Medi-Cal to Cover ABA Therapy Starting September 15th - Yeah, But...

A recent draft letter the State of CA Department of Healthcare Services addressed to all “Medi-Cal Managed Care Health Plans” opened with the following:

Medi-Cal.jpg

“PURPOSE:

The purpose of this All Plan Letter (APL) is to provide Medi-Cal managed care health plans (MCPs) with interim policy guidance for providing BHT services to Medi-Cal children and adolescent beneficiaries 0 to 21 years of age diagnosed with Autism Spectrum Disorder (ASD).”

The gist of the letter is that starting on September 15, 2014 California children on Medi-Cal will be eligible to received ABA therapy similar to their counterparts with private insurance.

Following a stakeholders meeting on the matter held on September 4, 2014, the Department of Health Care Services (DHCS) stated that Medi-Cal managed care plans would be informed by September 15, 2014 how to make ABA therapy available for their members.

On the face of it, this sounds like a giant step forward for thousands of low income families in CA who previously have not been able to access ABA therapy.

Yeah, but… upon reading the letter more carefully and looking at the dates on which the DHCS intends to release implementation details, it becomes strikingly clear that there are a number of MAJOR hurdles that need to be overcome:

1. Reimbursements:

“To the extent beneficiaries received ABA services from licensed providers between July 7 and up to and including September 14, 2014, and incurred out-of-pocket expenditures for such services, these expenditures shall be submitted to the Fiscal Intermediary for reimbursement of expenditures through the existing Medi-Cal Out-of-Pocket Expense Reimbursement (Conlan) process (http://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-Cal_Conlan.aspx). On and after September 15, 2014, beneficiaries must receive ABA services from the MCP (Managed Care Plan)...”

Yeah but…

A. Only those who paid “a licensed, provider” are actually eligible for the reimbursement. In other words, anyone who was working with a BCBA -- the most likely and prevalent appropriately trained provider of ABA services -- is out of luck; and

B. How much (as in, how much $) will those reimbursements be for the few and far between families who are eligible? What they actually paid? Some TBD rate? and

C. Since Medi-Cal historically has NOT covered ABA services, who exactly are these ABA providers that are part of the “managed care plan” that families must turn to starting on September 15?

2. Rates:

Implementation is slated for September 15, 2014 but rates are only going to begin to be addressed at the NEXT stakeholders' meeting scheduled for October 16 (yes, more than an entire month AFTER implementation).

So…

A. are providers expected to provide services and only find out LATER how much they will be paid? And again,

B. who are these providers that are going to begin to provide services on September 15?

3. Licensing:

Though, for the moment it appears that the DHCS is following the SB946 (Autism Insurance Reform) definitions for providers -- Qualified Autism Service Provider, Qualified Autism Service Professional and Qualified Autism Service Paraprofessional -- the issue of a licensure requirement is lurking in the language of the letter:

“In consultation with stakeholders, the department will develop and define eligibility criteria, provider participation criteria, utilization controls, and the delivery system for BHT services, subject to the limitations allowed under federal law.”

There is a concern that licensure may be an issue here as it was in the early discussion days before SB946 was passed, and this concern was raised by BCBAs who attended the September 4 stakeholders meeting.

4. Progress Requirement to meet medical necessity criteria:

“The following services do not meet medical necessity criteria, nor qualify as Medi-Cal covered ABA-based therapy services for reimbursement:

1. Therapy services rendered when measurable functional improvement is not expected or progress has plateaued; “

Yeah but…

A. A plateau or even regression are often a natural part of the ABA treatment timeline, particularly where behaviors are being addressed; and

B. On-going ABA therapy may be necessary to ensure that there is no regression… So based on the current service limitations, services would need to be suspended so things regressed to the point that progress could be documented. This is not only wrong, it is clinically unethical and inhumane.

The Department of Health Care Services plans to submit an autism coverage state plan amendment to CMS by Sept. 30, but it is not clear what will be in it.

Relevant Links:

Medi-Cal Provider enrollment page (There is, as of yet, no specific information regarding contracting for ABA providers).

DHCS Provider Enrollment Message Center: Tel: 916-323-1945, or by email at PEDCorr@dhcs.ca.gov

#atpian #autismtreatmentprovider #medical #contracting #abatherapy

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