State agrees to cover therapy for autistic children on Medicaid

After three children, Jennifer Collins thought she had it down.

But it became clear early on that her youngest son was struggling. Derek began talking late. He struggled with focus, cried more than usual and shunned affection. At age 2 came a diagnosis of autism.

“We were tearful, emotional all the time,” Collins said. “It’s heartbreaking to see your child locked in their own head and so unhappy and there’s nothing you can do about it.”

The Northwest Autism Project told her about the Cheney-based Domino Project, a preschool for autistic children that uses applied behavior analysis, an intensive therapy that focuses on early intervention through positive reinforcement.

After leaving the Domino Project and transitioning into Spokane Public Schools, Derek, now 6, skipped kindergarten and went straight into first grade.

“It changed our son’s life,” Collins said. “It was the best thing we ever could have done. He can communicate. He can talk to us. He has friends. They taught him how to learn.”

Now autistic children enrolled in the government-subsidized Medicaid program in Washington will have access to ABA therapy.

The change has been hailed as a turning point for struggling Washington families with autistic children.

The Washington State Health Care Authority has agreed to cover the cost of the therapy for children diagnosed with autism spectrum disorders, after it settled a lawsuit brought by the Washington Autism Alliance & Advocacy, the HCA announced last week.

“It requires a lot of time and effort, but ultimately the research shows this is the most effective therapy for treating the impacts of autism,” said attorney Scott Crain, with the Northwest Justice Project, which represented the plaintiffs. “There’s decades of research supporting its use to essentially modify problem behaviors.”

The lawsuit was filed in April, and the two parties entered into mediation.

U.S. District Judge Richard A. Jones approved the settlement, and beginning Jan. 1, the therapy will become part of the regular benefits offered by Apple Health for Kids, which includes people younger than 21 and enrolled in Medicaid.

“Recent evidence shows that this therapy has been effective and deserves to be covered by our benefit structure,” HCA Director MaryAnne Lindeblad said of the settlement in a prepared statement. “This is wonderful news for Medicaid parents and entire families who have had little recourse in the past in dealing with an autistic child.”

The treatment involves an ABA therapist analyzing and modifying problem behaviors through positive reinforcement.

“This settlement ensures children with autism and related disabilities have meaningful access to remediation of their condition, regardless of their funding source,” Arzu Forough, CEO of the autism alliance, said in a prepared statement. “This is a turning point for low-income Washington families involved with autism who have no other means of accessing medical treatment for their children.”

There are 9,000 youth on Apple Health for Kids who have an autism diagnosis and may benefit from the therapy. Overall, about 1 in 88 children have an autism disorder, according to the Centers for Disease Control and Prevention.

HCA officials expect the therapy coverage to cost $15.5 million in the biennium.

In 2011, the state’s Health Technology Assessment office ruled ABA therapy wouldn’t be covered because there wasn’t strong enough evidence supporting its efficacy.

HCA recently entered into a similar agreement to provide ABA coverage to state and other government employees and their dependents who need the therapy.

Medicaid clients were notified of the pending benefit change by mail this week.

The next step is building a statewide network of providers who can offer the therapy for Medicaid patients, Forough said.

“We’re very excited,” she said. “What we are really on the fence about is whether providers would be willing to jump through all the hoops that are required to bill Medicaid. It is a big next step.”

Gail Kreiger, manager of medical benefits and clinical review for HCA, said she has been in contact with providers to help them get the necessary licenses and enroll with Medicaid.

“I’m pleased that Medicaid is taking the leadership and providing the service,” she said. “I’m hoping … that it improves the lives of these families and the lives of these children.”