CMS Guidance and Autism Spectrum Disorder
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CMS Guidance and Autism Spectrum Disorder Autism Special Interest Group Webinar Series February 11, 2015
Transcript of CMS Guidance and Autism Spectrum Disorder
CMS Guidance and Autism Spectrum Disorder
Autism Special Interest Group Webinar Series
February 11, 2015
Webinar Overview Welcome!
Introductions
Presentations
Q & A
Survey
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Introductions
Dr. Cathy Pratt, BCBA-D
Director, Indiana Resource Center for Autism
Indiana Institute on Disability and Community
Indiana University
Welcome to the CMS Guidance and Autism Spectrum Disorder webinar organized thru the
Autism Special Interest Group (SIG).
Autism SIG provides mechanism for LEND and
UCEDD centers that are part of the AUCD
network to learn from and collaborate around
issues and interests.
Interest in CMS guidance around ASD, and in
learning how it is being interpreted in various
states.
Speakers: Abbi Coursolle (NHeLP)
Denise Rozell (Easter Seals)
Tonia Ferguson (Autism Society)
Jennifer Bogin (Connecticut Department of Developmental Services)
Kim Musheno (AUCD)
Presenter
Abbi Coursolle
Staff Attorney, National Health Law Program (NHeLP)
Los Angles, CA office
Medicaid and Youth with ASD
•3.8 Million children & youth under 21 in Medicaid
•Estimated 500,000 youth under 21 in Medicaid with ASD
42 U.S.C. § 1396a(a)(8)
Early
Children can be put on Medicaid at birth. Developmental delays are often
diagnosed within a child’s first two years.
Periodic
Medicaid programs must cover all of a child’s recommended routine
well-care visits, immunizations, etc. A regularly scheduled pediatrician
visit is often where potential Developmental disabilities are assessed,
resulting in referrals to specialists.
Screening
Includes standard health screenings for things like hearing and vision,
but also developmental screenings.
Diagnosis
Once a child’s pediatrician identifies a potential illness or condition,
Medicaid covers any needed follow-up testing or specialist visits.
Treatment
States can limit the treatment available to adults age 21 and over, but for
children and adolescents up to age 21, Medicaid programs must cover any
service that is listed in the Medicaid Act,
And cover as much of the service is needed to “correct or ameliorate” the
child’s condition.
Treatment for ASD
A lot of people think about ABA Therapy, but there are a
variety of behavioral therapies and approaches that may be
appropriate
The guidance was helpful for advocates, but left a lot of
questions.
What services, exactly, would states have to cover? By
when?
Many states said, we’re already in compliance. What
recourse left?
Presenter
Denise M. Rozell
Assistant Vice President, State Government Relations
Easter Seals
Washington, DC
CMS Guidance and Autism Spectrum
Disorders: The Provider Perspective
Denise Rozell
Assistant Vice President, State Government Relations
Easter Seals
202-347-3066
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National and international reach – Mexico,
Canada, Australia
Variety of services matching community need –
from early intervention to employment to adult day
services, camping, therapies, veterans services
Variety of ages – preschool, school age, adults
and seniors
Autism: Applied Behavioral Analysis, OT, PT, early
intervention, educational/school based services
State Autism Profiles www.easterseals.com/autism
Easter Seals: Easter Seals is working to build a better
world where all people with disabilities and their families
are equal in every way, and can realize their goals,
dreams and aspirations.
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Prior to the Guidance, most states were not
providing ABA or other autism services under
EPSDT
More individuals get access to “autism services”
But:
o Still have to define “autism services”
o Still have to be “medically necessary”
o Still have to fit within Medicaid state plan
o Still have to address denials
Why Does the Guidance Matter?
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While CMS issued one guidance, it is being
interpreted in states in 50 different ways…
o Hawaii – lawsuit
o California – expansion plus additional state
dollars
o Texas – State agency “studying” the definitions;
looking to file a state plan amendment
o Connecticut – Case Study; working through a
process
o Some states pretending it will go away…
What is Happening in YOUR State!
