ABA is finally available for children with ASDs on Medi-Cal! Beginning September 15, 2014 low-income families on Medi-Cal may call their health plan and their child's primary care physician and request an assessment for ABA therapy.
"This is a huge and long awaited good news," said Karen Fessel, executive director of the Autism Health Insurance Project. "This opens the door to critical treatment for thousands of low-income children in California with autism, who have not had access to ABA therapy."
In order to be eligible, children will need to have a diagnostic assessment of autism spectrum disorder, and a prescription for ABA therapy from either a psychologist or treating physician. The prescribing professional will need to explain why ABA therapy is medically necessary for a child.
In early July, the Centers for Medicare & Medicaid Services (CMS) issued guidance stating that state Medicaid programs must cover a full range of autism services, including ABA therapy, under the "early and periodic screening, diagnostic and treatment services," (EPSDT) program. At a subsequent meeting at the state capitol in Sacramento on September 4, 2014, high-level executives at the Department of Health Care Services (DHCS) explained that Medi-Cal managed care plans would be informed by September 15, 2014 about how to make ABA therapy available for their members. By September 30, 2014, the DHCS intends to file a state plan amendment which will allow them to make additional changes to how the ABA benefit is delivered.
"We are very pleased with how quickly California is moving to implement the federal guidance, and deliver this long awaited treatment to familes in need," said Fessel.
Because the federal guidance was issued on July 7, 2014, eligible Medi-Cal children whose families who have been paying for ABA out-of-pocket (to a licensed, provider) between July 1 andSept. 15, 2014 will be eligible for reimbursement.
Calfornia's Department of Health Care Services has been proactive in requesting feedback and suggestions from families, advocacy groups, ABA providers and other relevant parties about how to best implement this new ABA benefit. At the September 4, 2014 stakeholders meeting at the state capitol, several critical issues were raised by attendees.
Rate: Several ABA providers raised concerns about the Medi-Cal reimbursement rate, arguing that it had to be sufficient to fund high-quality treatment.
Continuity of Care: Families already receiving ABA therapy for their child through the Regional Centers expressed concerns about having to change providers, given long-standing, and established relationships.
Eligibility Criteria: AHIP's Karen Fessel expressed concern with the DHCS's draft eligibility criteria which suggested that services could be discontinued if progress plateaued. Fessel argued that Federal EPSDT criteria state that treatment to prevent the "worsening of a condition" is required under the EPSDT, which is a higher standard than medical necessity.
BCBAs: Board Certified Behavior Analysts, the primary providers of ABA therapy, raised the issue of Medi-Cal's approving ABA only from licensed providers, such as psychologist and Marriage & Family Therapists. While BCBA's are specifically trained to provide ABA, their certification comes from a national organization as opposed to from the state, and may not be recognized by the federal government until the state plan amendment (SPA) has been approved. Therefore, we advise those who seek coverage before the SPA is approved to do so through those that have state licensed providers available and who have been approved by their Managed Care Plans.