We are extremely concerned about the recently proposed changes to Medicaid's coverage of ABA therapy. These new policies would prevent thousands of children with autism from accessing the most essential, evidence-based treatment for their disability.
The proposed credentialing requirements are in excess of industry standards and will ironically lower the timeliness - and therefore quality - of care children on Medicaid receive.
Children with Medicaid coverage must already wait longer than children with private insurance for services. This is because Medicaid already requires that behavior technicians staff have a Registered Behavior Technician (RBT) certification while private insurance typically does not require this. Therefore, children on Medicaid must wait for a Medicaid approved provider to become available. The new requirements Medicaid proposed in December put even more severe barriers between the child and services. This will add months to their wait-time. This is in violation of EPSDT, according to which children should have immediate access to medically necessary care.
Furthermore, since this gap in average wait-time is based on the family's financial means and funding source, this will amplify socio-economic disparities in the provision of medically necessary services.
Additionally, these changes violate the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and the CMS requirements for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).
MHPAEA explicitly prohibits any kind of caps on mental health treatment (the exceptions provided for do not apply here). Medicaid is subject to MHPAEA regulations.
Under EPSDT, states are required to cover comprehensive services, including all services that could be covered under section 1905(a) of the Act that are needed to correct or ameliorate health conditions for EPSDT-eligible children.
Medicaid's allegations that ABA therapy must not be effective if it has not been able to correct all symptoms within a three year limit is both illogical and irrelevant. According to CMS's interpretation of "correct or ameliorate," a service need not cure a condition in order to be covered under EPSDT as a medically necessary service. EPSDT covers services that maintain or improve a child's current health condition because they prevent a condition from worsening or prevent development of additional health problems. This is absolutely true for ABA therapy. Since it is used for a wide range of symptom severity, it may certainly resolve mild symptoms within the lifetime limits proposed by Medicaid, but many other children will continue to require and benefit from ABA therapy for longer than a short three years.
Finally, although Medicaid alleges that these weekly time caps and lifetime limits are designed to eliminate misuse of funds by providers, the limits will in reality eliminate access to medical care for children with disabilities.
Since the lifetime limit follows the child, any time they spend in the service of a subpar provider is truly lost time. Families already face the difficult decision of accessing service quickly with a low quality provider or waiting for an opening with a high quality provider. Neither are good options. These proposals will lengthen those wait times and punish families who select a provider that is not a good fit.
Please help us prevent these harmful and unjust Medicaid limits from being enacted.
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