disease, disability, and other health conditions or their progression; 
(2) Prolong life; and 
(3) Promote physical and mental health and efficiency   Page 3-CMCS Informational Bulletin 
 
A regulatory change that took effect January 1, 2014, permits coverage of preventive services 
furnished by non-licensed practitioners who meet the qualifications set by the state, to furnish 
services under this state plan benefit as long at the services are recommended by a physician or 
other licensed practitioner.  Under the preventive services benefit, in the state plan, the state must 
1) list the services to be provided to ensure that services meet the definition of preventive 
services as stated in section 4385 of the State Medicaid Manual (including the requirement for 
the service to involve direct patient care); 2) identify the type(s) of non-licensed practitioners 
who may furnish the services; and 3) include a summary of the states provider qualifications 
that make these practitioners qualified to furnish the services,  including any required education, 
training, experience, credentialing, supervision, oversight and/ or registration.  
 
Therapy Services  
Physical therapy, occupational therapy and services for individuals with speech, hearing and 
language disorders, may be covered under the Medicaid therapies benefit at 42 CFR 440.110.  
Physical and occupational therapy must be prescribed by a physician or other licensed 
practitioner of the healing arts within the scope of his/her practice under state law and provided 
to a beneficiary by or under the direction of a qualified therapist.  Services for individuals with 
speech, hearing and language disorders mean diagnostic, screening, preventive or corrective 
services provided by or under the direction of a speech pathologist or audiologist, for which a 
patient is referred by a physician or other licensed practitioner of the healing arts within the 
scope of his or her practice under state law.  
 
States would need to include an assurance in the state plan that the state furnishes the therapy in 
accordance with 42 CFR 440.110.   States would also need to describe the supervisory 
arrangements if a practitioner is furnishing the therapy under the direction of a qualified 
therapist.  Finally, for audiology services, the state plan must reflect the supervision requirements 
as set forth at 42 CFR 440.110(c)(3). 
 
Section 1915(i) of the Social Security Act 
States can offer a variety of services under a section 1915(i) state plan Home and Community-
Based Services (HCBS) benefit.  The benefit may be targeted to one or more specific populations 
including individuals with ASD and can provide services and supports above and beyond those 
included in section 1905(a).  Participants must meet state-defined criteria based on need and 
typically receive a combination of acute-care medical services (like dental services, skilled 
nursing services) and other long-term services such as respite care, supported employment, 
habilitative supports, and environmental modifications. 
 
Other Medicaid Authorities  
 
There are several other Medicaid authorities that may be used to provide services to address 
ASD.  Below is a discussion of each of those authorities: 
 
Section 1915 (c) of the Social Security Act   
The section 1915(c) Home and Community-Based Services waiver program allows states to 
provide a combination of medical services and long-term services and supports.  Services include   Page 4-CMCS Informational Bulletin 
but are not limited to adult day health services, habilitation (both day and residential), and respite 
care.  States can also propose other types of services that may assist in diverting and/or 
transitioning individuals from institutional settings into their homes and community.  Participants 
must meet an institutional level of care but are served in the community.  Section 1915(c) waiver 
programs also require that services be furnished in home and community-based settings.  For 
individuals under the age of 21 who are eligible for EPSDT services, an HCBS waiver could 
provide services and supports for ASD that are above and beyond services listed in section 
1905(a), such as respite care.  Additionally, for individuals who are receiving state plan benefits 
as part of EPSDT that are not available to adults under the state plan, waiver services may be 
used to help these individuals transition into adulthood and not lose valuable necessary services 
and supports. 
 
Section 1115 Research and Demonstration Waiver  
Section 1115 of the Act provides the Secretary of the Department of Health and Human Services 
broad authority to authorize experimental, pilot, or demonstration programs that promote the 
objectives of the Medicaid program.  Flexibility under section 1115 is sufficiently broad to allow 
States to test substantially new ideas, including benefit design or delivery system reform, of 
policy merit.  The Secretary can approve an 1115 demonstration for up to five years, and states 
may submit extension requests to continue the program for additional periods of time. 
Demonstrations must be "budget neutral" over the life of the program, meaning they cannot be 
expected to cost the Federal government more than it would cost without the demonstration. 
 
