Some children with autism lose treatment services after Medicaid changes cut clinic revenue – VTDigger

For Jennifer Bean-Edgar, watching her son demonstrate how to express his needs.

She said of her 6-year-old: “She went from being completely non-verbal, non-communicative, non-engaging (and) able to play on her own and talk to friends.

Sam has severe autism. The diagnosis means he needs help with daily tasks such as going to the bathroom or eating. He will likely need 24/7 support for the rest of his life, his mother said.

After being discharged from a daycare that could not meet his high needs, Sam began attending an early intervention clinic for children with autism. The clinic, Keene Perspectives, in Hartford, is one of many in Vermont that specializes in applied behavior analysis, or ABA, therapy. Treatment focuses on establishing beneficial behaviors – such as communication or toileting – and reducing problem behaviors – such as walking on the street or kicking and scratching.

“The amount of growth I’ve seen is immeasurable. It’s incredible,” Ben-Edgar said.

Sam does puzzles and plays games. He is beginning to repeat words and can communicate his needs through something called a picture exchange communication system, which uses little examples to express things like “I want,” “toilet,” “water,” “toys.”

Yet Sam’s progress stalled in February when Keene Prospects informed his mother it was releasing him from the clinic, six months before he was due to transfer to public school.

It comes as Keene Perspectives and nearly 20 other ABA providers in Vermont race to adapt to changes in how Vermont Medicaid pays for its services. The change has led to a significant drop in income for many ABA providers—one that some say threatens their ability to provide services at all. Still, Medicaid says the change is a necessary way to protect against fraud and protect the ability to pay for ABA services in general. Although the changes are set to go into motion by late 2025, they now collide with congressional investigations into the state’s federal health insurance program.

At Keene Perspectives, Sam follows the specific protocol that a clinician called a Board Certified Behavior Analyst, or BCBA, has designed for him. A BCBA has graduate-level training and licensure as a health professional. Sam spends his days one-on-one with a behavioral technician who stays with him to implement the clinical guidelines and lessons that BCBA has designed. The Behavioral Technician position is an entry-level, non-professional role that requires very little training.

As part of the protocol, the BCBA spends part of the day with the child, such as Sam, and the behavioral technician, monitoring how the client is responding to treatment and where his plan needs to be changed.

Through the end of 2025, Medicaid will pay ABA centers for both behavioral technician and BCBA time. This January, Medicaid made new changes that no longer allow providers to bill both BCBA and behavioral tech for the same services.

That coordinated billing, explained Grace Johnson, Medicaid policy analyst for the Vermont Agency of Human Services’ Medicaid Policy Unit, simply wasn’t “correct coding.”

She and her colleagues identified the ABA as a primary area where the state is already acting to prevent potential federal investigations into Medicaid fraud, waste and abuse in Vermont.

Under President Donald Trump, the federal government has increasingly scrutinized how states spend money in the state-federal partnership health coverage program. Johnson noted that last summer, the federal government found that Wisconsin had paid $18.5 million for “improper” ABA billing claims.

She said Vermont Medicaid wants to mitigate its exposure to federal investigations to ensure its payments are in line with federal guidelines.

Cortney Keene, BCBA, who founded and runs Keene Perspectives with her husband, Chris Keene, said about half of the clinic’s clients are Medicaid patients. They said their revenue was down about 16% in January and February.

Medicaid billing for ABA services operates on a case-by-case basis, so providers bill the hours spent by the client receiving services rather than specific services. So, if a child attends a clinic like Keene Perspectives for 10 hours a week, working with a behavioral technician, Medicaid will reimburse the clinic for 10 hours – even if two of those 10 hours are spent with the behavioral technician. and A licensed BCBA, who guides and writes the protocol. Previously, these 10 hours could be billed as 12, to reflect the two hours of BCBA time, on top of the behavioral technician.

“Frankly, the structure of our work is too complex for a behavioral technician to do faithfully, the way it should be done, without BCBA oversight,” Keane said. “We are ethically required to provide services in this structure. You have to have two people part of the time to make sure it’s done right.”

So Keynes’ process remains the same. BCBAs still design the protocol and see how the child responds to it, they just don’t get paid for their time.

The same is true at Little Royals Early Intervention Center, an ABA center in Williston. It was important, explained Celia O’Flaherty, BCBA and the center’s clinical director, to maintain this standard of care.

But this has led to a 17% drop in revenue for the center and a drop in what they are paid for some individual clients of anywhere from 15%-50%.

“50% feels amazing to us,” O’Flaherty added.

Both he and Keynes know of clinics that are already looking to close their doors entirely.

For now, the Little Royals are expanding services and bringing in revenue in other ways — contracting clinicians with schools, for example, and Flaherty hopes to help retain them.

Little Royals has yet to discharge Medicaid clients or stop taking on new ones.

However, Keene Perspectives has already begun to respond to the loss of revenue by scaling back the number of its clients.

The Canes are already in the process of discharging half of their Medicaid patients — among them Ben-Edgar’s son Sam.

“We’re struggling to maintain our skills. We’re certainly not building any additional skills at this time,” Sam’s mother said.

Sam has already started attending speech therapy and occupational therapy at public school in the mornings, before his mother moves him to Keen Vision for the afternoon.

It’s a constant juxtaposition and changing schedule that prevents Ben-Edgar from being able to hold down any sort of stable job.

Cortney Keene is also concerned about how this can displace the high demand for care on parents or schools, which she says have very little resources and training to address the needs of autistic children. “They come here because they have a medical need for these services. That medical need has not gone away,” she said.

Johnson, the Medicaid policy analyst, said her colleagues at the Department of Human Services are monitoring how providers are responding by seeing how they can or cannot continue to provide services.

Coincidentally, the Medicaid team began studying its ABA rates as a result of the law passed last year..

Johnson pointed to it, however, as a possible solution for providers struggling to meet their needs in light of these changes.

“If the reimbursement that was happening wasn’t enough, the rate study would have pointed that out,” she said.

O’Flaherty, also at Little Royals, said if rates were changed to truly reflect the amount of work that goes into each hour a child receives care, it would ease the financial pressure the center faces.

“If this is our new reality, then there needs to be a price change,” she said.

Alex McCracken, a spokeswoman for the Vermont Department of Health Access, which also oversees Vermont’s Medicaid implementation, emphasized that her department will continue to monitor how providers respond to the billing rule changes implemented earlier this year. She said it’s already three months to see the impact of the billing change.

The department wants to make sure the changes “don’t put undue stress on patients and families,” McCracken said. “Our primary concern is ensuring that members have access to clinically appropriate care for their needs. So we are very plugged in about how to protect and maintain that access.”