States ques­tion whether new CMS pol­icy re­quires autism cov­er­age

Modern Healthcare - - NEWS - By Vir­gil Dick­son

States, in­sur­ers and pa­tient ad­vo­cates are de­bat­ing the mean­ing and scope of a new CMS bul­letin on cov­er­age for com­pre­hen­sive autism treat­ment un­der Med­i­caid and the Chil­dren’s Health In­sur­ance Pro­gram.

Some states and in­sur­ers ar­gue that the pol­icy is op­tional and that nar­rower state pro­grams for chil­dren with the most se­vere cases of autism are al­lowed. But some le­gal ex­perts and pa­tient ad­vo­cates say the CMS cov­er­age pol­icy is a re­quire­ment for all qual­i­fy­ing chil­dren and young adults up to age 21.

“I don’t see any­thing that man­dates that ser­vice,” said Joe Fair­banks, pol­icy devel­op­ment co­or­di­na­tor at the Ok­la­homa State Depart­ment of Health. An Ore­gon Med­i­caid of­fi­cial also said the bul­letin does not re­quire cov­er­age.

“Our un­der­stand­ing is the bul­letin did not man­date cov­er­age of th­ese ser­vices,” said Jamie Kelly, a spokes­woman for Tufts Health Plan, which has mem­bers in Mas­sachusetts and Rhode Is­land.

But oth­ers sharply dis­agreed. “This makes clear that a state has no dis­cre­tion to avoid pro­vid­ing to any child autism-re­lated ser­vices, in­clud­ing (ap­plied be­hav­ior anal­y­sis ther­apy), which are med­i­cally nec­es­sary,” said Shel­don Toub­man, a staff at­tor­ney and Med­i­caid spe­cial­ist at the New Haven (Conn.) Le­gal As­sis­tance As­so­ci­a­tion.

State Med­i­caid agen­cies in Delaware, Illi­nois, Ne­braska, Utah and Wis­con­sin said they are still try­ing to un­der­stand the bul­letin and its fi­nan­cial im­pact. Some states and in­sur­ers ex­pressed alarm about the costs in­volved, while oth­ers noted they al­ready were cov­er­ing some treat­ment. There are no of­fi­cial es­ti­mates of the cost of the CMS cov­er­age pol­icy. But some say it could boost costs by hun­dreds of mil­lions of dol­lars a year.

The CMS did not re­spond to re­quests for com­ment by dead­line.

In a lit­tle-no­ticed move on July 7, the CMS posted an in­for­ma­tion bul­letin about cov­er­age for autism ser­vices un­der the Med­i­caid law’s pro­vi­sion for early and pe­ri­odic screen­ing, and di­ag­nos­tic and treat­ment ser­vices. “In re­sponse to in­creased in­ter­est and ac­tiv­ity with re­spect to ser­vices avail­able to chil­dren with autism spec­trum dis­or­der (ASD), CMS is pro­vid­ing in­for­ma­tion on ap­proaches avail­able un­der the fed­eral Med­i­caid pro­gram for pro­vid­ing ser­vices to el­i­gi­ble in­di­vid­u­als with ASD,” the agency wrote. In the doc­u­ment, the CMS said it was in­ter­pret­ing cur­rent Med­i­caid reg­u­la­tions.

Fol­low­ing the an­nounce­ment, pa­tient ad­vo­cates said thou­sands of chil­dren in low-in­come families who cur­rently are not re­ceiv­ing any treat­ment could be­gin to get it. State Med­i­caid and CHIP pro­grams have had widely vary­ing cov­er­age poli­cies for com­pre­hen­sive autism ser­vices. For ex­am­ple, Ok­la­homa hasn’t cov­ered ap­plied-be­hav­ior anal­y­sis ther­apy at all and has no plans to, while Ore­gon will be­gin of­fer­ing it Jan. 1, but only for chil­dren up to age 12.

Ok­la­homa of­fi­cials ques­tioned whether ap­plied-be­hav­ior anal­y­sis ther­apy specif­i­cally was be­ing man­dated. ABA treat­ment in­volves be­hav­ioral spe­cial­ists lead­ing autism pa­tients through drills to help with speak­ing and so­cial skills. The an­nual cost of the ther­apy ranges from $25,000 to $70,000.

Of­fi­cials in the District of Columbia, Florida, Idaho, Maine, New Jer­sey, Ohio, Wash­ing­ton and West Vir­ginia said they are al­ready cov­er­ing the ser­vices dis­cussed in the CMS bul­letin.

The Cen­ters for Dis­ease Con­trol and Pre­ven­tion re­ported this year that autism rates in chil­dren have in­creased from 1 in 88 chil­dren in 2012 to 1 in 68 chil­dren in 2014. More than a third of chil­dren with autism are cov­ered by Med­i­caid or CHIP, ac­cord­ing to the As­so­ci­a­tion of Ma­ter­nal and Child Health Pro­grams.

A Mary­land of­fi­cial ex­pressed con­cern about the scope of the CMS pol­icy. Mary­land has a waiver to cover ABA ther­apy for only about 900 chil­dren and young adults with the most se­vere cases.

South Carolina also has a waiver, al­low­ing it to cover about 600 autis­tic chil­dren who are re­ceiv­ing ABA ther­apy. Of­fi­cials there in­ter­pret the CMS bul­letin to mean the state will have to cover ser­vices for all autis­tic chil­dren. “CMS doesn’t send things out as friendly re­minders,” said Tony Keck, direc­tor of the South Carolina Depart­ment of Health and Hu­man Ser­vices. He pre­dicted his state’s Med­i­caid ex­penses will in­crease from $12 mil­lion to more than $100 mil­lion as a re­sult.

Toub­man said states with limited cov­er­age waivers are not in com­pli­ance with the CMS bul­letin. “The fact that a state may have a very limited waiver to cover med­i­cally nec­es­sary ABA ser­vices for a small group of chil­dren in nar­row cir­cum­stances can­not be used to deny med­i­cally nec­es­sary ABA ser­vices to those chil­dren,” he ar­gued.

Cal­i­for­nia has told Med­i­caid man­aged-care plans that they must cover autism-re­lated ser­vices by Sept. 1, even though the state has not yet an­nounced how much it will pay the plans to cover th­ese ser­vices, said Pa­tri­cia Tan­quary, CEO for Con­tra Costa Health Plan. “Many plans are having to de­velop a new net­work and uti­liza­tion cri­te­ria.”

Some states fear the CMS pol­icy on autism treat­ment will re­quire ther­apy cost­ing up to $70,000 a year per child.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.