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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.