Nebraska won’t appeal ruling expanding autism coverage under Medicaid


Nebraska won’t appeal ruling expanding autism coverage under Medicaid

By Martha Stoddard / World-Herald bureau

LINCOLN — Nebraska won’t fight a judge’s order for Medicaid to start covering a potentially costly but effective treatment for children with autism.


Calder Lynch, the state Medicaid director, said Wednesday that the state would not appeal the June ruling. He wants to have all the pieces in place so Medicaid can start paying for applied behavior analysis and similar treatments by the end of the year.


“I think it’s a good service, and I’m glad that we’ve been able to move forward to provide it,” Lynch said.


The state’s decision represents a long-sought victory for parents of autistic children and their advocates.


In the past, Nebraska officials have resisted efforts to add coverage for the treatment, citing concerns about potential costs.


Lynch said the change in the state’s position stems from several factors, including a directive from the federal government and changes in what professionals consider best practices in autism treatment.


“Given the judge’s ruling and how we’ve seen this issue evolve, it didn’t make sense to continue the appeal process,” he said.


Lancaster County District Judge John Colborn issued the ruling June 30 in a class-action lawsuit.


The suit was filed in 2012 by the Nebraska Appleseed Center for Law in the Public Interest and the National Health Law Program on behalf of two boys, identified only as K.D. and S.L.


Robert McEwen, an attorney for the boys, said he was pleased that the state would not appeal.


“We now look forward to swift and complete implementation of the court’s decision so that children with serious behavioral needs can get the important services they need,” he said.


In his ruling, Colborn ordered Medicaid to start paying for applied behavior analysis and similar treatments for children if recommended by medical professionals.


Applied behavior analysis uses positive reinforcement and other techniques to change behavior. It can eliminate symptoms of autism for some children and dramatically reduce the symptoms in others. But depending on a child’s needs, it can be very intensive and expensive.


Previously Nebraska Medicaid barred coverage of behavior modification services, including applied behavior analysis. The program also prohibited coverage of mental health treatments when aimed at treating developmental disabilities.


In his order, Colborn found that the prohibitions violate federal law.


Lynch said it would take some time to implement the change, starting with developing a plan and getting court approval of the plan.


The process also involves getting federal approval, rewriting state regulations, contracting with providers and developing payment rates.


Lynch said it is too early to calculate the cost of covering the treatment.


The boys named in the lawsuit had both been denied coverage of applied behavior analysis, though their doctors had recommended the treatment to help them function better.


K.D., now 7, has been diagnosed with autism, among other conditions.


According to the petition, his behavior includes screaming, twirling, throwing tantrums, pinching, biting and banging his head.


A psychologist recommended applied behavior analysis to help him learn to follow directions, talk more, tolerate frustration better, and reduce aggression and tantrums.


S.L., now 6, has severe behavioral disorders, including running away, eating objects such as sponges and toys, slapping and biting himself, hitting others, destroying property, and licking electrical sockets.


A psychologist recommended applied behavior analysis to curb his aggression and self-injuring behavior, as well as to prolong his life and reduce his disabilities.


State officials last year estimated that 2,305 children in the Medicaid program may need the treatment. About 30 percent of Nebraska children have health coverage through Medicaid.


In Missouri, a study found that health insurance claims for applied behavior analysis treatment averaged $1,704 annually in 2013. However, the treatment can cost as much as $50,000 a year for some children.


Advocates argued that the treatment can reduce future costs by making autism less disabling or by helping people overcome it altogether.


Last year, Nebraska lawmakers mandated that some private health insurance plans cover autism diagnosis and treatment for children, including applied behavior analysis.


The new law, which applied to policies taking effect this year, was expected to benefit about 1,000 Nebraska children.


The law does not apply to self-funded insurance policies, which cover about 60 percent of Nebraskans and are regulated by federal law. The law also does not apply to most individual or small-group policies. Including those policies would have triggered a provision in the federal Affordable Care Act that requires states to pay for insurance mandates exceeding what the federal law requires.



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