Medicaid Coverage for Autism Spectrum Disorders (ASD) Treatment

Transcription

1 Medicaid Coverage for Autism Spectrum Disorders (ASD) Treatment Wisconsin Department of Health Services Division of Health Care Access and Accountability Division of Long Term Care October 9,

2 Federal Guidance On July 7 th, 2014 the Centers for Medicaid and Medicare Services (CMS) released an Informational Bulletin to State Medicaid Agencies providing guidance on the treatment of children with autism spectrum disorders (ASD). CMS also issued an FAQ document regarding this Bulletin in September In the Bulletin and clarified in the FAQs, CMS issued guidance on the types of ASD treatment services available for federal Medicaid funding. Historically, CMS took the position that habilitative services were non-coverable services through its 1905(a) regular Medicaid state plan authority. This Bulletin signals to states that some treatment modalities for ASD may be approvable as a part of the 1905(a) regular Medicaid State Plan authority as opposed to a waiver authority Wisconsin s current method. 2

3 ASD Treatment in Wisconsin Since January 1 st, 2004, Medicaid funding for autism treatment services in Wisconsin has been covered under the Children s Long Term Supports (CLTS) waiver program overseen by the Division of Long Term Care (DLTC). The CLTS waiver program provides ASD treatment designed to be delivered in the most appropriate setting and at the level necessary to improve physical and mental development. Treatment through the CLTS waiver includes intensive level services at hours per week, consultative level services at hours per week, and a lesser number of hours available through the Standard Program Category (SPC) 507. There are currently 386 children on the state wait list for intensive or consultative treatment, which represents about a 9 month wait. The CLTS waiver offers two different evidence-based therapies for autism treatment at the intensive and consultative levels (Applied Behavior Analysis and the Early Start Denver Model) and a number of other evidence-based therapies under SPC 507. Licensed behavior analysts and licensed psychologists provide treatment oversight for intensive and consultative therapies, while SPC 507 requires providers be state-licensed in a relevant discipline. 3

4 Wisconsin s Autism Insurance Mandate In 2009, the Wisconsin legislature passed a bill that amended state statute to require coverage of ASD treatment by specific health care coverage plans (private health insurance policies and self-insured governmental health plans). The Wisconsin Autism Insurance Mandate provides for intensive-level and nonintensive level services according to the medical needs of the insured individual. Intensive-level services are designed to provide an annual plan benefit of at least $50,000, with treatment occurring between 25 and 40 hours per week, while non-intensive level services provide an annual plan benefit of at least $25,000, with treatment occurring less than 25 hours per week. Qualified supervising professionals under the mandate include licensed behavior analysts, licensed psychologists, and licensed clinical social workers. 4

5 Interpreting the Federal Guidance: What does this mean? CMS is not endorsing or requiring state coverage of any one particular treatment modality, such as Applied Behavior Analysis (ABA). State agencies must determine what services are medically necessary and adhere to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) obligations to provide medically necessary services to children from birth to age 21. CMS guidance means that states covering ASD treatment through a waiver process, including Wisconsin, will need to transfer coverage of at least some ASD treatment services from waiver to 1905(a) Medicaid State Plan authority. o Wisconsin will need to seek federal authority to change the way it covers ASD treatment o Wisconsin must work with CMS on how to do this o This process will take time 5

6 The Way Ahead DHS intends to comply with CMS guidance. DHS is reviewing its current program and policy requirements. DHS will begin work to define ASD treatment services as a Medicaid benefit under its regular Medicaid plan in accordance with guidance from CMS. o Incorporate aspects of ASD treatment coverage from the CLTS waiver program o Align with coverage under the Wisconsin Autism Insurance Mandate o Review Medicaid coverage in other states o Assess prior authorization requirements o Assess allowable provider types and policies o Assess rates of payment for providers o Assess program operations and policies 6

7 Early and Periodic Screening, Diagnostic and Treatment Services Development of a new benefit structure will take time. While DHS is designing this benefit, DHS will comply with federal EPSDT requirements. In Wisconsin, EPSDT is known as HealthCheck. ASD treatment will fall under the HealthCheck Other Services (HCOS) category. Prior Authorization (PA) requests for Medicaid eligible individuals to receive ASD treatment services will be processed on a case by case basis through the ForwardHealth HCOS PA process. To obtain any services under the HCOS benefit, ForwardHealth requires that the provider of the service submit a PA request. o The provider of the service must be enrolled with ForwardHealth in order to request prior authorization, submit claims, and receive reimbursement for providing services to ForwardHealth members. In addition, to be eligible for services under the HCOS benefit, a member must have had a comprehensive HealthCheck screening within 365 days prior to ForwardHealth s receipt of the PA request. 7

8 Interim Process Until the new Medicaid benefit is created and the CLTS waiver authority is amended with federal government, the terms of the waiver remain intact. o If you are currently enrolled in the CLTS waiver for ASD treatment, you can continue to receive services o If you are on the waitlist for CLTS waiver services, you can stay on the waitlist o Your provider could choose to request ASD treatment services through HCOS PA o Individuals will not be able to obtain ASD treatment services under both the waiver and through HCOS 8

9 Questions? 9