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Autism spectrum disorder (ASD) 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 and Asperger syndrome. These conditions are now all called Autism Spectrum Disorder (ASD).

Recognizing that states frequently use waivers to control utilization and cost of ASD services, the Centers for Medicaid and Medicare Services (CMS) provided states guidance in the use of different authorities to cover a variety of therapies.

The South Carolina Department of Health and Human Services (SCDHHS) elected to cover all medically necessary care for children with autism through age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. SCDHHS will amend the South Carolina Title XIX State Plan to include these covered services for ASD, effective on or after July 1, 2017.

In order to determine eligibility for ASD State Plan services, based on medical necessity as outlined in our policy manual, the following information is required:

  • Healthy Connections Medicaid member identification (ID) number
  • Beneficiary age between 0-21
  • Comprehensive assessment report with established diagnosis of ASD
    o    Includes diagnostic criteria and severity levels via Diagnostic and Statistical Manual of Mental Disorders (DSM) ASD diagnosis

Please contact an ASD provider directly to assist in requesting an authorization for ASD program services. The ASD provider list can be found on the For Members and Families tab under “Find an Autism Provider.”

 

 

 

 

 

 

 

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