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Federal government further clarifies directive on ABA benefits
WASHINGTON, DC (September 29, 2014) -- The federal government has issued guidance to states emphasizing that they can neither delay nor deny medically necessary autism treatments, such as ABA, through their Medicaid programs for individuals up to age 21.
The message was delivered in FAQs posted September 24 regarding the July 7 Informational Bulletin issued by the federal Centers for Medicare & Medicaid Services (CMS) concerning autism benefits states must provide through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. While no specific deadline is set forth in the FAQs, "CMS believes states should complete this work expeditiously and should not delay or deny provision of medically necessary services."
In addition to questions on timing, there was confusion among some states because the July Bulletin did not explicitly state that ABA, the most well-accepted and efficacious therapy for individuals with autism, was a required treatment. In the FAQ's, "CMS made clear that while it did not single out ABA as a mandated treatment, just as it does not mandate other specific treatments, like chemotherapy for children with cancer, all care that is medically necessary for an individual must be provided," said Dan Unumb, executive director of the Autism Speaks Legal Resource Center.
According to the FAQs, this obligation to provide all medically necessary services that can be covered under Medicaid is part of the states' “long-standing EPSDT obligations” to children from birth to 21. Additional information about the states' EPSDT obligations is available HERE.
In the case of autism, medically necessary care includes ABA, which CMS has already indicated is a coverable service observed Unumb. "As indicated in professional literature and as held by numerous court cases, there is no question that ABA is medically necessary for many children with autism and therefore it must be made available based on individual determinations of medical necessity," he said.
Some states have also raised concerns over the cost of providing Medicaid coverage of ABA. “This is not a new issue,” said Unumb. “In almost all of the three dozen states that have mandated coverage for private insurance, nearly every state initially over-estimated the cost of providing ABA, sometimes by more than 1,000 percent.”
Unumb also said it is important to keep in mind the cost-savings of providing ABA. "Studies have shown that providing treatment to children ultimately saves the states taxpayer money by reducing the need for special education and other services and lowering long-term care costs when children reach adulthood."
The FAQs further spell out that while Medicaid State Plan Amendments are not a prerequisite to implement additional mandatory EPSDT coverage, they are strongly encouraged as a means to include the menu of services for ASD treatment as part of the State Plan's comprehensive written statement of services. The FAQs also discuss the relationship between EPSDT services and waiver services and the transition of medically necessary services from limited waiver coverage to broad state plan coverage for EPSDT-eligible individuals.
Autism Speaks seeks input on changes from military families, providers
WASHINGTON, DC (September 22, 2014) -- The Department of Defense has issued a new Comprehensive Autism Care Demonstration program, which consolidates the current three TRICARE programs covering ABA for beneficiaries with autism. Autism Speaks is analyzing the new program and has requested input from TRICARE beneficiaries and ABA providers on the changes.
"We will be reviewing feedback from stakeholders to understand how the new program will impact families and access to care," said Karen Driscoll, Autism Speaks' associate director for federal government affairs & military relations. "We urge military families and ABA providers to email us their input and recommendations at email@example.com."
The new demonstration program sets an October 20 implementation date, and a retroactive effective date of July 25, 2014. To review the new policies, go HERE.
TRICARE currently has limited ABA coverage through its Basic, ECHO Autism Demonstration, and ABA Pilot programs. The new Demonstration program would consolidate and replace those offerings into one uniform benefit.
Agreement on disabilities savings accounts emerges from Senate Finance Committee
WASHINGTON, DC (September 22, 2014) -- The Senate Finance Committee announced that it has reached abipartisan agreement to move the ABLE Act allowing the creation of tax-exempt savings accounts for people with disabilities.Congress is expected totake up the bill after it returns from the November mid-term elections.
The agreement was announced by Senators Ron Wyden (D-OR), [on left]the committee chairman, and Orrin Hatch (R-UT), [on right]the ranking member, along with the lead Senate sponsors of the bill, Senators Bob Casey (D-PA) and Richard Burr (R-NC).
“Under the leadership of Senators Casey and Burr, the Senate has generated positive momentum on the ABLE Act," according to the committee statement. "Thanks to constructive and bipartisan dialogue, the bill sponsors, collaborating with Chairman Wyden and Ranking Member Hatch, have reached a policy agreement that will serve as the foundation for final passage. We are committed to working with our House colleagues to ensure this legislation will be passed in a bipartisan, bicameral manner and sent to the President's desk in the lame duck session.”
Autism Speaks commended the statement as a positive breakthrough.
"Autism Speaksthanks the leaders of the Senate Finance Committee for committing to finalize thisbill which will make such a critical difference in the lives of Americans withdisabilities," said Stuart Spielman, senior policy advisor and counsel."With rising povertyand high unemployment plaguing the disabilities community, ABLE sends a signal thatindividuals and families will be able to help themselves without suffering adverse consequences.
"We look forward to quick action when Congress returns so that the bill can get to President Obama and become law," Spielman said.
The Achieving a Better Life Experience (ABLE) Acthas attracted extraordinary support. S.313 has 74 cosponsors, including the Senate's Majority Leader Harry Reid (D-NV) and Minority Leader Mitch McConnell (R-KY).The House version, HR.647, sponsored by Rep. Ander Crenshaw (R-FL), is cosponsored by 380 of the House's 435 members.
The ABLE Act would allow tax-exempt Section 529 savings accounts, such as now permitted for college savings, for people with disabilities. The accounts could be used to pay for housing, medical, educational, transportation and other expenses.
