The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Benefit
Washington Autism Alliance & Advocacy and Northwest Justice Project filed a lawsuit in U.S. District Court on April 26, 2012 regarding HCA’s lack of coverage for ABA therapy as part of the EPSDT obligation for children with autism. HCA had previously settled a lawsuit regarding its public employees health plan. HCA agreed to settle the lawsuit for Medicaid children and developed an ABA program for low-income children.
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is a required benefit for all “categorically needy” and “Medicaid eligible” children 3-21 years old (must be income eligible, receive Supplemental Security Income, or receive federal foster care or adoption assistance).
EPSDT’s rules reflect the greater health needs of low-income children, as well as children whose special health needs qualify them for assistance. It’s required in every state and is designed to improve the health of eligible children, by financing appropriate and necessary pediatric services.
***We need your input on the extremely fragmented access to developmental pediatricians, neuropsychologists, Speech, language & communication specialists with bonafide experience with autism, occupational therapists and ABA providers. Please call our office and share any information that reflects unreasonable distance you have to travel to access care OR if there are NO in network providers currently available to your child
THE EPSDT BENEFIT
These services include:
• Medical care or any other type of remedial care recognized under state law or furnished by licensed practitioners within the scope of their practice, as defined by state law (this includes psychosocial treatments and other structured behavior treatments such as Applied Behavior Analysis-WAAA reached a settlement with Medicaid to add ABA as a benefit under EPSDT.
• Home-based care
• Dental services
• Clinic services
• Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial service (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.
• Physician services
• Hospital services (outpatient and inpatient)
• Federal qualified health center services
• Rural health clinic services
• Case management
• Personal care services
• Any other medical or remedial care recognized by the Secretary of Health and Human Services
“Preventive” standard of medical necessity: recognized in agency implementing guidelines and a long line of judicial decisions, which recognizes the prevention of disabilities as the standard of coverage and emphasizes attainment of growth and development.
Necessary health care diagnosis services, treatment, and other measures classified as medical assistance to correct or ameliorate defects and physical and neurological chronic health conditions discovered by screening services, whether or not such services are covered under the state medical assistance plan.
Courts have consistently determined evidence based treatment for autism should be covered by EPSDT. Centers for Medicare and Medicaid Services (CMS), however, took the position that ALL autism related treatments are covered under IDEA for school aged children (3-21). This position was challenged in court over EPSDT coverage of (ABA),CMS lost.
CMS appealed the decision in the 6th Circuit court & lost. The precedence has been set that ABA/Behavioral therapies and Neurodevelopmental therapies SHOULD be covered through EPSDT, even in Washington state! If your child has been denied, visit our Appeals page, Washington Autism Alliance & Advocacy will help.