Plan Proposed to Cover Autistic Children

by David Gorn

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A Senate subcommittee last week proposed a $50 million solution to temporarily address the lack of coverage of a type of autism treatment under Medi-Cal -- a gap in care that recently affected hundreds of Healthy Families children when the state moved them to Medi-Cal managed care plans.

The new proposal would appropriate $50 million to make sure Medi-Cal children with autism are able to receive applied behavioral analysis treatment --  known as ABA therapy -- through the end of 2013. The assumption is that ABA therapy will be available as an essential health benefit under the Affordable Care Act starting in 2014.

"Clearly this item is to bridge a gap of service," said Sen. Bill Monning (D-Monterey), chair of the Senate Budget Subcommittee on Health and Human Services, at a hearing last week.

Medi-Cal covers autism services through contracted regional centers around the state, but the eligibility criteria to receive ABA therapy is much more stringent than under the Healthy Families plan. An estimated 75% of children who were eligible under Healthy Families would not qualify for the same services under Medi-Cal. The percentage who do qualify may be even lower than 25%, according to Melissa Cortez-Roth, legislative advocate for Autism Speaks.

"Not everyone who qualifies for Healthy Families who will be losing coverage qualifies for coverage at a regional center," Cortez-Roth said. "Only a fraction of those children qualify for the regional centers."

Toby Douglas, director of the Department of Health Care Services that has orchestrated the Healthy Families transition, said the Senate subcommittee's plan might be difficult to implement.

"We do just want to raise a couple concerns," Douglas said. "First of all, we are concerned about the fiscal estimate. Given that this needs to be built into the plans, this would have to be built into the plans' rates. …We are concerned it may underestimate the cost for our plans."

The second concern, Douglas said, is timing. "Any change to our plans requires contractual changes, as well as building in the rates," Douglas said. "And we need to get approval from our federal partners, including amendments to our 1115 waiver to add this benefit, which will take several months."

Douglas said July 1 was not "a realistic implementation date."

The state's Department of Finance raised similar concerns.

"As this proposal is unfunded, we have some concerns about the impacts it will have on the general fund reserve," said Scott Ogus, representing the finance department. "We're concerned about the capacity of the reserve to absorb this significant augmentation of expenditures."

According to Dan Chick, director of government affairs at Health Net, the Medi-Cal managed care plans may not have enough providers in-network to handle the proposal.

"Whether we even have enough ABA providers in our network, I will go and check on that, but it is a bit concerning to know, if we don't have this type of network established, we would have to do so in such a very short period of time," Chick said.

The trailer bill language passed subcommittee on a bipartisan 3-0 vote.

Karen Fessel
It is curious that Mr Douglas names getting approval from federal partners as a potential barrier for being able to provide ABA to children with autism through Medi-Cal. When this population transitioned from Healthy Families to Medi-Cal, ABA services were abruptly terminated, in spite of the fact that "prior to receiving CMS approval.. the state must demonstrate... appropriate plans for maintaining continuity of care for all services." (this is from the approval letter from CMS to Mr Douglas, 12-31/2013). Federal partners should not object, as continuity of care for all services was a requirement from the start. Gratitude for the additional funds would have been the appropriate response.
Alice Mayall
As a parent of one of the children who lost medically authorized ABA services with the transition from Healthy Families to MediCal, I think it is only fair that Mr. Douglas move quickly to figure out how to reinstate services that were so abruptly revoked. Apparently DHCS had plenty of notice before that transition that there would be autistic spectrum (ASD) children losing all health insurance coverage for ASD issues and treatments. The complaint that it would be hard to implement continuation of care for those children carries little weight when one considers how hard it has been for families to lose medically necessary services for their children with no warning, and how hard it is to try to negotiate the hassles created by Mr Douglas and his agency rushing to a transition of Healthy Families to MediCal.

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