Medicaid and Autism Spectrum Disorder

For many Georgia families, Medicaid is the best option for getting autism services for their child.  However, navigating government services can get complicated.  Below, we talk about what Medicaid is, how to apply for it, and what Medicaid can do for autistic people.

What is Medicaid?

Medicaid is a health insurance program that pays medical bills for eligible people with low-incomes. Medicaid is funded by the state and federal governments. In Georgia, Medicaid is administered by the Georgia Department of Community Health (DHC).  

To learn more, follow this link:  https://medicaid.georgia.gov/general-information-faqs

Who is eligible for Medicaid?

Eligibility varies by state. The Georgia Medicaid website states that you should apply for Medicaid if you have a low income and match one the following descriptions:

• You think you are pregnant
• You are a child or teenager age 18 or under
• You are over the age of 65
• You are legally blind
• You have a disability
• You need nursing home care
• You have been diagnosed with breast or cervical cancer

Other situations which may make you eligible:

• If you are leaving Temporary Assistance for Needy Families (TANF) and need health coverage.
• If you are a family with children under 19 and have very low or no income.
• If your income is higher than the limits and you have medical bills you owe (and you are pregnant, under 18 or over 65, blind, or disabled).
• If a child is in foster care or adopted
• If you or someone in your family needs health care, you should apply for Medicaid even if you are not sure whether you qualify.  Some income and resources do not count against you.  For example, owning your home may not stop you from getting Medicaid. Every group has its own income limits, which increase on a regular basis.

Income limits vary by family size and situation.  To determine if you qualify for Medicaid, you can speak with your local Division of Family & Children Services (DFCS) office.  You can call the DFCS information line at 877-423-4746 for someone to direct you to your local office. Alternatively, you can click here to search for the contact information of your county’s DFCS office.

To learn more, follow this link: https://medicaid.georgia.gov/eligibility-faqs

Katie Beckett Program

For the Katie Beckett Program, family income may be ignored for Medicaid eligibility if a child living at home is disabled and requires a high level of care.  Conditions like autism are recognized as potentially disabling (note: an autism diagnosis alone may not be enough to qualify for this program).  An application can be obtained by contacting the Centralized Katie Beckett Medicaid Team at 678-248-7449 or from your local DFCS office.

To learn more, follow this link: https://medicaid.georgia.gov/programs/all-programs/tefrakatie-beckett

Citizenship & Residency

You must be a Georgia resident and either a U.S. citizen or legally residing non-citizen to obtain full Medicaid benefits in Georgia. Non-citizens (residing legally or illegally) can qualify for emergency coverage if income requirements are met. For more information, click the link below.

Link: https://medicaid.georgia.gov/citizenship-and-residency-faqs#:~:text=To%20obtain%20full%20Medicaid%20benefits,if%20income%20requirements%20are%20met.

How do I apply?

You can apply using one of the following methods: 

Online: www.gateway.ga.gov

Phone: Call 877-423-474

Mail: An application from this link can be filled out and mailed to:  

Division of Family and Children Services

Customer Contact Center

P.O. Box 4190

Albany, GA 31706 

What do I need in order to apply for Medicaid?

Some things you may need to determine eligibility include: 

• Social security numbers (or document numbers)
• Employer and income information for everyone in your family
• Documentation of Citizenship (Click this link to download a PDF of what qualifies as documentation of citizenship and who is required to submit it)

Webpage: https://dfcs.georgia.gov/what-do-i-need-apply-medicaid

How long will Medicaid benefits remain active?

According to the Georgia Medicaid website, Medicaid is based on month to month eligibility. However, benefits are reevaluated on a yearly basis for aged, blind, disabled (ABD) recipients.  Medicaid will confirm whether you remain eligible for the program you have. You will receive a notice when it is time to renew your Medicaid benefits. 

Renewal can be done online at www.gateway.ga.gov or by calling the DFCS Contact Center at 877-423-4746 to have a review form mailed to you.

Medicaid requires that changes to the household be reported within 10 days of the change. Examples of changes to report include things like a new income, moving to a new address, leaving or starting a job, vehicle purchase, people moving in or out of the home, medical deductions, Social Security or other programs. Information may be reported to DFCS by phone at 877-423-4746 or online at www.gateway.ga.gov

What is generally covered by Medicaid?

