Effective for dates of service on or after Sept. 1, 2025, the South Carolina Department of Health and Human Services (SCDHHS) will update the medical necessity requirements for autism spectrum disorder (ASD) treatment services for eligible South Carolina Healthy Connections Medicaid members 0 to 21 years of age. These changes will be reflected in SCDHHS' Autism Spectrum Disorder (ASD) Services Provider Manual by Sept. 1, 2025.

Updated Medical Necessity Criteria for ASD Services

To improve access to services used to treat ASD for children enrolled in the Healthy Connections Medicaid program, SCDHHS is implementing the following changes to the criteria to establish medical necessity:

1. The term "Comprehensive Psychological Evaluation" will be replaced by "Comprehensive Diagnostic Assessment" (CDA).
2. The CDA must be directly administered and completed by one of the following providers: licensed physicians (MD, DO), licensed psychologists (PhD, PsyD) or licensed psychoeducational specialists (LPES).
3. The CDA must include a structured observation to support the diagnostic criteria outlined by the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The following validated tools will be approved to conduct ASD assessments:
   1. Autism Diagnostic Interview, Revised (ADI-R)
   2. Autism Diagnostic Observation Schedule (ADOS)
   3. Childhood Autism Rating Scale (CARS)
4. The Medical Care Home Autism Assessment will be added as an approved option for primary care physicians to determine medical necessity for certain Healthy Connections Medicaid members without requiring members to be referred for completion of a CDA.
5. Medicaid members between 18-36 months of age who are determined to be "at-risk" by a qualified provider using a validated secondary autism screener can be determined presumptively eligible for autism services while awaiting a referral and completion of a CDA. Qualifying criteria, including screening requirements, and age ranges for presumptive eligibility will be further described in the ASD Services Provider Manual.

SCDHHS will host virtual provider training sessions in September 2025 for providers who are interested in additional guidance regarding these policy changes. Date, time and registration information for these live webinars is available below.

• Sept. 4, 11 a.m.-12:30 p.m.
  • Register: https://events.gcc.teams.microsoft.com/event/784141cc-babc-4efa-b10a-b9de4bf9fe8d@45843448-87c2-4911-a7e2-1079f0f4aac3
• Sept. 12, 2-3:30 p.m.
  • Register: https://events.gcc.teams.microsoft.com/event/9e0f0ec8-d941-4b5e-840f-092ce9526740@45843448-87c2-4911-a7e2-1079f0f4aac3

Providers should direct questions about this bulletin to ASDProvider@scdhhs.gov. Providers can also request additional opportunities for physician Rapid Interactive Test for Autism in Toddlers (RITA-T) training by emailing ASDProvider@scdhhs.gov.

South Carolina's Medicaid managed care organizations (MCOs) are responsible for the authorizations, coverage and reimbursement related to the services described in this bulletin for Healthy Connections Medicaid members who are enrolled in an MCO.

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