The New Autism Insurance Legislation and Medicaid Autism Benefit Colleen M. Allen, Ph.D. Chair, MI Autism Council CEO, Autism Alliance of MI Stacie Rulison, MS, M.ED, BCBA Candidate Michigan Autism Council (Appointed) Operations Director, Autism Alliance of MI Lori Irish, Manager of Services to Children with Developmental Disabilities Michigan Department of Community Health November 8, 2012 1
Agenda Clinical Best Practice Management Autism Bills Specifics: What Is and Is Not Covered Who Can Provide Care The Medicaid Autism Benefit Workforce Development 2
Purpose of Presentation Provide best practice clinical management of Autism Spectrum Disorders (ASD) Provide overview of the new autism insurance laws Provide an overview of the Medicaid Autism Benefit along with roles and responsibilities Provide similarities and differences between the private insurance autism benefit and Medicaid Autism Benefit Provide resources available to the community for understanding the new autism insurance and the Medicaid Autism Benefit 3
The Autism Alliance of Michigan Why We Started Who We Are Strategic Initiatives Service Delivery Model for Insurance Autism Safety Initiative Autism Navigator 4
Clinical Best Practice Management Screening, Identification, and Referral Evaluation and Diagnosis Evidence Based (EB) Intervention What are EB treatments? What is Applied Behavior Analysis? Speech and Occupational Therapies 5
Understanding the New Autism Insurance Legislation The Michigan Autism Insurance Law Senate Bills (SB) 414/415, Law became effective October 15, 2012 Bills for BCBSM and all other HMO s/private insurers Includes all insurers covered under state regulated laws Does NOT include ERISA (self insured, federally regulated) companies (larger companies): overrides state mandates Does NOT include Medicaid & MI Child eligible children Is limited to services for children MEDICALLY diagnosed with an ASD (classic autism, PDD NOS, Asperger s) Does not cover co pays or deductibles Established a $15M appropriation fund for reimbursement to stateregulated and self funded insurance companies from State of Michigan REMEMBER: Law is effective mid October but most insurance plans do not renew until January, 2013, some even later. 6
Understanding the New Autism Insurance Legislation Autism Bill Specifics: What s Covered Covers ABA, Speech and Occupational Therapies, Psychiatric and Psychological Care Dollar Limits/Caps $50,000 (ages birth through 6) $40,000 (ages 7 through12) $30,000 (ages 13 through 18) What the caps mean All inclusive of therapies listed above 7
Understanding the New Autism Insurance Legislation Autism Bill Specifics: Who Can Provide Care Provider Qualifications: Evaluation and Diagnosis Licensed Psychologist or Physician (minimum) Documentation of a standardized test like the Autism Diagnostic Observation Schedule (ADOS), Social Communication Questionnaire (SCQ), etc. Note: Educational Eligibility of ASD DOES NOT COUNT! Your child will still need a medical diagnosis of ASD! BCBS/BCN Approved Autism Evaluation Center (AAEC): requires diagnosis be done at AAEC to access benefit; if within 3 years, and done at AAEC, verify whether rediagnosis needed REMEMBER: Insurers determine through networks and centers of excellence who can give your child a diagnosis 8
Understanding the New Autism Insurance Legislation Autism Bill Specifics: Who Can Provide Care Provider Qualifications: Therapy Speech Therapy: Certified and Licensed SLP Occupational Therapy: Licensed OT Physical Therapy: Licensed PT Psychological Care: LLP working under LP ABA Therapy: Board Certified Behavior Analyst (BCBA) or Licensed Psychologist meeting very specific qualifications as an ABA provider Insurers determine through networks and centers of excellence who can provide treatment for the child 9
Understanding the New Autism Insurance Legislation Autism Bill Essentials: Diagnosis Insurers will confirm that all of these criteria are met and nothing more is needed Does the child have a medical diagnosis of Autism Spectrum Disorder? The diagnostic code for autism is 299.0 Autism, Asperger's, Pervasive Developmental Disability Not Otherwise Specified Is there a report or some type of documentation of the diagnosis by a licensed physician or psychologist? How long ago and where was that evaluation conducted? If less than 3 years ago and a standardized test was used, the child may be ready to start therapy in October 10
Understanding the New Autism Insurance Legislation Autism Bill Essentials: Diagnosis What if the child has not had a medical evaluation in more than 3 years? Insurers will likely require that the child be re evaluated Parents need to inquire of their doctor or psychologist if a standardized tool is used.(example: ADOS) Parents may want to consider an evaluation NOW, with a center or individual physician or psychologist that can administer the ADOS and is approved by your insurance company 11