 EPSDT Benefit Requirements 
 
Section 1905(r) of the Act defines the EPSDT benefit to include  a comprehensive array of 
preventive, diagnostic, and treatment services for low-income infants, children and adolescents 
under age 21.  States are required to arrange for and cover for 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.  The 
EPSDT benefit is more robust than the Medicaid benefit package required for adults and is 
designed to assure that children receive early detection and preventive care, in addition to 
medically necessary treatment services, so that health problems are averted or diagnosed and 
treated as early as possible.  All children, including children with ASD, must receive EPSDT 
screenings designed to identify health and developmental issues, including ASD, as early as 
possible.  Good clinical practice requires ruling out any additional medical issues and not 
assuming that a behavioral manifestation is always attributable to the ASD.  EPSDT also 
requires medically necessary diagnostic and treatment services.  When a screening examination 
indicates the need for further evaluation of a childs health, the child should be appropriately 
referred for diagnosis and treatment without delay.  Ultimately, the goal of EPSDT is to assure 
that children get the health care they need, when they need it  the right care to the right child at 
the right time in the right setting. 
 
The role of states is to make sure all covered services are available as well as to assure that 
families of enrolled children, including children with ASD, are aware of and have access to a 
broad range of services to meet the individual childs needs; that is, all services that can be 
covered under section 1905(a), including licensed practitioners services; speech, occupational,   Page 5-CMCS Informational Bulletin 
and physical therapies; physician services; private duty nursing; personal care services; home 
health, medical equipment and supplies; rehabilitative services; and vision, hearing, and dental 
services. 
 
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 states 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.  This longstanding coverage design is intended to ensure a comprehensive, high-quality 
health care benefit for eligible individuals under age 21, including for those with ASD, based on 
individual determinations of medical necessity. 
 
Implications for Existing Section 1915(c), Section 1915 (i) and Section 1115 Programs 
In states with existing 1915(c) waivers that provide services to address ASD, this 1905(a) policy 
clarification may impact on an individuals eligibility for the waiver.  Waiver services are 
separated into two categories:  waiver services and extended state plan services.  Extended state 
plan services related to section 1905(a) services are not available to individuals under the age of 
21 (individuals eligible for EPSDT) because of the expectation that EPSDT will meet the 
individuals needs.  There are therefore a limited number of services that can be provided to this 
age group under 1915 (c) waivers, primarily respite, and/or environmental/vehicle modifications.   
For states that currently provide waiver services to individuals under age 21 to address ASD, the 
ability to provide services under the 1905(a) state plan may have the effect of making these 
individuals ineligible for the waiver unless another waiver service is provided.  This implication 
is especially important for individuals with ASD who may not otherwise be eligible for Medicaid 
absent the (c) waiver.  States need to ensure that these individuals are receiving a waiver service, 
not coverable under section 1905(a), to ensure that they do not lose access to all Medicaid 
services by losing waiver eligibility.  Individuals age 21 and older may continue to receive 
services to address ASD through the waiver if a state does not elect to provide these services to 
adults under its Medicaid state plan.   
The same issues arise for children under the 1915(i) authority, which allows for services above 
and beyond section 1905(a) to be provided under the state plan.  CMS is available to provide 
technical assistance to states that currently have approved waivers or state plans that may be 
impacted by this clarification.  Similarly, states with existing 1115 demonstrations authorizing 
reimbursement for services provided to children with autism should contact CMS to ensure that 
EPSDT requirements are met. 
 
We hope this information is helpful.  If you have questions please send them to 
AutismServicesQuestions@cms.hhs.gov.