Does Medicare Cover Autism Services?

According to the Centers for Disease Control and Prevention (CDC), approximately one in every 54 children has an autism spectrum disorder (ASD).

While there is no cure for autism, there are treatments available. Behavioral and educational interventions, complementary and alternative medicine, dietary changes, and medication may all be used to manage or alleviate autism symptoms.

One common question for those seeking treatment for themselves or a loved one is, “Does Medicare cover autism services?”

In this article, we answer the question in clear, plain English.

Does Medicare Cover Autism Services?

The short answer is yes; Medicare will often cover the cost of autism treatment. But this is not the case 100% of the time.

As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your autism treatment. Let’s look at these below, so you know what to expect.

Original Medicare Coverage of Autism Services

Original Medicare (Medicare Part A and Part B) provides coverage for autism treatment. This plan provides coverage for autism services if they are considered medically necessary. Usually, the treatment will have to be prescribed by a healthcare provider in order for Original Medicare to provide coverage.

As for the specifics, unfortunately, there is not much data regarding autism treatment coverage with Original Medicare.

When are Autism Services Covered by Part A versus Part B?

Coverage for health services such as autism treatment is provided by Medicare Part A if it takes place in an inpatient setting.

On the other hand, Medicare Part B provides coverage for these health services in an outpatient setting.

Medicare Part B also provides coverage for Chronic Care Management Services to beneficiaries with multiple chronic conditions, including autism.

Medicare Advantage Coverage of Autism Services

Similarly, Medicare Advantage plans (Medicare Part C) also provide coverage for autism. These plans must cover all the same conditions, treatments, services, and more that Original Medicare covers.

Medicare Advantage plans go above what Original Medicare offers, though. These plans include some benefits that Part A or B do not cover. However, precisely what a Part C plan covers and how much the out-of-pocket costs are will vary depending on the specifics of your plan.

How Much Does Autism Treatment Cost?

According to the CDC, the average medical expenditures of a child with ASD are $4,110 – $6,200 higher than those of a child without ASD. Health care, education, ASD-related therapy, family-coordinated services, and caregiver time are all included in the costs.

In addition to these medical costs, intensive behavioral interventions cost between $40,000 and $60,000 per child per year for children with ASD.

For children aged four or younger, intensive behavioral interventions may consist of 20-40 hours per week of individualized instruction that typically lasts 2-3 years.

What Are Treatment Options For Autism?

Applied Behavior Analysis (ABA) therapy is one type of treatment for autism. ABA therapy is an evidence-based treatment option for individuals with ASD and is covered by insurance when medically necessary. ABA treatment is frequently covered by private insurance when medically necessary.

Other types of treatments can generally be classified as follows, although some treatments employ multiple approaches:

Developmental
Educational
Social-Relational
Pharmacological
Psychological
Complementary and Alternative

Autism can be managed through different approaches, but therapy is the most effective treatment for it.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.