Proposed changes for Medicaid coverage of ABA (Indiana)

If you are a parent of a child with Autism receiving ABA services in the state of Indiana, you have likely heard about the proposed changes in ABA coverage that are supposed to go into effect in April 2025. The following changes are being proposed and the public notice period is up on February 14, 2025:

• Comprehensive ABA services in fee-for-service and managed care Medicaid will be limited to 30 hours per week for a duration of no longer than three (3) years as a lifetime maximum.

• Following the maximum three (3) year duration, ABA recipients would be permitted to continue limited hour, behavior-specific, focused ABA, if medically necessary.

What does this mean for your child?

ABA care can be provided as “comprehensive” meaning that the individual receives 30-40 hours of weekly therapy. This is usually recommended when individuals have delays across multiple domains (ie language, socialization, etc.) as well as significant behavioral issues, especially those that pose a danger to self and others. Comprehensive therapy is often recommended in early intervention as research has demonstrated a link between hours provided and outcomes (more services has been shown to lead to better outcomes).

ABA care can also be provided for 10-25 hours per week. This is considered “focused” care. Focused care is usually appropriate for individuals that require services for a few specific targeted skills or targeted behaviors. In focused care, individuals typically receive other services outside of ABA (examples include special education, speech, music therapy, occupational therapy, day services, vocational rehabilitation, etc.). Focused care may also be provided as a client transitions out of ABA services into an educational placement, other day services, etc.

If your child has received 3 years or more of ABA at 30 hours of care or greater, then this proposal would require providers to reduce service hours as of April 2025 due to Medicaid not covering comprehensive care. ABA providers are always required to show medical necessity for ongoing services.

Medical necessity is a term that insurers use to determine whether services are covered under their policy. Your ABA team provides information about assessment results, symptoms, behaviors, progress, etc. every 6 months to your insurer in order to provide explanation of medical necessity and ongoing need for treatment.

If your child has received less than 3 years but is currently receiving more than 30 hours per week, their hours will likely be reduced to 30 hours maximum.

What can you do?

• Write about your concerns: Written comments may be directed to FSSA, Office of Medicaid Policy and Planning, Attention: Madison MayGruthusen, 402 West Washington Street, Room W382, P.O. Box 7083, Indianapolis, IN 46207-7083 or by email to spacomment@fssa.in.gov. Correspondence should be identified in the following manner: COMMENT RE: ABA THERAPY COVERAGE. Written comments will be made available for public inspection at the address herein of the OMPP.

• Contact your representatives: https://iga.in.gov/information/find-legislators

• Have a back up plan and discuss it with your provider: Now is the time to begin looking at potential placements and options for your child if the proposed Medicaid plan changes are approved. Discuss with your current BCBA what your child’s transition plan looks like, where they are at in developing those skills, and what the longterm goals are for your child. Ask for current assessment results and discuss with your provider so that you understand your child’s needs. It will also be helpful to have your ABA provider attend meetings with you to talk to other programs in your community. Knowledge is power, and the more you know about your child’s progress, skills, and needs the better you can advocate for him or her moving forward.

Topics in ABA: The Controversy and the Research

As practitioners it is our ethical responsibility to listen to autistic self-advocates and adjust our practice to ensure that we are implementing protocols that are both evidence based and compassionate.

The Ethics Code for Behavior Analysts requires that BCBAs actively “engage in professional development activities to acquire knowledge and skills related to cultural responsiveness and diversity (1.07). Another founding principle is that our field is applied meaning that we must start with the question “How immediately important is these behaviors or these stimuli to my subject?” (Baer, Wolf, & Risley, 1968).

We also have a responsibility to provide effective treatment to our clients. This means that we rely on evidence based procedures to support behavior change.

How do practitioners and autistic self-advocates collaborate to provide better, more ethical services for children? What behaviors do we target? What other services may be appropriate as part of a treatment package? What skills are fundamental to implementing behavior intervention services with autistic learners?

Address Ableism

To move forward in our field in a meaningful way, we need to be able to identify instances of ableism and respond appropriately. This includes recognizing your own internalized ableism as a practitioner. If your unsure where to start, There are a number of books, articles, podcasts, etc. that are available for you to educate yourself. If you work with children with disabilities, it is critical that you are aware of the bias that your clients face and that you reckon with your own assumptions, attitudes, and beliefs.

In order to select targets as a professional you MUST reflect on your attitudes and beliefs about what a person should know and how a person should behave across settings. How important are the skills you are teaching to your learner? Are you trying to improve their quality of life, or are you focusing on making the people around them more comfortable? We all adjust our behavior to some extent when we’re around others (e.g. I would not cough in someone’s face or blast my music loudly while in a waiting room). We teach our children to sit at a table in a restaurant instead of climbing or running around, but at what point does teaching socially expected behavior conflict with our responsibility to work on behalf of the interests of our clients?