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It depends…
Questions providers will be asking:
o Where will the referrals come from?
o Will there be enough provider agencies?
o Will there be enough ABA’s? Enough other
providers?
o Will the rate pay for the service?
o Do the providers have enough infrastructure to
bill?
What Does It Mean for Providers?
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Take the Guidance to your Medicaid agency and
ask what they are doing.
Share what other states (Connecticut?) are doing
– no need for everyone to invent this from scratch!
Volunteer to be on implementation work groups.
YOU are the experts!
Reach out to providers to form partnerships –
share knowledge, outcome measures, training,
expertise.
Hold local community forum with families,
providers, Medicaid to share information.
What Can YOU Do?
Presenter
Tonia Ferguson, Esq.
Vice President, External Affairs
Autism Society
Bethesda, MD
Family Perspective
What does all of this mean for my family?
The opportunity
• EPSDT is an opportunity for families to access quality and accessible preventive and early intervention services that is fundamental for the health, safety, and success of children on on the spectrum.
Education is Key
• We must inform families about EPSDT services and assisting families to access.
• Families must first understand, what is EPSDT?
• What does it cover?
• What does it not cover?
• Educate and target outreach to at-risk groups
What do families say to physician or service providers?
• Must understand the right language, What is medical necessity? What is not?
• Must have proper documentation
• Know the length of time the individual will need services
• Families must request Medicaid payment for services
What if I am denied benefits?
• Service is not considered medically necessary treatment
• Service not allowed in an integrated way beyond clinic-based behavioral model
• Appeal, Appeal, Appeal
Where do we go from here, It’s all so complicated!
• Continue to educate families. Educate, Educate, and educate.
• Align and integrate the way we deliver care to children and families to promote a seamless continuum of EPSDT services
• Outside the box thinking
Presenter
Jennifer Bogin, M.S.ed, BCBA
Director
Division of Autism Spectrum services
Connecticut department of developmental services
J E N N I F E R B O G I N , M . S . E D , B C B A D I R E C T O R
D I V I S I O N O F A U T I S M S P E C T R U M S E R V I C E S C O N N E C T I C U T D E P A R T M E N T O F D E V E L O P M E N T A L
S E R V I C E S
Connecticut’s Proposed Coverage for Autism Spectrum Disorder
Services Under Medicaid
About me...
Director
Researcher Consultant Advocate
Sister Sister-in-Law Aunt
Direct Support Professional
Background/How We Got Here
• On July 7, 2014, the federal Centers for Medicare and Medicaid Services (CMS) issued an Informational Bulletin clarifying that state Medicaid programs must cover a full menu of services for individuals under 21 with autism spectrum disorder (ASD) under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit if they are medically necessary
• Bulletin is posted online at: http://www.medicaid.gov/ Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf
Background/How We Got Here
• August 29, 2014 – Governor Malloy directed the Departments of Social Services (DSS) and Developmental Services (DDS) to develop a plan to implement CMS’ bulletin and to share initial recommendations with the Autism Advisory Council on how to implement the CMS guidance
• Other state agencies involved in the development of the plan: Departments of Children and Families, Mental Health & Addiction Services, Education, and Office of Policy Management
Goals of Covering ASD Services
• Services should be based on a comprehensive diagnostic evaluation that is individualized and holistic in order to identify the most appropriate treatment / interventions
• Evaluations and assessments should inform a plan of care that specifically identifies treatment / interventions uniquely tailored to each individual and a means to measure progress
• Medicaid-covered services must effectively coordinate with and complement other sources of support
• Services are provided by qualified, experienced providers
• Efficacy of the services must be evaluated and, as necessary, adjusted or modified, to best meet the needs of the individual and ensure high quality services
Background Information
• Nationally, 1 in 68 children has Autism Spectrum Disorder (ASD)
• There is no known cure for ASD
