California Healthline: Legal Expert Says State May Be Out of Compliance on Autism Therapy Benefit

By Tom Gorn

A legal expert at the National Health Law Program said California health officials might be flirting with legal risk by moving slowly to implement federal guidance on Medi-Cal coverage of autism treatment.

According to Kimberly Lewis, managing attorney of the Los Angeles office of the National Health Law Program, California is mandated to cover an autism treatment called applied behavior analysis as part of the Early and Periodic Screening, Diagnosis and Treatment benefits for all children covered by Medicaid. Federal guidance issued July 7 makes it clear that ABA therapy is an EPSDT benefit and should be provided for all Medi-Cal beneficiaries under age 21, Lewis said.

"If it's covered under the EPSDT mandate for children, then they have to cover it," Lewis said. "If it's medically necessary, that's a required benefit. It is our belief that this means the state is not in compliance with the EPSDT mandate."

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