The major services covered by Georgia Medicaid are:

• Prescriptions
• Doctor visits
• Inpatient and outpatient hospital care
• Lab tests
• X-rays
• Home health care
• Hospice care
• Medical equipment and supplies
• Non emergency medical transportation services
• Dental care (up to age 21)
• Covered services for the Georgia Medicaid are listed on the Medicaid Benefits page.

For more information on using Medicaid Services, the Georgia Department of Community Health made a handbook which can be downloaded by clicking on this link.

Non-Emergency Medical Transportation (NEMT) Program

NEMT provides eligible members transportation to medical appointments.  To be eligible for this program, the Medicaid member must have no other means of transportation available.  This program provides transportation for medical evaluation, medical treatment, and obtaining prescription drugs or medical equipment. 

To learn more, follow this link: https://medicaid.georgia.gov/programs/all-programs/non-emergency-medical-transportation#:~:text=To%20be%20eligible%20for%20these,Regulation%20(CFR)%20(42CFR431.

Medicaid & Autism Spectrum Disorder

Medicaid provides coverage for Autism Spectrum Disorder services for individuals under 21 years old.  Coverage is provided for initial and follow-up assessments and treatment based on medical necessity.  To be eligible for Adaptive Behavior Services (ABS), one must have a documented ASD diagnosis from a licensed physician, psychologist, or other licensed professional. 

Once a diagnosis is made, a request for Applied Behavior Analysis (ABA) may be made.  Then, a separate prior approval is required for ABS treatment.  To continue receiving services, follow-up assessments must be completed every six months.  See the section on ABA for more information about these services.

If you are eligible and receiving services from the Georgia Department of Public Health Babies Can’t Wait program, evaluation, assessment, and treatment services for ASD are provided to children from birth to three years old.

To learn more, follow this link: https://medicaid.georgia.gov/programs/all-programs/autism-spectrum-disorder#:~:text=Effective%20January%201%2C%202018%20the,is%20based%20on%20medical%20necessity.

How do I find healthcare providers that accept Medicaid?

To find a provider enrolled in Georgia Medicaid near you, click this link.

Click this link to find a dentist near you that accepts Medicaid.

What other services are available?

Children 1st

Children 1st seeks to identify children from birth to five years old at risk for poor health and developmental outcomes so necessary early interventions can be made. Children 1st is the single point of entry to the child health programs such as Babies Can’t Wait, Early Hearing Detection and Intervention, and Children’s Medical Services. 

A referral to Children 1st should be made if you have any concerns about your child’s growth and development including medical conditions and socio-environmental risks (see the link above for specific examples). 

You can send an application to your local Children 1st coordinator or call and complete the screening and referral form by phone. To find the contact information for your county’s Children 1st coordinator, use the Georgia Maternal Child Health Coordinator Locator at this link. Click this link for a PDF of the application.

After contacting Children 1st, a local coordinator will schedule a visit for a developmental screening and a family needs assessment to determine if a referral to one of their programs, such as Babies Can’t Wait, is appropriate.

Babies Can’t Wait

Babies Can’t Wait (BCW) is Georgia’s early intervention program for children with significant developmental delays or at risk for delays due to a diagnosed medical condition. BCW is a program under the umbrella of Children 1st. Services are provided to eligible children from birth to three years old. There are no income requirements for this program.

Children qualify if they have either a diagnosed physical or mental condition known to result in developmental delays (e.g., blindness, Down syndrome, Spina Bifida) or have a diagnosed developmental delay. Click this link for a PDF of frequently asked questions about this program including which services may be included.

PeachCare for Kids

If you apply for Medicaid for your children and learn they are not eligible, ask about PeachCare for Kids or call 877-427-3224 for more information. You can also apply for PeachCare for Kids online at www.peachcare.org

PeachCare for Kids provides health insurance for eligible uninsured children who do not qualify for Medicaid. For children over 6 years old, there is a premium based on family income and household size. You can click this link for more information and to see eligibility requirements. Click this link for PeachCare for Kids frequently asked questions.

Free, low-cost, or sliding scale clinics

Click the link above for help finding free or income-sliding medical, dental, mental health, or substance use disorder clinics near you.

Ava’s Law 

Ava’s Law is named after Ava Bullard whose early autism treatment helped recover her ability to speak. This law was passed in Georgia in 2015, and requires certain private insurance companies to provide coverage of treatments like ABA for children diagnosed with autism. It is limited to children under six years old with a maximum yearly benefit that varies. Since this law only applies to some insurance plans, check if your plan provides coverage for behavioral health therapy.