Dec 4, 2024, 1011NOW, Lincoln, NE: Nebraska DHHS probes Medicaid service for autistic youths as costs escalate
LINCOLN, Neb. Max Perry was ousted from day care as a tot.
His special needs became so intense that his mom quit her job to be nearby 24-7. His parents once chartered a private plane to transport Max, challenged by autism and epilepsy, to a major surgery because commercial flights sent him into panic mode, frantically kicking, screaming and peeling off clothes.
Max and his family eventually found doses of calm, joy and progress through a widely known therapy called applied behavior analysis (ABA), which has been shown to help autistic kids function better in society.
Now 15, Max has gained the reading ability of a first grader and social skills that allow the Perrys to plan a quick trip to a family get-together or a drive to a Kansas City doctor appointment.
“We were living in hell,” said Nikki Perry, a law school graduate who left a pharmaceutical sales job to be more involved in her son’s treatments. “If you don’t live it, you don’t get it. Truly our lives changed through ABA to where we could function as a family.”
But the Lincoln mom and other advocates now face a different anxiety, worried that such services could be jeopardized for a growing number of Nebraska’s most vulnerable youths. Experts say one in 36 youths has autism.
Skyrocketing expense
Advocates cite a recent notice sent out by one of the three mega insurers that manage health care benefits for Nebraskans enrolled in Medicaid. They said the state contractor had sought to slash Medicaid rates paid to ABA providers by as much as half.
Advocates feared that such a change could lead to reduced access to services and would perhaps drive away providers they say are scarce enough already in Nebraska.
Matt Ahern, interim director of the Medicaid and Long-Term Care division in the Nebraska Department of Health and Human Services, said he was aware of the situation and has made it “absolutely clear” to the contractor that access to services can’t be compromised.
However, in the broader picture, Ahern said that providers, families and others should brace for more restrictive guardrails and controls next year related to ABA — a service area where costs over a three-year period have skyrocketed more than 1,000%.
According to state data, Medicaid claims paid to ABA providers in the state leaped from $4.6 million in 2020 to nearly $52 million in 2023. Medicaid-eligible youths who were served during that period multiplied from 169 to about 1,150, a nearly 600% jump.
Acceleration continued in 2024, and Ahern said the spend by year-end could reach $75 million, which would mean a 1,500% increase since 2020.
“It is definitely a sharp increase, probably one of the sharper increases I’ve actually seen across any service line,” Ahern said.
‘Perfect storm’
Driving the surge is a combination of factors, he said, including pay rate increases to service providers. The Nebraska Legislature approved a 17% hike in behavioral health services in 2023. Ahern said Nebraska Medicaid rates paid to ABA providers now are among the highest in the country.
In addition, a “big relaxation” of telehealth services during the pandemic opened the door to young people in rural areas who before hadn’t had as much access. Ahern said several providers came into the state without establishing a physical presence, though some have since opened offices and hired local staff.
Moreover, Ahern said, ABA providers operate under “looser controls” than many other disciplines, which, he said, can lead to overauthorization of services.
“That kind of made the perfect storm for the rapid increase,” he said. . . .
DHHS more recently has tightened telehealth services, such as requiring the on-site presence of a registered behavior technician who can be supervised by a higher authority, a board-certified behavioral analyst.
Currently, Ahern said, DHHS is focusing on developing clearer definitions and parameters related to ABA therapy. He said the state does not aim to reduce access to services needed by youths with developmental disabilities, but wants to ensure that billing practices are appropriate and services are sustainable.
He foresees a rollout of potential changes early next year.
“The door’s been a little too open for our liking,” Ahern said.
Nudging DHHS to re-examine the program is recent scrutiny by federal auditors looking at other states’ behavioral health programs to ferret out possible misuse, fraud and inefficiencies. Ahern said his team wants to be proactive. . . .
Comments