Medicaid Coverage of ABA: A Progress Report

Within the first three months of launching on April 1, 2020, an estimated 500 children were participating in this benefit, approximately half of whom were under a pilot program administered by the Children’s System of Care (CSOC). For these youth, responsibility for their treatment was transferred from CSOC to DMAHS and one of its five Managed Care Organizations (MCO) that administer the benefit to NJ FamilyCare beneficiaries. Over the following 9 months, 700 more children have accessed this benefit for a total of 1,200.

It is heartening to see the growth in the number of Medicaid-eligible children with autism who are now participating in treatment. Yet, with approximately 12,000 Medicaid-eligible children with autism, that figure represents only 10% who are accessing ABA treatment.

Over the same period of time, while the number of providers has increased, it has not kept pace with the number of children accessing the benefit. Thus, families continue to experience long wait times. We remain concerned that the number of both individual providers and provider agencies does not currently nor is it likely to meet the treatment needs of the Medicaid-eligible autism community. Network adequacy must be improved.

Over the past year, we have received calls to our 800.4.AUTISM Helpline from parents inquiring about how to access the benefit and from providers exploring how to become an approved provider. We created guides that walk parents and providers through these processes and have provided assistance to both as they navigated real-world challenges. Through our helpline, we continue to capture families’ and providers’ experiences with this benefit and use this information to make recommendations for systemic improvement to our colleagues at DMAHS.

As is the case with any new program, there are bound to be hurdles and challenges along the way. The most obvious challenge for the launch of this benefit was the unfortunate timing.

With years of preparation leading up to the launch, no one could have ever imagined that we would have been in lock-down due to a pandemic when this benefit went live. With everyone’s attention on COVID, the launch of the benefit did not get the media attention that it deserved, which ultimately led to a lack of awareness by many families. Many simply did not know that the benefit was available.

Social distancing and work-from-home requirements led to an overall hesitancy from families and behavior analysts to move forward with in-person services and, for many of the children, telehealth was not an effective medium for treatment.

In addition to pandemic-related challenges, families and providers experienced other obstacles, too.

Families’ major challenge was finding an appropriate provider and, if they did, many were placed on wait lists for extended periods of time. Providers reported long wait times to become credentialed, billing and authorization issues, and concerns that the reimbursement rates do not cover the cost of providing the service. These issues have been preventing many ABA provider agencies from enrolling to become Medicaid-approved providers and leading some approved providers to disenroll.

Without a growing network of providers, the demand for ABA services is outpacing the supply, leaving more and more children without the treatment.