1. 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

2. 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

3. 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

4. 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)

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. QUESTIONS?

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

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

16. Medicaid and ABA-Louisiana
Current Status
Chisholm revisited
ABA implemented

17. QUESTIONS?