States Skirting Obligation To Cover ABA Therapy
Despite a federal mandate nearly five years ago, several state Medicaid programs are still failing to cover treatment like applied behavior analysis for children with autism, advocates say.
In 2014, the Centers for Medicaid and Medicare Services issued a bulletin telling states to pay for “medically necessary diagnostic and treatment services” for kids with autism, but stopped short of directly requiring ABA therapy.
However, advocates say that because some children on the spectrum require ABA, every state should offer coverage to those who do. Most states have since done so, but some legislatures have not allocated funding, even though they’ve passed laws that require private insurers to cover ABA therapy.
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“That inequity does not look good,” said Lorri Unumb, vice president of state government affairs for Autism Speaks. “It’s just critical that family finances not be a barrier to children being able to get this critically important intervention as soon as possible.”
The states that do not offer ABA therapy to all children who meet medical necessity criteria are: Idaho, Illinois, Maine, New Jersey, New York, Ohio, Oklahoma and Texas. ABA therapy uses reward-based motivation to help children with autism learn new skills and reduce harmful behavior.
But already this year, advocates are seeing progress.
In Texas, families affected by autism spoke earlier this month at a hearing before the state legislature, which could allocate a proposed $192 million for behavioral intervention, including ABA. And in late January, advocates won a legal victory in Oklahoma when an administrative law judge ordered the state’s Medicaid program, called SoonerCare, to pay for up to 12 hours a week of ABA for an 8-year-old girl with autism.
In the administrative proceeding in Oklahoma, the judge cited Early and Periodic Screening, Diagnostic and Treatment, or EPSDT, a collection of medically necessary services that all state Medicaid programs must cover for children under age 21. The 2014 CMS bulletin said that coverage for children with autism falls under EPSDT, just like everything from speech and occupational therapy to personal care services and medical equipment.
“We don’t want people having to leave our state just to get better services,” said the girl’s attorney, Brian Wilkerson, director of litigation and legal services at the Oklahoma Disability Law Center. “If your only coverage is through SoonerCare, we’re leaving a large number of citizens that need these vital services out in the cold.”
Katelynn Burns, a spokeswoman for the Oklahoma Health Care Authority, said the state hopes to begin offering ABA in July, pending legislative approval of $15 million in state and federal funds.
“Due to the state budget struggles the last few years, we weren’t able to provide the coverage,” Burns said. “However, since things are looking better financially, we added a request for ABA funding in this year’s budget request and have begun the state plan amendment and rule making process to cover this service.”
A CMS spokesperson said the federal agency is available to provide technical assistance and support to states regarding the provision of autism services, but did not respond to questions about states failing to cover ABA therapy.
Wilkinson, the Oklahoma attorney, said families can play a powerful role in the remaining states by requesting ABA for their children.
“Nationwide, it’s going to have to be a push from the advocacy groups and parents and family members of individuals who need these services,” Wilkinson said.
Ironically, Unumb of Autism Speaks said that the eight states without the Medicaid coverage have passed laws that require private insurers to cover ABA.
“I’m very optimistic that all 50 states will provide ABA coverage under EPSDT,” she said. “I can’t say exactly how quickly we’re going to get there. There is rapid movement in most of the remaining states.”