Guide to Using Medicaid for Autism Treatment in 2021
Medicaid is a federal program meant to work as a critical safety net for people who need health care but can’t afford to pay for it. If your family meets financial benchmarks, you could qualify right away. If you don’t, you may need to prove that one family member has a disability that qualifies them for Medicaid.
Autism is considered a disability via Medicaid rules. If you’re accepted into the program, you can get help for the treatments you need. Despite what you may have heard or read, Medicaid is considered a good form of insurance. In fact, people with Medicaid get coverage equal to or better than what’s available in private programs.
But Medicaid does come with drawbacks you should know about as you determine if it’s the right choice for your family in 2021.
How Does Medicaid Work?
Think of Medicaid as a project shared by federal and state governments. They both add money to keep the work going, and they both have a say in how the money is spent.
The Kaiser Family Foundation explains that Medicaid is based on two guarantees.
- Coverage: People who meet requirements will get help. You can’t qualify and get a denial based on a technicality.
- Funding: States pay for qualified services for people who are eligible for Medicaid. The dollars spent by the states get matched by the federal government. Some states get a 50% match; others get a little more or a little less.
States have quite a bit of Medicaid leeway. They can determine what sorts of things are covered and set limits on other types of care. But experts say some of their decisions are locked if these states want to secure federal funding. For example, states must cover mandatory populations, including:
- Children up to age 18 from low-income families.
- Pregnant women from low-income families.
- Parents or caretakers in low-income families.
- Seniors and people with disabilities who get cash assistance through the Supplemental Security Income program.
States determine how to distribute health care. Most use managed care plans, and those look very similar to those used by people with private health insurance. But other states use health homes or accountable care organizations.
In general, you must use providers that accept Medicaid payments. Not all doctors, hospitals, and health clinics accept that form of insurance. If you step outside of the network Medicaid uses in your state, you could be stuck with some or all of the bill.
Medicaid plans cover several different forms of autism treatment, as mandated by the Department of Health and Human Services. Those treatment types include:
- Speech, physical, and occupational therapy.
- Physician services.
- Private-duty nursing.
- Personal care services.
- Home health.
- Medical equipment.
- Rehabilitation services.
- Vision care.
- Dental care.
Applied behavior analysis (ABA) is the gold standard of treatment for people with autism, and parents might enroll in Medicaid to pay for that care. Medicaid doesn’t explicitly mandate ABA coverage. In fact, the Department of Health and Human Services says ABA is just one type of autism treatment, and the organization doesn’t endorse one form of care over another.
In some states, ABA is routinely covered. But due to this gray area, some states require families to use other therapies instead. Confirm that a particular type of therapy is covered by Medicaid before you commit. This will prevent financial surprises down the road.
How to Apply for Medicaid in 2021
Choose one of two ways to apply for Medicaid in your state. No matter which method you pick, prepare to gather information about your income, health history, and family ties.
The Centers for Medicare and Medicaid Services says you can sign up for Medicaid via:
- The Health Insurance Marketplace. This is the website families use to buy insurance that comes with subsidies from the federal government. The application is online, and you must answer several questions. If you qualify, you’ll find out right away.
- Your state Medicaid agency. If you’re uncomfortable using computers to fill out important forms, contact the Medicaid agency within your state. Meet with an expert and talk about your eligibility in person.
Some families don’t quite meet eligibility requirements for Medicaid, but they do need financial assistance. If you’re in this category and you use the Health Insurance Marketplace, you’ll find that out when you apply, and you’ll see options that help you choose the health insurance plan that’s right for you.
But be careful. If you qualify for Medicaid, you can’t decline the offer and ask for subsidized health insurance. The program doesn’t work that way, experts say.
How Do States Use Medicaid for Autism Care?
Since states dictate how money is spent within their borders, coverage varies widely depending on where you live. That’s especially true if you’re searching for information about Medicaid autism coverage.
Consider ABA therapy. Here’s a rundown of how a few states deal with requests to cover that form of autism treatment:
- Texas: In 2019, the governor signed a budget bill that mandated Medicaid coverage for necessary autism care, including ABA therapy.
- Utah: ABA benefits are available, but they must be provided by someone specially trained to hold treatment sessions.
- North Carolina: The Medicaid authority in this state recognizes that ABA might be right for some people, but the organization also says some people could benefit from another form of treatment. Coverage isn’t guaranteed.
- Washington: ABA is covered for people ages 2 through 20.
The Centers for Medicare and Medicaid Services keeps a comprehensive list of all state offices. Contact the department in your state for more information on how ABA is handled where you live.
