Expanding Medicaid Access for Children with ASD Through Home-and-Community-Based Waivers and the TEFRA Medicaid Eligibility Option: A National Study

Background: While the number of youth diagnosed with autism spectrum disorders (ASD) has grown dramatically, both commercial plans and public insurance programs have been slow to include the types of services that result in the greatest improvements for children with ASD. Commercial plans often limit the type and intensity of services available to youth with ASD or exclude ASD as a covered diagnosis altogether (Peele, Lave, & Kelleher, 2002). Standard state Medicaid plans also limit the types of available services (Ridgely & Maglione, 2006).

There are at least two ways that states can be flexible in the way that they use Medicaid dollars to improve access for youth with ASD. First, a state can apply for a federally-approved Medicaid waiver, which permits states to disregard or waive particular Medicaid requirements. For example, states could expand access by allowing youth in higher-income families to qualify for Medicaid; they also can add services that are not included in the state’s regular Medicaid plan. Second, states can exercise the TEFRA Medicaid eligibility option, which allows youth in higher-income families to qualify for Medicaid and therefore access all services available under the state’s regular Medicaid plan (R. M. Semansky & Koyanagi, 2004).

Studies estimate that as many as one third of children diagnosed with ASD in the US are served through the Medicaid system (Mandell et al., 2010; R. Semansky, Xie, & Mandell, Under review); however, little is known about the extent to which states expand access for youth with ASD through these Medicaid-specific policies.

Objectives: This study determined which states allow children to quality on the basis of their ASD diagnosis only for Medicaid home-and-community based waivers and the TEFRA eligibility option.

Methods: Trained research staff collected available rules, program descriptions and other relevant information on each state’s Medicaid waivers and eligibility processes through searches of online databases. Brief telephone interviews were conducted with state Medicaid staff and protection and advocacy legal staff to confirm the characterization of each state’s Medicaid program.

Results: By 2010, 10 states had implemented autism-specific Medicaid waivers. Though nearly all states have broadly-focused home-and-community based waivers for intellectual disabilities/development disabilities, only a small number permit children with ASD to qualify. Children diagnosed with Asperger’s syndrome are often explicitly excluded from the waivers. The TEFRA Medicaid eligibility option has been adopted by one-third of states and a small but growing number of states allow children with autism diagnosis to qualify. Analyses regarding the specific eligibility requirements and covered services under these waivers is ongoing.

Conclusions: These findings indicate that more can be done to improve access to Medicaid coverage for youth with ASD. State officials, autism service providers, families of youth with ASD have opportunities to expand access to Medicaid-reimbursed services by advocating for the adoption of autism-specific HCBWs and the TEFRA Medicaid eligibility option in their state