• Early screening, identification, and treatment are critical – the earlier the better
• National research reports have been updated in 2014, identifying several evidence-based practices for children with ASD
Medicaid Coverage
DSS and DDS explored:
• The two potential ways to cover autism services under the Medicaid State Plan
– Other Licensed Practitioner Services
– Preventive Services
• Ways to cover other (non-State Plan) autism services
– Home and Community-Based Services 1915(i) Amendment
– Home and Community-Based Services 1915(c) Waiver
– Research and Demonstration 1115 Waiver
Medicaid State Plan Authorities
• Other Licensed Practitioner – Must directly link licensed practitioner to service
– Focuses more on provider than on the service
• Preventive Services – Focuses more on the service than on the provider
– Must be recommended by a licensed practitioner
– Unlicensed provider, such as Board Certified Behavior Analysts (BCBAs) can be directly reimbursed in this category
– Ability to group different provider types (physicians, non-physicians) into one category of ASD service providers for data collection, reporting, and quality monitoring purposes
Medicaid Coverage Recommendation
Recommendation #1:
Utilize the Preventive Services benefit category to cover autism treatment services
The Preventive Services authority is flexible, allows non-licensed practitioners in independent practice to provide treatment, and enables the Medicaid program to group all ASD providers into one category
Medicaid State Plan
• In order to cover new or different Medicaid services, DSS must submit a State Plan Amendment (SPA) to CMS
• The state plan is the contract between the state and CMS that describes the Medicaid program
• After the SPA is approved, CMS is expected to reimburse the state 50% for these services under the Medicaid program
Service Description Recommendation
Recommendation #2
Cover ASD services that are medically necessary based on an individualized comprehensive diagnostic evaluation, behavior assessment, and individualized plan of care
Target Population
• CMS clarified that the Medicaid program must provide medically necessary ASD services to members under age 21
• The majority of the evidence-based ASD interventions are designed for children
Target Population Recommendation
Recommendation #3
The target population for immediate action are Medicaid members under the age of 21 with an autism spectrum disorder diagnosis and for whom these services are medically necessary
Based on the CMS guidance and because the EPSDT requirements apply only for members under the age of 21, and the literature on evidence-based practices focuses on children
Implementation- January 1, 2015
ELIGIBLE MEDICAID MEMBERS
Individuals eligible for ASD evaluation and treatment services must be enrolled in Medicaid (HUSKY A, C, or D) and under the age of 21.
In order for an individual to receive treatment services, he or she must have a comprehensive diagnostic evaluation that recommends ASD services based on an ASD diagnosis consistent with the Diagnostic and Statistical Manual for Mental Disorder (DSM 5) definition of Autism Spectrum Disorder.
EVALUATION SERVICES
Medical/Physical Evaluation:
A medical/physical examination is necessary prior to receipt of services to treat ASD.
The evaluation will review the individual’s overall medical health, hearing, speech, and vision, as appropriate, and should include a validated ASD screening tool.
The evaluation is intended to rule out medical or behavioral conditions that may co-occur with the ASD
EVALUATION SERVICES
Comprehensive Diagnostic Evaluation: Neurodevelopmental review of cognitive, behavioral,
emotional, adaptive, and social functioning
Should use validated evaluation tools in order to diagnose and recommend general ASD treatment interventions and issue a comprehensive diagnostic evaluation including an evaluation report.
The comprehensive diagnostic evaluation must be performed by a licensed practitioner (e.g. psychiatrist, neurologist, pediatrician including a developmental pediatrician, psychologist, licensed clinical social worker) working within his/her scope of practice and who is qualified and experienced in providing ASD evaluation services
EVALUATION SERVICES
Behavior Assessment: A behavior assessment is a clinical compilation of observational data,
behavior rating scales, and reports from various sources (e.g. schools, family, pediatricians, etc.) designed to identify the individual’s current strengths and needs across developmental and behavior domains.