Enroll in Medicaid, and most of your health care costs are covered. You won’t have a monthly premium to pay, and if you work within the network, you may not have copayments to make either. But Medicaid does have a few limitations all families should be aware of.
Common limitations include:
- Denials. Your state may cover only one type of autism treatment, or the plan won’t cover therapies that aren’t delivered by a specific type of trained professional. Confirm the professional you choose fits the requirements before enlisting in therapy.
- Lack of approved professionals. Doctors, therapists, and other treatment providers must accept Medicaid payments. Sometimes, families can’t find anyone to care for their children with autism due to the low reimbursement rates Medicaid offers.
- Political battles. Some legislators aim to keep the federal budget in check, and they hope to do that by cutting Medicaid entitlements. Federal Medicaid fund caps could strip families of the care they need, even if they qualify for subsidized treatment through Medicaid.
- Age caps. Most of the autism treatments we’ve discussed apply to children. Once people celebrate their 21st birthday, most benefits stop. There aren’t comparable programs for adults, advocates say, even when those adults still qualify for Medicaid.
These limitations shouldn’t dissuade you from Medicaid autism coverage. If you qualify, the program offers real help for your family. But it’s good to know as much as you can about the program before you sign up.
Medicaid Autism Benefits Are Real
It’s worth repeating: Coverage through Medicaid is worthwhile for the families that qualify.
Your coverage could help your family:
- Go back to work. Researchers say families that gain Medicaid coverage get so much help that family members can return to the workforce. That could give your family a real economic boost.
- Get good health care. Researchers say the coverage you get through Medicaid is as good as (or better) than the benefits you’d get through a private health insurance company.
- Save money. Researchers also say that people with Medicaid coverage have a lower risk of high out-of-pocket expenses, when compared to people with private insurance coverage.
Given all of these benefits, it makes sense for families to at least try to access Medicaid autism coverage in 2021. It could be just what you need to get your family back on track.
- 10 Things to Know About Medicaid: Setting the Facts Straight. (March 2019). Kaiser Family Foundation.
- Policy Basics: Introduction to Medicaid. (April 2020). Center on Budget and Policy Priorities.
- Frequently Asked Questions About Medicaid. (November 2019). Center on Budget and Policy Priorities.
- Clarification of Medicaid Coverage of Services to Children With Autism. (July 2014). Department of Health and Human Services.
- Medicaid and CHIP FAQs: Services to Address Autism. (September 2014). Department of Health and Human Services.
- Medicaid and CHIP Coverage. U.S. Centers for Medicare and Medicaid Services.
- Is Medicaid Good Insurance? (December 213). Consumer Reports.
- Texas Medicaid Adds Coverage for Autism. (June 2019). Autism Speaks.
- Utah Medicaid Provider Manual. (March 2019). Division of Medicaid and Health Financing.
- Autism-Related Services in North Carolina. (2015). Disability Rights North Carolina.
- Autism and Applied Behavior Analysis Therapy. Washington State Health Care Authority.
- Contact Your State With Questions. Centers for Medicare and Medicaid Services.
- Health Insurance and Medicaid Coverage for Autism Services: A Guide for Individuals and Families. (May 2015). Autistic Self-Advocacy Network.
- Children with Autism Left Behind by Low Medicaid Rates. (June 2018). The Pew Charitable Trusts.
- Medicaid’s Role for Children With Special Health Care Needs: A Look at Eligibility, Services, and Spending. (June 2019). Kaiser Family Foundation.
- Medicaid Must Cover Autism Care for Kids, but What About Adults? (September 2014). Governing.
- Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce the Need for Parents to Stop Working. (February 2017). Health Affairs.
- New Report: Medicaid Provides Equal- or Better-Quality Health Insurance Coverage Than Private Plans as Well as More Financial Protections. (April 2017). The Commonwealth Fund.
- Access and Quality of Care by Insurance Type for Low-Income Adults Before the Affordable Care Act. (August 2016). American Journal of Public Health.
- Federal Officials Order Medicaid to Cover Autism Services. (August 2014). Kaiser Health News.
- Caring for People With ASD and Their Caregivers: Federal and State Autism-Specific Insurance Reform. (2015). AMA Journal of Ethics.
- Medicaid Still Has a Bull’s-Eye on Its Back. (September 2017). Spectrum.
- Bill Advances to Expand Medicaid Coverage for Early Autism Diagnosis. (March 2019). Commercial News.
- Medicaid Providers at the End of the Line for Federal Coronavirus Funding. (May 2020). Disability News.