Ohio Autism Insurance Coalition / Ohio Association for Behavior Analysis / Autism Society of Ohio / Autism Speaks
Ohio’s Medicaid-Eligible Children Have Little to No Access to the Gold Standard of Autism Treatment, Applied Behavior Analysis (ABA) Therapy
June 17, 2024
Problem Statement: Ohio Medicaid has no uniform medical or reimbursement policies for ABA therapy, which results in Members facing inequities in coverage approvals and little to no access to care. The strained and inadequate provider network is seeing long delays in claims processing and reimbursement, making the ABA coverage within Medicaid unstable.
Ohio Medicaid has seven different medical and reimbursement policies for ABA with inconsistent medical necessity criteria between the seven managed care plans (MCP). This, and an inadequate provider network, drive patient protection violations in the federal parity law (MHPAEA) and Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate. An inadequate Medicaid provider network is a non-quantitative treatment limitation that violates both the federal mental health parity law andMedicaid’s EPSDT mandate.
The Numbers: Access and Therapy Authorization Challenges
• Only 8% of Medicaid-eligible children with Autism are getting access to the most prescribed treatment for Autism, ABA Therapy.
• ABA providers state over 50% of all ABA authorizations are forced to have a peer-to-peer medical review.
• Per ODM in 2023, 18% of 1,781 Autistic children had fully denied or partially denied authorizations.
• We estimate less than 350 or 24% of Ohio’s 1,400 Behavior Analysts are credentialed in Medicaid.
• 52% of Medicaid providers have reduced the number of children served due to claim reimbursement delaysand intensive and overburdensome scrutiny on each ABA authorization.
• Two MCPs recently decided to deny telehealth delivery of ABA despite being told by ODM that this is anapproved delivery format. The February and March 2024 claims still have not been paid.
• 55% of Medicaid and non-Medicaid providers stated more children would be served if coverage were stable.
• 58% of Medicaid providers reported significant challenges in credentialing their group and practitioners.
• 69% of Medicaid providers experienced multiple episodes of continuing services in the past two yearswithout confidence that reimbursement would be timely. Some providers are struggling to make payrollsince ODM’s system has denied many claims since the end of March. We have not yet seen evidence ofsuccessful claim submissions in the recent ODM temporary system fix.
Solution & Our Request: We are requesting an emergency hearing in the Joint Medicaid Oversight Committee (JMOC) to discuss the following five action items needed to stabilize ABA coverage in Ohio Medicaid.
1. ODM needs to announce uniform medical and reimbursement policies for ABA.
2. Behavior Analysts need a permanent and recognizable practitioner type in Medicaid.
3. All ABA CPT codes need a 15% reimbursement increase from 2016 suggested rates and without reductions.
4. Direct Treatment Staff, called Technicians, need to be billable after completing the national training requirement and deemed competent by the Behavior Analyst. The Technician can then sit for certification.
5.ODM’s announced provider accreditation requirement needs to wait until coverage is stabilized.
Note: Once the five items above are completed, ODM could continue Medicaid’s current stakeholder group and continue working with the actuarial firm to develop long-term, sustainable reimbursement rates.
Details of The Numbers: Autistic Children in Medicaid, Practitioners, Denial Rates & Provider Map
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Source: |
Dept of Medicaid (ODM) Website & ODM’s letter to a Legislator in April 2024 |
Ohio’s Autism Interagency Workgroup Report 2023 |
Where the Children are experiencing access barriers. |
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Number of Ohio’s Children with Autism |
53,346 Children on Aged, Blind, & Disabled Medicaid. No data specific to Autism. |
45,000 children with Autism under age 21 had Medicaid claims. |
Fee for Service children are not enrolled on managed care plans and have no formal prior authorization process. |
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Children with Autism and Access to ABA in Medicaid |
2,417 Children with Autism receive ABA Therapy within Medicaid. Medical policies allow ABA for children up to age 21. |
Two-thirds of the 45,000 children are under the age of 21. 30,000 Children with Autism in Medicaid are under the age of 21. |
Only 8% of children in Medicaid with Autism are getting access to the most prescribed treatment for Autism, ABA Therapy. 2417/30,000 = .08 |
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Providers |
ODM does not have a unique provider number for the main practitioner-type of ABA, the behavior analysts. ODM could not provide a practitioner count for behavior analysts. |
N/A |
A Medicaid website search result showed 127 credentialed behavior analyst practitioners. Ohio has 1,400 behavior analysts. We found some Medicaid approved behavior analysts missing from their provider list. We estimate only 350 are credentialed with Medicaid. |
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Denial Rates for Request for ABA |
In 2023, 3,483 authorizations for ABA therapy (2 per year per child) occurred. Based on ODM data, the following are the denial rates. 3483/2 = 1,741 Children with ABA authorizations denial rate of 18%. Full Denials: 161 or 4.6% Partial Denials: 468 or 13.4% |
N/A |
Providers stated authorization denials are closer to 30%, with 50% to 60% of all authorizations forced into peer-to-peer medical reviews. |
Details on Patient Protection Violations: Access problems are caused by more than just the lack of claims payments.
