MediCal-Funded ABA Pursued by Advocates

Source: Flickr

Disability Rights California, National Health Law Program, and Western Center on Law and Poverty are conducting an investigation regarding the provision of Applied Behavioral Analysis (“ABA”) therapy to children on Medi-Cal, which is California’s implementation of Medicaid. ABA is an evidence-based, clinically proven behavioral modification and instructional methodology that works with all living creatures.

ABA has been demonstrated in peer-reviewed research to be an effective treatment for children with autism and autism spectrum disorders and private health insurance companies have been required to fund ABA for children in California since 2011. However, Medi-Cal has not been required to provide it, as well.

Some children in California have received ABA through regional centers, private health insurance, or their school districts. In California, some children received this benefit through the Healthy Families program, but lost it when their benefits transitioned to Medi-Cal. Other Medi-Cal eligible children had ABA through regional center but lost it when they turned three, because they did not continue to qualify for regional center services. Other children may have been recommended to receive ABA, but have never been able to receive it because Medi-Cal does not pay for it, they have no other insurance, they are not regional center consumers, and/or their school district will not provide it.

 

Related Article:  ”Autism & Insurance Coverage” from the National Conference of State Legislatures

 

Please contact the following people if you or anyone you know of may fit the profile below:

Southern California: Abbi Coursolle at the National Health Law Program at coursolle@healthlaw.org
Northern California: Will Leiner at Disability Rights California at William.leiner@disabilityrightsca.org

These advocates are looking for children who:

  1. Are age 7 or under (preferably under age 4) and diagnosed with an autistic spectrum disorder.
  2. Have had an assessment by a health or other qualified professional which supports the need for your child to get ABA.
  3. Are not currently eligible for regional center services (including Early Start). This includes children who were found ineligible for Early Start and referred to Prevention Resource and Referral Programs (PRR) at Family Resource Centers.
  4. Are Medi-Cal recipients.
  5. Meet any of the following circumstances:
    • Received ABA through Healthy Families and ABA was terminated prior to or on August 1, or will be terminated this fall.
    • Medi-Cal recipient unable to access ABA through Medi-Cal.

This is not a research study.  These advocates are exploring ways to help children obtain benefits.

2 Responses to “MediCal-Funded ABA Pursued by Advocates”

  • Michael:

    Hi, My 14-year old son started receiving ABA last year when Kaiser was forced by law to comply with a law to provide it. Kaiser did not tell me; I found out and had to request it. They never provided ABA prior to this time to him. He received ABA for only a small fraction of that period because, even though we were on the books as getting ABA, Kaiser’s subcontractor, Ste Consultants, could not find a therapist. After they did find a therapist, they could not keep him because he could not get enough hours or wages. AFter three months with no therapy, we switched subcontractors and had to start the process all over again.

    We were on COBRA at $1100/month then, but recently applied for Obamacare (covered Cal). We were told that we now qualified for Medi-Cal, which thrilled me. However, after three months of having health care, we are still waiting to be members of some plan! To top that off, I was just informed today that Medi-Cal recipients will not be provided ABA therapy or any therapy related to autism. Why are they shutting these kids out? My son is 14 and still can’t get treatment. Where do we go? Do we have to move to a autism-friendly state? Are there loopholes in the law in California? Anyone in the same situation?

    • If your son is also eligible for regional center services, as the payer of last resort, the regional center must pick up whatever nobody else is legally required to pay for but your son still needs. Some regional centers will tell families that they have to turn to their public schools for services and that regional centers will only step in once children are no longer K-12 students, which is entirely untrue. In California under the Lanterman Act, regional centers exist to serve those with developmental disabilities their entire lives.

      The K-12 stage of life is not a window during which regional center services are not available; the distinction is that anything the schools must provide under the law are things that regional centers don’t have to pay for. So, while schools may push ABA services into their programs for a student with autism, for home and community purposes, if private insurance doesn’t cover it in those settings and it’s still needed, then regional center must provide it. Regional centers often try to get out of paying for things by pointing to everybody else (schools, insurance, the man in the moon, etc.), but the bottom line is that they must pick up the tab for person-centered services needed by an individual with developmental disabilities that isn’t being picked up – and cannot be made to be picked up – by any other entity.

      Regional centers in California have also become somewhat notorious for finding ways to exit individuals from their caseloads who actually remain eligible (or denying eligible children from access to their services) just because they don’t want to pay for whatever end-of-the-line service needs these individuals may have. For kids on the autism spectrum, this may include a manipulation of the revised clinical definition of Autism Spectrum Disorders in the DSM-V. We’ll be publishing on that issue in the near future.

      However, there are strict rules about how regional centers are supposed to assess for autism and none of them in my experience have ever complied with those assessment requirements. You may have to file for a due process hearing to get services for your son from regional center, presuming your son is truly eligible for them.

      Unfortunately, if you have to involve an attorney, because the regional centers are not actually government programs but are rather non-profit organizations contracted with the California Department of Developmental Services (DDS) and because of how the due process system has been orchestrated, parents cannot recover attorney’s fees and costs upon prevailing against a regional center in due process. The only way to recover those monies is if DDS is also named in the suit, because then you are taking on the government in a private attorney general-type action and can recover fees from holding DDS accountable. The problem is that the Lanterman Act and its complaint and due process procedures are meant to prevent DDS from getting named in due process actions. As such, at least in due process cases, the real function of regional centers seems to be to shield the government from being held accountable for failing to serve individuals with developmental disabilities in California, but further investigation is needed to figure out how deep that rabbit hole really runs.

      All that said, if your son is not eligible for regional center services, he can still get an ABA program at school if that is what is necessary in order for him to receive a free and appropriate public education. To the extent that behaviors at home directly impact his participation at school (such as school-refusal behaviors, for example), then the ABA can be brought into the home but only to the extent that it addresses school-related behaviors. The public schools can only address educational needs that arise from a student’s disability-related challenges. Educational needs, particularly for a teenager, include pre-vocational and vocational skills that will follow him/her into life after high school, so as your son gets older, this can include skills that help him access the community including his behavioral needs. Depending on the type of curriculum appropriate for your son, as he gets older, he could receive supports under his IEP that include ABA-based programming to facilitate increases in his independent functioning.

      Once he turns 16, his school district is obligated to give him a transition plan in his IEP that addresses his post-secondary needs and goals and this is where any community-based programming would most likely be described. If he needs a behavior plan at school and anything less than ABA isn’t getting the job done, then you can push for an ABA-based behavior program and the involved BCBA as a member of the IEP team can help shape what that would look like.

      I seriously hope this helps! ABA is not only available through private insurance. You just have to know who all else may have to provide it and exhaust your options with those entities before looking elsewhere. Start at school for anything happening during the school day and go to regional center for everything happening outside of the school day and see how far you can get.

      Anne

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