It assesses which autism treatment services would be most appropriate for the individual’s care.
Validated assessment tools or instruments must be utilized and can include direct observational assessment, observation, record review, data collection, and analysis.
The behavior assessment must include the current level of functioning using one or more validated data collection instruments or tools.
The assessment must be performed or updated not more than six months before treatment services are requested.
EVALUATION SERVICES
Plan of Care:
The practitioner who conducted the behavior assessment will develop a detailed Plan of Care specifically tailored to each individual that must include, but is not limited, to the following elements:
a) measureable goals and expected outcomes if treatment services are effective;
b) specific description of the recommended amount, type, frequency, setting, and duration of ASD treatment services needed to best meet the needs of the member; and
c) amount and type of parent/care giver participation required to maximize success.
ASD TREATMENT SERVICES
ASD treatment services include (A) services identified as evidence-based by nationally recognized
research reviews, (B) services identified as evidence-based by other nationally recognized
substantial scientific and clinical evidence or (C) any other intervention supported by credible scientific or clinical
evidence, as appropriate to each individual. ASD treatment services include a variety of behavioral interventions that
meet the criteria in one or more of (A), (B) or (C) above, such as evidence-based Applied Behavior Analysis interventions that meet one or more of those criteria.
The ASD treatment intervention services must be done under the supervision of a qualified licensed practitioner working within his/her scope of practice or by a qualified Board Certified Behavior Analyst (BCBA) working within his/her scope of practice.
The supervising practitioner is responsible for all of the care provided to the member and for supervising the technician and any other support staff.
ASD TREATMENT SERVICES
Caregiver Participation in ASD Treatment Services A caregiver (e.g. parent, guardian, family member, babysitter,
child care worker, etc.) shall participate in treatment sessions in a manner specified in the behavioral plan of care that is sufficient to maximize the quality and clinical effectiveness of the services, as tailored to the needs of each member.
Specifically, the caregiver shall participate in at least 50% of all treatment sessions, which may be reduced if appropriate for a member’s unique circumstances in a manner that continues to ensure the medical necessity, quality and clinical effectiveness of the services, as documented and explained in the plan of care.
Provider Types and Qualification
• Providing high quality and properly coordinated services is critical
• Unqualified or inexperienced professionals may do harm to members and their families
• Some licensed or board certified professionals have limited expertise in working with children with ASD
• DDS and DSS are committed to ensuring that the provider network is qualified; federal Medicaid rules also require the program to ensure high quality services
PROVIDER QUALIFICATIONS AND ENROLLMENT
Practitioners who provide the comprehensive diagnostic evaluation, behavior assessment, and plan of care, and who supervise the treatment intervention services must be enrolled in the Connecticut Medical Assistance Program either as a performing provider associated to a billing provider (such as a group practice or a clinic) or as an individual billing provider.
Providers must work within their scope of practice, and have specific experience, training, and specialization in ASD services.
PROVIDER QUALIFICATIONS AND ENROLLMENT
Starting January 1, 2015, all BCBAs must be credentialed in writing by the Department of Development Services (DDS) as meeting the applicable qualifications described below.
Starting January 1, 2016, all licensed practitioners who provide the comprehensive diagnostic evaluation, behavior assessment, plan of care, and treatment services must also be credentialed in writing by DDS. All licensed practitioners performing behavior assessments and
treatment services must still comply with all qualification requirements described below beginning January 1, 2015, and the Department or the ASO may request documentation that the provider meets those qualifications.
PROVIDER QUALIFICATIONS AND ENROLLMENT
Providers of Comprehensive Diagnostic Evaluations
Qualified providers of comprehensive diagnostic evaluations must comply with section 17b-262-1056(c) of the proposed regulation.
In addition, starting January 1, 2016, all providers of comprehensive diagnostic evaluations must also meet the qualifications set forth in section 17a-262-1057(d) of the proposed regulation.