Stay Current

Research is constantly evolving and it is our ethical responsibility to evolve our practice with it. That doesn’t mean that you should abandon any established intervention as soon as it is questioned; however, we do have a responsibility to accept feedback and identify both the benefits and harmful effects of a given strategy.

Extinction is a strategy that is well-researched; however, it is also associated with heightened emotional responding. We know well that an extinction burst is expected. While research has demonstrated that differential reinforcement + extinction are effective, there is a growing body of research demonstrating alternatives to extinction that are effective at reducing problem behavior. For example in 2017, Phillips et al. used non contingent reinforcement to reduce problem behavior in 14 of 15 participants whose behavior was maintained by social reinforcement.

Understand the Discussion

Behavior analysts and RBTs should be aware that the puzzle piece is not widely used by autistic self-advocates and can be seen as a suggestion that there is something “missing.” Another issue is that puzzles can be associated with young children. You need to understand that Autism Speaks is controversial because of its focus on a “cure” for autism, and the lack of representation by autistic individuals on the board. The color blue is actually associated with this organization, and “light it up blue” isn’t necessarily the best way to show your support for or acceptance of your autistic loved ones. I’m actually not sure whether I should have chosen this theme for my website, but I genuinely like the color palette.

Another area for reflection is how we talk about the spectrum. “High functioning” and “low functioning” give the impression that ability can be stretched out into a straight line where you have “nearly normal” on one end, and “very disabled” on the other. This is clearly problematic and not true to real experience.

What does this mean for practice?

At the end of the day, practitioners want to help people. We entered this field because we saw that we could have a profound and positive impact on people’s real lives, and that is what we live for. So how do we proceed? Remain curious. Remain engaged. Listen. Educate yourself and educate others. Own up to your mistakes. Do better next time.

References:

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97. https://doi.org/10.1901/jaba.1968.1-91

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/

Phillips CL, Iannaccone JA, Rooker GW, Hagopian LP. Noncontingent reinforcement for the treatment of severe problem behavior: An analysis of 27 consecutive applications. J Appl Behav Anal. 2017 Apr;50(2):357-376. doi: 10.1002/jaba.376. Epub 2017 Feb 8. PMID: 28177118; PMCID: PMC8793041.

Autism Services Should Serve You

I met my daughter in 2017. She was 15 years old and we were both attending an adoption event hosted by the Special Needs Adoption Program in Indiana. To protect her privacy I will not be detailing her story, but I will share that my daughter is Autistic and she is my reason for finally moving forward with establishing this company.

I first entered the field of Applied Behavior Analysis (ABA) in 2013. At the time I was a graduate student at Ball State University and seeking opportunities to gain clinical experience in order to eventually become a BCBA. I have had the support of several incredible BCBAs throughout the years as I learned about this science. At the same time, I was going through my adoption journey with my daughter and navigating disability services from the perspective of a parent in need of support. What I found was that therapists frequently canceled or quit. Sessions were canceled with little notice. Staffing for respite care seemed like a myth (unless you could provide your own). Insurance would frequently refuse prior authorization even though your doctor recommended a medication or service and battles were common.

My daughter is an amazing young woman who has thrived with the support she has received, but I also had the privilege of being inside the system. I knew who to contact, how to argue, and how to make sure my daughter received what she needed. I knew this information because I was also a provider and my connections meant that she did not wait in line, and she was not ignored.

Many providers have long waitlists. Some providers have issues with overall quality of services region to region because the quality drastically varies based on the BCBA and RBTs you are working with. Direct professionals (RBTs) are often under-payed, undertrained, and burnt out. RBTs are rotated frequently in the name of “generalization” without regard for attachment theory and child development research.

My goals with establish Adapt Ability Autism Services, LLC are to:

• Center the client in all decision making: Every client is different, and every client deserves quality care. We prioritize choice and self-advocacy at Adapt Ability

• Decrease turnover among direct care staff: We believe that RBTs are the heart of ABA services and should be treated with the utmost compassion and respect. We expect professionalism and consistent, quality care from our staff.

• Foster an environment that supports neurodiversity and dismantles ableism: My most loved family and friends are neurodiverse. I believe in care that is affirming of difference, and compassionate to the needs of autistic individuals. We will move forward with a strong commitment to ethics and neurodiversity.

Ultimately, my wish in establishing Adapt Ability Autism Services is that the neurodiverse children, adolescents, and adults of East Central Indiana and beyond will find a community in which they can grow and thrive. I want to create a community that can be counted upon to support you and your family when you find yourself in need.

If you or a loved one are in need of support or would like additional information, please reach out. I am available at jvaughn@adaptabilityautism.com