Frequently Asked Questions

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.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:93386

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-PolicyGuidance/Downloads/CIB-07-07-14.pdf (PDF, 143.2 KB)), 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.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:93401

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 state's Medicaid program, a SPA is strongly encouraged to articulate the state's menu of services for ASD treatment.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:93406

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.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:93241

Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94276

The certification must be current. If it has lapsed but the physician still practices as an eligible specialist the self-attestation would need to be supported with a 60 percent claims history.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94296

As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94361

The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94376

States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.

FAQ ID:92686

The final rule specifies that such payments must be made no less frequently than quarterly, as does the final preprint issued by the Centers for Medicare & Medicaid Services (CMS).

FAQ ID:92691