PROVIDER QUALIFICATIONS AND ENROLLMENT
Providers of Behavior Assessments and ASD Treatment Services Qualified providers of the behavior assessment and ASD treatment services must possess specialized training, experience or expertise in ASD. Qualified providers include:
Physicians;
Advanced Practice Registered Nurses;
Physician Assistants;
Licensed Psychologists;
Licensed Clinical Social Workers;
Licensed Marital and Family Therapists;
Licensed Professional Counselors; and
Board Certified Behavior Analysts.
PROVIDER QUALIFICATIONS AND ENROLLMENT
Training
18 hours of continuing education in ASD services in the last three years, which may include training approved for maintenance of certification for BCBAs, or any appropriate training approved for license maintenance for any category of licensed practitioners listed immediately above; and
PROVIDER QUALIFICATIONS AND ENROLLMENT
Professional Experience
Two years of full-time equivalent work experience in treating individuals with ASD beginning after the individual graduated with a degree that made the individual eligible for applicable licensure or certification or the date of actual certification, whichever is later; and
PROVIDER QUALIFICATIONS AND ENROLLMENT
ASD Education or Supervised Professional Experience All licensed practitioners and BCBAs shall meet the requirements of
either subparagraph (A) or subparagraph (B) below: ASD Education: Passing grades in not less than 15 credit hours or the
equivalent of graduate-level courses from an accredited college or university which, include significant content in all of the following: ASD treatment, diagnosis and assessment; child development; psychopathology; family systems; and multi-cultural diversity and care; or
Supervised Professional Experience: At least one year of supervised experience under a licensed practitioner or a BCBA who is also a licensed practitioner who meets all of the following (i) works within such individual’s scope of practice, (ii) have experience in providing applicable ASD services and (iii) already meet the requirements of this subsection. Supervised professional experience may overlap with one or more years of professional experience described in (2) above.
PROVIDER QUALIFICATIONS AND ENROLLMENT
Technician’s Qualifications ASD treatment services may be provided by an unlicensed professional
under the direct supervision of a Medicaid enrolled licensed practitioner/provider or BCBA who is qualified to provide ASD services. The technician must meet at least the following minimum qualifications:
Education and Experience: Have either (A) A bachelor’s degree from an accredited college or
university in a behavioral health field, behavior analysis, or a related field, plus one year of full-time equivalent experience working with children with a diagnosis of ASD, or
An associate’s degree or an equivalent number of credit hours with a passing grade from an accredited college or university in a behavioral health field, behavior analysis, or a related field, plus two years of full-time equivalent experience working with children with ASD; and
18 hours of continuing education in ASD services within the last three years.
Additional ASD Services Available to Members and Families
In addition to the Medicaid evaluation and treatment services described above, the behavioral health ASO will provide additional support services to members with ASD, including adults and family members.
Support services include care coordination, family navigators, and peer specialists. These support services are designed to support the needs of members and/or their families in need of ASD services.
Looking towards the Future
Thank You!
Jennifer Bogin, M.S.ed, BCBA Director
Division of Autism Spectrum Services Connecticut Department of Developmental Services
(860)418-6026 [email protected]
Conclusion
Kim Musheno
Director of Public Policy
Association of University Centers on Disabilities
Questions and Answers
Presenters Contact Information:
Cathy Pratt - [email protected]
Abbi Coursolle - [email protected]
Denise Rozell - [email protected]
Tonia Ferguson - [email protected]
Jennifer Bogin- [email protected]
Kim Musheno – [email protected]
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CMS Guidelines Questions:
o http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-24-2014.pdf
Visit the Websites:
◦ AUCD Website: http://www.aucd.org
◦ Autism SIG Website: http://www.aucd.org/template/page.cfm?id=508
Questions about the SIG?:
◦ SIG Chair - Cathy Pratt: [email protected]
Questions about the Webinar?
◦ Shannon Haworth: [email protected]
Please take a few minutes to complete our survey!
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