An inadequate provider network is a non-quantitative treatment limitation that violates both the federal mentalhealth parity law and Medicaid’s EPSDT mandate, ensuring access to care for all children with Medicaidinsurance under 21 years old. Autism Spectrum Disorder carries mental health protections and is listed in theDiagnostic and Statistical Manual of Mental Disorders (DSM-5), a guide created by the American PsychiatricAssociation.
Violations: Inadequate Provider Networks & Overburdensome Process to Access to Care in Medicaid
• Children in Medicaid struggle to access ABA therapy due to an inadequate provider network.• Providers state higher scrutiny for ABA authorizations than seen from commercial plans.• Parents experience a high number of peer-to-peer reviews with medical directors, denials or partial denials(lowering the intensity of treatment), and state hearings to access care.
• There are many inconsistencies in medical necessity criteria within the seven MCPs' medical policies.• Children on Fee for Service (non-MCPs) have no formal prior authorization process and have to call a staffmember at the Department of Medicaid to begin the prior authorization process.
• Only 8% of Ohio’s Medicaid-eligible children with Autism are accessing ABA coverage even thoughABA is the most prescribed treatment for Autism.
• ODM’s claims submission fix on Sunday, June 13th, has not resulted in an overall fix for claimssubmission, leaving many providers with extremely high receivables and very low cash flow.• The treating communities agreed on generally accepted standards for ABA Therapy in the treatment of Autism Spectrum Disorder called the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers with the Council for Autism Service Providers. These are the standards that should be driving medical necessity determinations.
Concerns: Survey Results from Medicaid-Approved ABA Providers:
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77% believe patient protection violations are occurring.
- 42% have considered putting ABA on hold or discharging children because of a lack of claims paymentsand, for many, the inability to meet payroll demands.
- 52% have reduced the number of Medicaid children served due to payment delays, multiple medicalpolicy contradictions, and authorization denials well above commercial plans.
- 69% experienced multiple episodes of providing services without the confidence they would seereimbursement within a three-month period.
- 55% of Medicaid and Non-Medicaid providers would serve more Medicaid children and open more centers if the ABA coverage was stabilized.
- 57% experienced significant challenges in credentialing their medical group and practitioners.
- 73% experienced lengthy delays in reimbursement.
Conclusion: An inadequate Ohio Medicaid provider network is a non-quantitative treatment limitation that violatesboth the federal mental health parity law and Medicaid’s EPSDT mandate.
We request an emergency hearing in the Joint Medicaid Oversight Committee (JMOC) to discuss the five action items from page one that we believe will help stabilize ABA therapy coverage in Ohio.
The EPSDT Medicaid mandate states, “Children’s health problems should be addressed before they become advanced, and treatment is more difficult and costly.” Unfortunately, Ohio’s Medicaid-eligible children with Autism are not getting access to critical ABA services. Ohio still does not have codified ABA coverage in the administrative code or a state plan amendment, even though families have won lawsuits in 2008 and 2012. In
2014, the Centers for Medicaid and Medicare issued a memo telling Medicaid departments to cover ABA therapy.
We appreciate your time and request your help scheduling a hearing in the Joint Medicaid Oversight Committee. Please reach out to us with any questions you may have.
Thank you.
Initiative Leaders:
Jen Gonda, BCBA, COBA
Community Behavior Consulting
Owner, Provider Mahoning County
Ohio Association for Behavior Analysis
Practitioner Professional Association
Public Policy Chair
jgonda@abaforall.com
(330) 507-3893
Marla Root
Ohio Autism Insurance Coalition
Founder, ABA Provider Network
Parent of an adult with autism
help@ASDOhio.com
(614) 565-5765
Kelly Headrick, MPA
Sr Director, State Governmnent Affairs & Grassroots Advocacy
Autism Speaks
Kelly.headrick@autismspeaks.org
(720) 207-8102
Laurie Cramer
Autism Society of Grater Akron Execurive Director
Autism Society of Central Ohio
Autism Society of Greater Cleveland
Autism Society of Dayton
Autism Society of Mahoning Valley
Autism Society of Northwest Ohio
Laurie@autismakron.org
(330) 940-1441 x3
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