Congress urged to pass ABLE to address as need grows more urgent
WASHINGTON, DC (September 18, 2014) -- As unemployment and poverty decline across the nation, both indicators for Americans with disabilities are now double the national average and poverty is on the rise, a Senate committee reported today. The release ofthe U.S. Census Bureau statistics prompted renewed calls on Congress to pass the ABLE Actto dramatically increase the private resources available for adults with disabilities to pay for their housing, medical, transportation and other needs.
“If almost 30 percent of people with disabilities are living in poverty; a rate that is going up; and the unemployment rate for people with disabilities continues to be double that of people without disabilities, and only 20 percent participate in the workforce, then we face a serious problem – indeed, a crisis," said Sen. Tom Harkin (D-IA), chair of the Senate Health, Education, Labor and Pensions (HELP) Committee.
"We are far from meeting the ADA's goal of economic self-sufficiency for people with disabilities," said Harkin [pictured (right)with ranking member Sen. Lamar Alexander (R-TN)], referring to the landmark Americans with Disabilities Act (ADA) that he authored in 1990. “To state the obvious, not being part of the workforce contributes powerfully to the incidence of poverty."
The Census Bureau data showed the rate of poverty in America in 2013 declined overallto 14.5 percent; but the rate for people with disabilities increased to 28.8 percent. Separately, the latest unemployment data shows joblessness nationwide has declined to 6 percent, but for those with disabilities it stands at 12.8 percent. Less than 20 percent of the 29 million Americans with disabilities over 16 years of age participate in the workforce compared with nearly 70 percent of those without a disability.
For the autism community, an estimated half-million Amerricans with ASDs are expected to "age out" of school-based supports as they reach age 21 over the next 10 years, accelerating the need for housing, employment and adult services.
Harkin released a committee report, "Fulfilling the Promise: Overcoming Persistent Barriers to Economic Self-Sufficiency for People with Disabilities," assessing the housing, employment, transportation and other barriers facing Americans with disabililties. The findings were based on interviews with 400 Americans with disabilities living in poverty.
Among those findingswere:
- Living with a disability in America can be both economically and socially costly
- Many people with disabilities fear that earning or saving too much money could cause them to lose access to supports that they need to live independently in the community
- People with disabilities often cannot save for emergencies and unanticipated challenges
- People with disabilities continue to report experiencing employment discrimination, discriminatory wages, inaccessible workplaces, and persistently low expectations about what they can accomplish
The Achieving A Better Life Experience (ABLE) Act (S.313/HR.647) now before Congress would allow tax-exempt savings accounts for individuals with disabilities without losing their eligibility for Social Security supplemental income, Medicaid and other public benefits. Holding more than $2,000 in lifetime savings under current law puts those benefits at risk. ABLE accounts could be used to pay for housing, medical, transportation, educationaland other needs.
Alexander andSen. Robert Casey (D-PA), the original Senate sponsor of S.313, urged passage of the bill and several witnesses who testified before the HELP committee also saidABLE could be a valuable tool to tackle poverty.
"There is no way to save for emergencies and other things to help pull them out of poverty," said Becky Duncan Massey, aTennessee state senator who has worked 21 years as a disabilities provider. "The $2,000 limit that was established when the program was started is equal to almost $13,000 in today's dollars. The ABLE act could help with this."
The bill (HR.647) awaits a House floor vote; S.313 awaits Senate action. Supporters, including Autism Speaks, are urging Congress to vote on the legislation before it recesses for the November elections. The ABLE bills have gained cosponsorships from 80 percent of the House and 75 percent of the Senate, including Majority Leader Harry Reid (D-NV) and Minority Leader Mitch McConnell (R-KY).
In response to federal directive, states adding ABA coverage, facing litigation
NEW YORK (September 15, 2014) -- In response to a July directive from the federal government to step up Medicaid-fundedtreatment forautism, a number ofstates are quickly moving forward to add benefits for behavioral health treatment. One state--Hawai'i--has been hit with a class action suit for failing to provide the coverage.
The Autism Speaks Legal Resource Center (ASLRC) has been working with advocatesandstateofficials from around the country onimplementing the July 7 directive from the Centers for Medicare & Medicaid Services (CMS), said Dan Unumb, ASLRC's executive director.
One-third of all children with autism receive primary insurance coverage throughMedicaid; including secondary coverage, half of all American children with autism are impacted. Medicaid is a joint federal/state program.
"This a game-changer for the autism community," Unumb said. "How soon this will play out in each state and kidsget treatment remains to be seen, but the ball is moving down the field."
Among the highlights sincethe CMS announcement was issued:
- California has moved forward with plans to require coverage of behavioral health treatment, including applied behavior analysis (ABA), starting Monday. An estimated 12,000 children will gain coverage through Medi-Cal, including 6,000 who currently have no coverage for treatment.
- Nevada is hosting a public workshop today to start implementing behavioral health treatment coverage through its Medicaid program.Based on the public input and further review, the state will submit a Medicaid plan change to CMS for approval.
- Connecticut Gov. Dannel Malloyhas directed his administration to develop a "full range" of autism treatments, including ABA, to be covered through the state's Medicaid program. Further details are to be provided in October at a meeting of the Autism Spectrum Disorders Advisory Council.
- A federal class action suit has been filed against Hawai'i for denying ABA benefits through its Medicaidprogram for autism treatment.The complaint, Egan vMcManaman, estimates that 1,500 to 1,900 children under the age of 21 would be affected.