Changes in Medicaid Billing May Reduce Autism Therapy Access for Some Vermont Families

Some kids with autism are losing therapy services after a Medicaid change reduces clinics' revenue.

The focus on how services for autistic children are billed through Vermont Medicaid has led to significant revenue reductions for numerous Applied Behavior Analysis (ABA) providers. This situation is becoming increasingly critical as it may diminish the availability of essential therapeutic services for children with autism.

Sam, a six-year-old boy with profound autism, has relied on therapies from Keene Perspectives, an ABA clinic in Hartford. His mother, Jennifer Beane-Edgar, has noted his substantial improvements, including his ability to engage and communicate using Picture Exchange Communication Systems. However, her optimism has been challenged after being informed that Sam would be discharged from services earlier than anticipated due to recent changes in Medicaid policy.

The new billing structure under Medicaid, which commenced in January, has eliminated the ability for clinics to bill for the time spent by both a licensed behavior analyst and a behavior technician when they are working with a client simultaneously. Providers now can only bill for the total number of hours a child receives services, rather than itemizing the specific contributions of each professional.

Medicaid policy analysts have identified this change as a necessary measure to align with federal coding standards and to minimize risks of fraud associated with Medicaid billing. This adjustment has caused Keene Perspectives to report a 16% drop in revenue, prompting it to reduce the number of Medicaid clients, a decision that directly affects families like Sam's.

While other centers like Little Royals in Williston are also feeling the financial pinch, they are actively pursuing alternative revenue streams to maintain operations. However, Little Royals has not yet had to reduce its Medicaid clientele.

Cortney Keene, one of the co-founders of Keene Perspectives, expressed concern that the new reimbursement policies may push the responsibility of care onto schools or parents who may lack the necessary resources. She underlined the importance of maintaining quality care, emphasizing that the medical need for such services remains unchanged despite the funding model.

Currently, state officials are monitoring the effects of these changes on service provision. Plans are underway to assess reimbursement rates amid legislative mandates that could provide relief if the existing rates continue to prove insufficient.

While Medicaid representatives acknowledge that it is early to gauge the long-term consequences of the billing changes, they are committed to ensuring that families maintain access to appropriate care and support.