Indianapolis parents Breanna and Dakota Powell have two autistic children, ages 3 and 6, and spent years in early intervention services but saw little improvement — until they started Applied Behavioral Analysis therapy, or ABA therapy for short.
Caption Parents Breanna and Dakota Powell outside of the Governor’s Mansion on Aug. 17, 2023. (Niki Kelly/Indiana Capital Chronicle)
“ABA has shown my children their voice,” Breanna Powell said, adding that her daughter recently said her first word, ‘ear.’ Previously, the Powells had communicated with their children using an iPad.
But a proposed cut to the Medicaid reimbursement rate for ABA therapy could threaten that, prompting the Powells to join dozens of families in a Thursday protest outside of the Governor’s Residence.
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When the Powell’s provider, Applied Behavior Center for Autism, told them about the cuts, they knew they needed to act. Doctors told the parents their children risked regressing without access to the therapy.
“It’s really messed up to cut special needs programs,” Breanna Powell said.
The proposed cuts
Indiana’s Medicaid program didn’t start covering ABA therapy — a type of skills-based therapy beneficial to some families — until 2016. Without a precedent to set base rates, the Family and Social Services Administration (FSSA) decided to pay a flat, 40% percentage of whatever providers charged the insurance policy.
“Payment of a percent of billed charges has resulted in widely different reimbursement amounts for different providers of the same service,” FSSA detailed on its site earlier this month. “Over the last three years ABA expenditures have increased by more than 50% per year, which is not a sustainable rate.”
Costs for ABA therapy have increased rapidly, according to FSSA. (From an Aug. 8, 2023 FSSA presentation)
The agency reported that in 2022 it spent $420 million on ABA claims for 6,200 children and young adults. Costs could continue to climb if a fee schedule — similar to what’s used for other services — isn’t implemented, the post warned.
In the third quarter of 2022, paid hourly rates for ABA services averaged $91 but ranged from $46 to $222 — according to an FSSA presentation from August 8, 2023. Some of that included non-allowable costs and pushed Indiana’s reimbursement rate higher than peer states, according to FSSA.
The new rates would be $55.16 per hour of ABA therapy administered by a Registered Behavioral Technician — the majority of ABA services — or $103.77 for services rendered by a physician or other qualified health care professional.
Rates will take effect in late 2023 or earlier 2024, with rate reviews scheduled every four years.
“The goal is to transition away from individual reimbursement amounts that are essentially set by providers and move to transparent statewide ABA rates that promote uniform access for families and allow providers to retain a stable workforce, while ensuring sustainability for Indiana’s Medicaid program.”
Pushback from families, providers
The Indiana Providers of Effective Autism Treatment (InPEAT) criticized the methodology used by FSSA to determine the new reimbursement rate, saying it relied too heavily on rates for home- and community-based services when most ABA therapists work in centers.
“While we support the state’s efforts to put a fixed fee schedule in place and better manage costs, this reduction is so steep that it will mean thousands of children losing services and thousands of therapists losing their jobs,” said Jason Shaw, president of the InPEAT board of directors in a statement. “ABA therapy is a medical treatment that provides children with autism vital skills to gain independence and function better in their community. Losing access to this service will have lifelong consequences.”
The deadline for comments from ABA providers is Wednesday via INabatherapy@mslc.com.
“We’re asking FSSA to establish a new fixed rate that balances the state’s objectives to better control Medicaid expenditures while preserving access to quality care. There’s a way to do both without leaving these children and families behind,” Shaw continued.
Criticism of the cuts came from lawmakers as well, including licensed occupational therapist Victoria Garcia-Wilburn, who said she spent two years working at an autism center.
“… I am deeply disappointed in this FSSA proposal to cut families’ ability to provide this sound and proven therapy for their children with autism. Decades have shown that ABA therapy is effective in improving quality of life for people with autism. Anything but sufficient reimbursement is harmful,” Garcia-Wilburn said in a statement.
The growing costs to Medicaid and the growing number of Hoosiers using the service demonstrated the effectiveness of ABA therapy, she said, urging FSSA to reconsider and calling for the State Budget Committee to reject the proposal.
“ABA therapy sets autistic kids up for success for life,” Garcia-Wilburn continued. “… I cannot stress enough that it would be inhumane to deny someone who needs ABA therapy this treatment.”
‘Long overdue’ process
Last week, before the protests outside his home, Gov. Eric Holcomb defended the agency’s actions, saying it was appropriate and dependent upon feedback from stakeholders to set a statewide standard.
“I would say (it’s) long overdue that we have some standards set,” Holcomb said.
Some had called for Holcomb to slow the process down but he rebuffed those appeals, saying it would be unfair for everyone and that the months-long process is still ongoing.
“We’ll make sure we get it right; we’ll make sure that we’ve done our research,” Holcomb said. “We know where we place in the country in terms of this reimbursement and so, again, we’ll arrive at a fair spot for families and for the state of Indiana that’s paying the bills.”
