Changes to Medicaid Coverage of ASD 2015 Leadership Conference “All In: Achieving Results Together” Changes to Medicaid Coverage of ASD State Approaches and Impact on Early Intervention Services Ron Benham, Bureau of Family Health & Nutrition, MA Dept. of Public Health Carolyn Langer, MD, JD, MPH, Chief Medical Officer, Mass Health Brenda Sharp, Office for Citizens with Developmental Disabilities, LA Department of Health and Hospitals

Medical Management of Applied Behavior Analysis Ron Benham Director, Bureau of Family Health & Nutrition Massachusetts Department of Public Health Carolyn Langer, MD, JD, MPH Chief Medical Officer, MassHealth

Outline Background/Prevalence of ASDs Legislative/Regulatory Authority for Coverage Diagnosis Treatment Provider Roles and Qualifications Prior Authorization Process Medical Management Implications for EI Programs

2014 Changes in State and Federal Rules for ABA Coverage Massachusetts 2014 Autism Omnibus Legislation requires MassHealth to cover ABA for children under 21, subject to the availability of federal funding Federal CMS previously considered ABA as not coverable under traditional Medicaid State Plan authority CMS’ July 2014 guidance reversed this position and made medically necessary services for children with Autism Spectrum Disorder, including ABA, coverable through traditional Medicaid state plan authority Such services are now available to children under age 21 years through early prevention screening diagnosis and treatment (EPSDT)

Background/Prevalence Prevalence (CDC 2014): 1 in 68 children 5 times more common in boys than girls 1 in 42 boys and 1 in 189 girls  Occurs in all racial, ethnic, and socioeconomic groups

Diagnosis of ASDs By age 2, a diagnosis by an experienced professional can be considered very reliable ASD can sometimes be detected at 18 months or younger Diagnosis usually occurs in two steps: Developmental Screening General developmental screening: 9 , 18, and 24 or 30 months ASD screening: 18 and 24 months Developmental/ASD screening tool (e.g., M-CHAT-R) Comprehensive Diagnostic Evaluation Developmental pediatrician, pediatric neurologist, child psychologist or psychiatrist  ASD diagnostic tools (e.g., ADOS)

Diagnostic Criteria for 299.00 Autism Spectrum Disorder Persistent deficits in social communication and social interaction Restricted, repetitive patterns of behavior, interests, or activities Symptoms must be present in the early developmental period Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning Not better explained by intellectual developmental disorder or global developmental delay

What is the Evidence for ASD Treatments? Applied Behavior Analysis (ABA) Floortime (Developmental, Individual Differences, Relationship-Based Approach or DIR) OT/sensory integration Speech therapy Medication Dietary treatments Experimental treatments

Definition of Applied Behavior Analysis* ABA is a well-developed scientific discipline among the helping professions that focuses on the analysis, design, implementation, and evaluation of social and other environmental modifications to produce meaningful changes in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses changes in environmental events, including antecedent stimuli and consequences, to produce practical and significant changes in behavior.” *from the Behavior Analyst Certification Board

Provider Roles and Qualifications The role of the Board Certified Behavior Analyst (BCBA) Board certification Licensure The role of the Paraprofessional The Board Certified Assistant Behavior Analyst (BCaBA)

Prior Authorization of ABA Therapy Medical necessity Clinical documentation Comprehensive diagnostic evaluation from a qualified physician or psychologist experienced in the diagnosis and treatment of autism Behavioral assessment Detailed, individualized treatment plan and goals submitted by BCBA Level of services requested is consistent with severity and treatment goals Method to measure and quantify progress Adequacy of former diagnostic evaluations or ABA evaluations Location of services Duration of services

Medical Management Implications for EI Programs Continuity of care as toddlers age out of EI Generalization and coordination to prevent fragmentation of care Other potential sources of ABA services: schools, commercial insurance, state waiver programs, private pay Documentation to ensure smooth transition

QUESTIONS?

Medicaid and ABA-Louisiana Brenda B. Sharp, Program Manager EarlySteps – Louisiana Part C Developmental Disabilities Department of Health and Hospitals

Medicaid and ABA-Louisiana Louisiana Service System Medicaid Waivers EPSDT services “Chisholm” Law Suit Connection to Early Intervention Early Intervention and autism services

Medicaid and ABA-Louisiana Current Status Chisholm revisited ABA implemented http://www.lamedicaid.com/provweb1/Providermanuals/ABA_Main.htm http://new.dhh.louisiana.gov/index.cfm/page/1718

QUESTIONS?