Understanding the New Autism Insurance Legislation Autism Bill Essentials: Therapies How will insurers know what is evidence based and what is not? Provider qualifications will be first indication Objective criteria will be used to evaluate what gets covered and what does not Several organizations are considered at the forefront of evidence based practice in treating autism 12
Understanding the New Autism Insurance Legislation Autism Bill Essentials: What Families Need to Know Now Therapies Only evidence based therapies will be covered Evidence Based Practice Defined: Maintains strength in research, based on sound theory and empirical data, and assures replication of research demonstrating effectiveness of treatments via peer reviews and consistencies across studies Clinical support and usefulness Works for families Number of expert panels, task forces, and reports reviewing research agree on the following points (ASAT): Behavioral and educational interventions currently main treatments Applied Behavior Analysis (ABA) has received most extensive research, supporting its effectiveness Medications also may be effective for challenging behaviors, when appropriate Majority of research conducted focusing on young children; additional research is needed for older children and adults with ASD 13
Understanding the New Autism Insurance Legislation Autism Bill Essentials: What Families Need to Know Now Therapies Organizations currently leading EBP research in Autism Interventions (ASAT, NPDC, NSP) *National Autism Center (NAC) National Standards Project (NSP), 2010: evaluated over 770 peerreviewed studies in treatment efficacy for ASD Behavioral based interventions identified as primary EBP as concluded in this large initiative National Professional Development Center (NPDC): Multi university center promoting use of EBP s in treating ASD s including UC Davis Medical School MIND Institute, University of North Carolina at Chapel Hill, and the Waisman Center at University of Wisconsin at Madison Alignment of EBP agreement between NSP and NPDC Behavioral based interventions identified as primary EBP Association for Science in Autism Treatment (ASAT): Purpose is to share objective, accurate, and scientifically sound ASD treatment information. Provides extensive information on treatments available, EBP definition and summaries, pseudoscience information, and being an informed consumer ASD s: Missouri Best Practice Guidelines: for screening, diagnosis, assessment * NSP used by insurers to determine what is EBP Note both NSP and NPDC overlap in findings significantly, representing greater reliability of data. 14
Understanding the New Autism Insurance Legislation Autism Specifics: Treatment What is Applied Behavior Analysis (ABA)? Applied Behavior Analysis (ABA) addresses two areas: 1) behavior management and 2) skill development ABA Therapy Programs can vary depending on child s needs. Hours needed Parent training vs consultation vs direct treatment with the child Take place in a clinic, home, or in the school (potential insurance coverage at school by a private clinician still being reviewed) The earlier the behavior pocedures can be implemented the better: i.e. modeling, shaping, fading, natural environmental teaching, incidental teaching, visuals, joint attention, etc. 15
Understanding the New Autism Insurance Legislation Autism Specifics: Treatment ABA: BEHAVIOR MANAGEMENT What is maintaining undesired behavior? What is the FUNCTION of the behavior? Attention, Escape, Tangible, Automatic (i.e. sensory) Interventions/treatments DEPENDENT on function of behavior Derive function of behavior by conducting functional behavior assessment (FBA) to determine antecedents, behavior, consquence (ABC): valid data must be collected Full functional assessment (FA) testing contingecies of behavior, conduct FBA, interviews, etc. Should ONLY be facilitated by BCBA TRAINED in conducting FA s 16
Understanding the New Autism Insurance Legislation ABA: SKILL DEVELOPMENT Initial assessment to baseline skills with specific tool (ABLLS R or VB Mapp) Program initially designed around baseline findings, with prerequisite skill (core to growth) being targeted first Input from team and parents vital to setting targets Implementation maps to programs targeted with extensive data collection on probes and probe procedures followed Data analyzed by BCBA or professional trained extensively in this protocol and targets modified as mastery achieved Program decision making=data based decision making Overall goal for maintenance and generalization of skills: should be built into programming with data collection 17
Understanding the New Autism Insurance Legislation Autism Specifics: Treatment What is Applied Behavior Analysis (ABA)? Approach to teaching in a stepwise approach Prerequisite skills are are addressed before additional skills added Tasks broken down to basic levels and behavior shaped incrementally Example Teach Handwashing 1. Walk to sink 2. Turn on water 3. Hands under water 4. Apply soap 5. Rinse 6. Dry hands When teaching/shaping behaviors: 1. Master each task before moving to next 2. Data should reflect mastery 3. Use of extensive positive reinforcement based on motivators for specific individual 4. Reinforce at regular intervals initially and fade to random intervals to maintain behavior 5. Time to teach will vary on frequency and intensity of programming; every individual is different and program has to be unique to each individual 18
