Progress Brings More Challenges

October 21, 2014

In January, I wrote about the Affordable Care Act (ACA) and Medicaid Expansion ( Since then, at Grafton, we have been trackingchanges in Medicaid services across the United States.

During that time, we saw California broaden its Medicaid coverage for children in response to a recent rule by the U.S. Centers for Medicare & Medicaid Services that extends coverage to Applied Behavior Analysis (ABA), when deemed medically necessary, as part of a comprehensive array of preventive, diagnostic, and treatment services. These services must be included in each state’s Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), a package of offerings all states must provide to children, under age 21, who qualify for Medicaid.

While this represents a major win for children with autistic spectrum disorder, helping families access these services takes patience and dedication.

In discussions about these changes and challenges with my peer Jason Craig, Grafton’s Director of ABA Services, he related that he has personally faced many similar obstacles in helping his clients access appropriate services at the most beneficial time. In fact, accessing those services has proven difficult not only here in Virginia, but in every region where Grafton serves individuals with autism spectrum disorder, including West Virginia.

According to Jason, Virginia has been covering ABA through EPSDT, but access to the services has involved a quality improvement process that has taken time to implement and understand. And limitations in the environments where the services are provided underscore the challenges.

For example, regulations state that the services can only be performed in the home. According to Virginia’s Department of Medical Assistance Services (DMAS), “Home is defined as the family residence and includes a child living with natural and adoptive parents, relatives, or a guardian, or the family residence of the child’s permanent or temporary foster care or pre-adoption placement.” But while consultative services may be included in educational services, these services are not authorized for community-based group home environments.

Jason also reported the state of West Virginia has acknowledged that ABA, if deemed medically necessary, should be covered under EPSDT, but the authorization process has not been adjusted to allow for accessibility. Current processes require for inappropriate and excessive approximations toward authorization and have slowed intake to a snail’s pace when time is of the essence with this vulnerable population.

Federal officials telling states that Medicaid coverage must include treatments like applied behavior analysis for children with autism represents a huge first step, but revisions will be necessary to accommodate these changes.

In summary, although Virginia and West Virginia have made great progress, that progress brings with it many new challenges for families and providers. In response, Grafton and other agencies must deliver not only quality clinical services, but just as importantly, exemplary care coordination, which includes securing appropriate funding for services at the right location and right time.

As Jason frequently says, “Kent, it does take a person-centered team, but the outcomes are truly life changing.”