Does Medicare cover autism services?

Symptoms of autism often show within the first 2 years of life, meaning a diagnosis is more common in children, although it can occur at any age. Medicare is health insurance typically for people over 65, so it would not usually cover services for autistic individuals under this age.

However, Medicaid may offer services such as screening and therapy to autistic people who qualify for coverage. It must also provide any medically necessary diagnostic or treatment services for eligible autistic children.

Medicaid also offers assistance and coverage for those with limited income or resources, including coverage for care and services that Medicare may not cover. However, specific benefits and eligibility requirements may differ from state to state.

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) ensures that people under 21 years receive certain services for early detection and prevention in addition to medically necessary care.

The EPSDT ensures that all children, including autistic children, get screenings to identify any health or developmental issues as early as possible.

This may be particularly important for autistic children, who may have a higher rate of comorbidities than those without autism.

The EPSDT emphasizes that clinicians should not assume symptoms are due to autism and rule out other potential medical causes to ensure children receive timely, suitable care.

The Centers for Medicare and Medicaid Services does not endorse any particular treatment or management service for autism spectrum disorder. Medicaid agencies are responsible for determining medically necessary services for eligible individuals.

Autistic people over 65 years will automatically qualify for Medicare. Those with end stage renal disease or amyotrophic lateral sclerosis may also be eligible for earlier coverage.

According to a 2019 study of Medicare data, nearly all physical and mental health conditions were more common in autistic older adults, including:

• cognitive (thinking) disorders
• osteoporosis
• heart disease
• osteoarthritis
• cancer

Adults who qualify for Medicare coverage may be able to access services and medically necessary care for co-occurring health conditions. However, services and medically necessary treatments may depend on the specific condition.

Autism does not qualify someone for a Medicare Special Needs Plan. However, adults with autism spectrum disorder and at least one other chronic condition may be eligible for Medicare’s chronic care management (CCM) services.

CCM services offer benefits such as a continuous relationship with a healthcare professional and constant access to care and health information.