Understanding the New Autism Insurance Legislation Autism Bill Essentials: Therapies Alternative and non conventional therapies WILL NOT be covered as they are not considered evidence based: Special Diets Supplements Chelation Hyperbaric Oxygen Chambers Listening Therapies Recreational Therapies 19
Understanding the Proposed Medicaid Autism Benefit Not covered by the autism bills, but approved in state budget at $21M for year 1 [$17.5 M for implementation of Medicaid ABA and $3.1 M for MI CHILD, $400,000 for positions, effective Fiscal Year 2013] Plan to submit request to Centers for Medicare & Medicaid Services (CMS) to add ABA to State Plan using authority of 1915(i) Broader provider qualifications Includes Early Intensive Behavioral Intervention (EIBI) 20 25 hours/week and Applied Behavioral Intervention (ABI) 5 15 hours/week)aba Speech and Occupational Therapy and other specialty services and supports available through 1915(b) Medicaid Managed Mental Health Specialty Services and Supports Waiver PIHPs responsible for implementing 20
Development of the Medicaid Autism Benefit Since 2010. Class Action Lawsuit was filed in Federal Court for failure to provide ABA to Medicaid children with Autism under the federal EPSDT statute MDCH is currently in negotiations to settle Michigan s lawsuit The State of Florida was sued in Federal Court and recently lost a similar lawsuit 21
Development of the Medicaid Autism Benefit In 2012. Lt. Governor Calley asked a group to develop a best practice approach to serve children with ASD Colleen Allen, Autism Alliance of Michigan, led the group. As Michigan moved to settle the lawsuit, the Department convened a workgroup, in cooperation with The Standards Group of the MACMHB, to develop the Medicaid Autism Benefit to identify the best practice approach to deliver ABA services to children via the PIHPs 22
MDCH is pursuing : Development of the Medicaid Autism Benefit 1915(i) State Plan Amendment (ispa) to add ABA services to the Medicaid State Plan Amendment to the 1915(b)Medicaid Managed Mental Health Specialty Services and Supports Waiver Both the MDCH Behavioral Health and Developmental Disabilities Administration(BHDDA) and the Medical Services Administration (MSA) are working with CMS regarding the amendments Actuarial is identifying amounts of funds and how the funding will flow 23
Development of the Medicaid Autism Benefit Tasks to Implement the Medicaid Benefit: Submit the 1915(i) SPA and 1915(b) Waiver Amendment to (and receive approval from) CMS Issue Medicaid Policy for Public Comment Set up payment infrastructure Train clinical staff in standardized tests for diagnosis Implement the ABA Benefit 24
Development of the Medicaid Autism Benefit Proposed Rate Structure Medicaid Autism Benefit: An interim payment would be added to the PIHP capitation for infrastructure building (training on ADOS and ADI R). A case rate structure with 2 levels, based on level of intensity of service, paid as an interim payment to the PIHP on a monthly basis with a valid ABA encounter following the end of a quarter The interim payments for case rates would be subject to an annual cost settlement because of the lack of fee for service history for ABA 25
Implementing the Autism Benefit Please note that the process we will be describing and specific information we are providing today about the Medicaid Autism Benefit is evolving and the information regarding the implementation of the Autism Benefit is provided as it stands today. 26
Identifying Children in the Target Group Target Group Children and young adults between the ages of 18 months through 18 years who meet the Medical Necessity Criteria for Autism Spectrum Disorder Process to identify the Target Group: 1. Screening 2. Referral 3. Diagnostic Testing 27
Identifying Children in the Target Group Screening & Referral Role of the Medicaid Health Plan (MHP) Providers: Screening for ASD typically occurs during a wellchild visit with the pediatrician or family physician using a validated age appropriate screening tool can be completed by the parent and reviewed/verified by the nurse/ physician A child who screens positive for ASD must be referred to the PIHP in the geographic service area for further evaluation The primary care physician will contact the PIHP directly to arrange for a follow up evaluation 28
Identifying Children in the Target Group Screening & Referral Role of the PIHP: Each PIHP will identify a specific point of access and process for children who have a positive screen and are being referred for a diagnostic evaluation for ASD The PIHP is responsible for assuring that the results of the evaluation are communicated to the referring physician If child has not been screened by MHP, the screening tool can be completed by PIHP or a provider within the network if the child or young adult is already receiving services or was referred from other than the MHP 29
Identifying Children in the Target Group Diagnostic Testing PIHP will perform the evaluation to determine if the child or young adult who has screened positive for ASD is in the Target Group Provider Qualifications: Must be provided by a Child Mental Health Professional with a Master s degree in a mental health related field One year of experience in the examination, evaluation and treatment of children with ASD Able to diagnose within their scope of practice and professional license 30
Identifying Children in the Target Group Diagnostic Testing The Child Mental Health Professional will diagnose the child with autism spectrum disorder using the Autism Diagnostic Observation Schedule Second Edition (ADOS 2) tool and a developmental symptom history interview such as the Autism Diagnostic Interview Revised (ADI R) Diagnosis validated by a physician preferably a child psychiatrist or fully licensed psychologist Diagnosis leads to being included in the Target Group using the Medical Necessity Criteria as specified in Medicaid Policy (to be issued in the future) 31
Steps in the ispa Process Once the child or young adult has been determined to be in the Target Group, the following steps are required by the ispa: 1. Independent Evaluation to determine eligibility for ABA services 2. Independent Assessment to determine amount, scope, type and duration of ABA 3. Development of the plan of service 4. Delivery of ABA service 32
Independent Evaluation The ispa requires an Independent Evaluation that applies the Needs Based Criteria to determine if the child or young adult is eligible for ABA services Needs Based Criteria established in ispa Based on functional skills Closely mirrors the Medical Necessity Criteria for Asperger s Provider Qualifications: Child Mental Health Professional with a Master s degree in a mental health related field One year experience in the examination, evaluation and treatment of children with ASD Able to diagnose within their scope of practice and professional license 33
Independent Evaluation MDCH is currently planning to submit the ispa describing the existing PIHP system MDCH anticipates discussions with CMS related to Conflict of Interest requirements of the ispa for Independent Evaluation, as well as firewalls for the Independent Assessment, Plan of Service Development, and Delivery of ABA Services 34
Independent Assessment for ABA Once the child or young adult has been determined eligible for ABA services by meeting the Needs Based Criteria in the Independent Evaluation, the next step in the ispa process is the Independent Assessment The Independent Assessment for ABA is part of the comprehensive assessment and planning process. A comprehensive multi disciplinary assessment should include the following essential components: adaptive functioning communication sensory and motor functioning social, emotional and behavioral functioning (functional assessment of behavior) health/medical concerns psychosocial/family support needs 35
Independent Assessment Provider Qualifications for Independent Assessment of amount, scope, type, and duration of ABA: Psychologist: Fully Licensed Limited Licensed Temporary Limited Licensed 36
Development of Individual Plan of Service (IPOS) including ABA Parents are central to participation in the diagnostic and treatment planning process and development of the plan of service which is to be family driven and youth guided Provider Qualifications for IPOS Development Supports Coordinator Bachelor s degree in human services field One year of experience with population the supports coordinator will be serving Case Manager QMRP or QMHP: if Case Manager has only bachelor s degree without specialized training or experience they must be supervised by a QMHP or QMRP 37
Delivery of ABA Services Applied Behavior Analysis (ABA) services are available for all levels of severity for autistic spectrum disorders. This may include varying levels of intensity in hours per week or specific ABA intervention programs to target problem behaviors Parents are to be integral to the development and delivery of the ABA therapy and other services to be provided based on the plan of service 38
Delivery of ABA Services There are 2 levels of service intensity for ABA under this benefit: 1. Early Intensive Behavioral Intervention (EIBI) is a structured applied behavior analysis program that relies upon discrete trial training methods. This intensive intervention is typically 20 25 hour per week and is appropriate for children 18 months to age 6 years. It is provided in the home or in a center, several hours per day, 5 7 days per week for 2 to 3 years for reducing intrusive, disruptive behaviors, and/or stereotypic autistic behaviors and improving socially acceptable behaviors and communication skills. 39
Delivery of ABA Services 2. Applied behavioral Intervention (ABI) includes a variety of established treatments to increase functional communication, independent self care tasks, receptive language, expressive language, play behaviors, social skills, imitation, and/or any additional behaviors that will enable the child to more readily integrate with typically developing peers. This intervention may include an average of 5 15 hours per week of treatment. Children from 18 mos. to 19 years may receive this level of intensity. 40
Delivery of ABA Services There are 2 tiers of ABA service delivery: 1. Supervisory level is responsible for: designing the ABA intervention plan training staff on ABA techniques implementing the intervention and ensuring that the ABA plan of intervention is delivered by properly trained ABA Aides or Board Certified Assistant Behavioral Analysts (BCaBAs). BCBA, Psychologist, Child Mental Health Professional 2. Direct service delivery BCaBA, ABA Aide 41
Delivery of ABA Services TIER 1 Provider Qualifications: Board Certified Behavior Analyst (BCBA) or Fully licensed psychologist or limited licensed psychologist working within scope of practice and who has extensive applied behavior analysis education/ university training and experience in behavior analysis [consults with BCBA] or Child Mental Health Professional with Master s degree and one year experience treating children with ASD [supervised by BCBA] NOTE: All Supervisory Tier 1 personnel must have a BCBA no later than 9/30/16. Questions regarding adequate background preparation will be resolved by the PIHP and supported by technical assistance by DCH upon request. 42
Delivery of ABA Services TIER 2 Provider Qualifications: BCaBA or ABA Aide Meet all requirements of Aide as defined in the Michigan PIHP/CMHSP Provider Qualifications per Medicaid Services & HCPCS/CPT Codes Has received training in principles of behavior, behavior measurement & data collection, functions of behavior and basic concepts of ABA Works under supervision of Tier 1 Supervisor 43
Implementing the Autism Benefit Provision of Other Services The benefit that is being added to the Medicaid State Plan 1915(i) is specifically for the provision of ABA therapy. Other services may be provided based on assessment and plan of service as currently covered in the Medicaid Provider Manual, Mental Health/Substance Abuse Services Chapter, and as covered under the 1915(b) waiver for Mental Health Specialty Services and Supports. 44
Workforce Development ADOS Training: Sunfield Center October 14 & 15, 2012 Another ADOS training: Planned for December 2012 ADI R Training Sunfield Center November 14 & 15, 2012 45
Questions and Answers Discussion 46
Resources Available Resources NEW! AAoM Insurance Collaborative Portal: has information for parents, insurers, providers, employers, universities, workshops, handouts from presentations: https://sites.google.com/site/aaominscollaborative/home Today s Power Point (on Portal under Calendar and Events/Parents Informational Webinars) LARA http://www.michigan.gov/lara Autism Coverage Reimbursement Program http://www.michigan.gov/lara/0,4601,7 154 62954 287554,00.html AAoM Website: www.autismallianceofmichigan.org AAoM Resources: Colleen Allen: colleen.allen@aaomi.org Stacie Rulison: stacie.rulison@aaomi.org 47
Resources American Academy of Pediatrics (AAP), http://aappolicy.aappublications.org/cgi/search American Psychiatric Association, DSM 5 Development: www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=94 Association for Science in Autism Treatment (ASAT): www.asatonline.org Behavior Analyst Certification Board (BACB): www.bacb.com Centers for Disease Control and Prevention, Autism Spectrum Disorders, DSM IV Diagnostic Criteria: www.cdc.gov/ncbddd/autism/hcp dsm.html Cooper, Heron, & Heward (2007). Cooper, J., Heron, T., & Heward, W. (2007). Applied behavior analysis (2 nd Ed.), Upper Saddle River, NJ:Pearson Education Inc. Educating Children with Autism, National Research Council (2001). Online: http://www8.nationalacademies.org/onpinews/newsitem.aspx?recordid=10017 Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 5, 3 9. Missouri Autism Guidelines Initiative, http://www.autismguidelines.dmh.mo.gov/ National Standards Project (2010). National Autism Center: www.nationalautismcenter.org/about/national.php National Professional Development Center. on Autism Spectrum Disorders: http://autismpdc.fpg.unc.edu Prelock, P.A. (2006). Working with families and teams to address the needs of children with MRDD. Perspectives in Language, Learning, and Education 13(3), 7-11. Statewide Autism Resources and Training (START): http://www.gvsu.edu/autismcenter 48
Contact Information for MDCH Sheri Falvay (517) 241 5762 FalvayS@michigan.gov Price Pullins (517) 241 3371 Pullins@michigan.gov Lori Irish (517) 241 5762 Irishl@michigan.gov 49