Cover Image - Autism And Medicaid: A Roadmap To Mental Health Services

Autism and Medicaid: a Roadmap to Mental Health Services

By Sean M Inderbitzen APSW, Member of MINT


In this article, author Sean Inderbitzen from Seaninderbitzen.com, a behavioral health clinician who lives on the spectrum and provides consultation to other clinicians, outlines how to advocate for more access to mental health services for people with autism. Sean highlights Wisconsin’s Autism Mandate which is an oppressive interpretation of federal legislation that is more focused on business than people with autism’s right to mental health services. It closes with practical recommendations for readers to engage in to assist in moving Medicaid forward in your own state. 

What is the Autism Mandate in Wisconsin?

Wisconsin Statute 632.895(12m) or more commonly what has come to be known as the Autism Mandate, is a statute which mandates Wisconsin Medicaid (Forward Health herein) pays for $50,000 of intensive in-home services for individuals with Autism (Wisconsin DHS).  The waiver is granted under the Wisconsin Long Term Waiver program and requires that Forward Health pay for services deemed evidence-based by the Treatment Intervention Advisory Committee and the Division of Medicaid Services (Division of Medicaid Services). At present, the only services considered reimbursable by Forward Health are Applied Behavioral Analysis (ABA) or Early Start Denver Model (another form of ABA) (Forward Health Wisconsin). The Treatment Intervention Advisory Committee is comprised of 9 members, all of whom are behavioral analysts (ABA practitioners) or special education directors. None of them have lived experience with autism and all are advocates of ABA and it is the only reimbursable modality for autism in the state of Wisconsin.

The problem with Forward Health’s Autism Mandate interpretation

Forward Health’s interpretation of the 26 year old legislation regarding non-intensive behavioral interventions encourages these three problems:

  1. Therapists need to find a secondary diagnosis to deliver services to individuals with autism. For instance, if a client with ASD requests help with social skills, mental health providers have to treat something other than the ASD.
  2. Decreased access to mental health services for those with autism.
  3. Decreased confidence of psychological service providers in working with patients with ASD. 

Evidence of the problem of the current medicaid rule on ASD treatment

Evidence:
With approximately 37,750 people living with ASD in the greater Milwaukee area, the Autism Society of Southeastern Wisconsin identifies 17 outpatient service providers who are comfortable in providing therapy to kids with ASD and co-occurring mental health concerns (Autism Society of Southeastern Wisconsin, 2019). That is a ratio of 1 service provider agency to the general population is 2,220 in Wisconsin’s most urbanized community.

In an unpublished dataset by Inderbitzen Consulting Services LLC, of 55 Wisconsin based mental health clinicians and social workers, 27.2% of respondents are either completely uncomfortable or uncomfortable working with people with ASD (Inderbitzen, 2021).

Solution:
Policy Objective: Revise Forward Health’s policy which limits coverage of ASD services to be inclusive of more behavioral therapies which are not applied behavioral analytic therapies by January 2023. The definition should be inclusive of therapies with evidence based practices like:

A. Cognitive Behavioral Therapy and ASD: (Blakeley-Smith et al., 2021), (Hill et al., 2021), (Meyer et al., 2020), (Wood et al., 2009) .

B. Motivational Interviewing and ASD: (Bellesheim et al., 2018), (Hartman et al., 2019), (Rogers et al., 2019)

C. Feedback Informed Treatment and ASD: (De Jong et al., 2019)

Recommendation:
States like Wisconsin’s Department of Health Services, Division of Medicaid Services need to revise their position on Medicaid Billable strategies for inclusion of all three evidence based practices to state Medicaid. Across states this will result in:

  1. Increased access to mental health services for children with ASD
  2. Less monopolizing on services by BCBA providers
  3. Increased training opportunities for autism and mental health trainings for Continuing Education Units 
  4. Increased number of providers providing MH services to ASD patients for mental health problems.

What can I do?

  1. Call your state’s Division of Health Services and demand mental health treatment for you or your child’s autism beyond Applied Behavioral Analysis.
  2. The privilege of choice to evidence-based practices is your constitutional right. Your states department of Health Services does not have the right to limit you or your child’s right to pursue mental health therapy. As states like Wisconsin already do.
  3. Therapies beyond Applied Behavioral Analysis, like Cognitive Behavioral Therapy are scientifically supported evidence based practices to treat Autism Spectrum Disorder.

References:

Autism Mandate. Wisc. Stat. 632.895(12m) (1994, rev 2004).        
https://docs.legis.wisconsin.gov/statutes/statutes/632/VI/895/12m

Autism Society of Southeastern Wisconsin (2019). Retrieved from https://www.assew.org/wp-        content/uploads/2019/06/RESOURCE-DIRECTORY-2019_v18.pdf on June 30, 2021.

Bellesheim KR, Cole L, Coury DL, et al. Family-Driven Goals To Improve Care for Children  
With Autism Spectrum Disorder. Pediatrics. 2018; 142(3):e20173225

Blakeley-Smith, A., Meyer, A. T., Boles, R. E., & Reaven, J. (2021). Group Cognitive  
Behavioural Treatment for Anxiety in Autistic Adolescents with Intellectual Disability: A    Pilot and Feasibility Study. Journal of applied research in intellectual disabilities :
JARID
, 34(3), 777– 788. https://doi.org/10.1111/jar.12854

De Jong, R. K., Snoek, H., Staal, W. G., & Klip, H. (2019). The effect of patients’ feedback on   
treatment outcome in a child and adolescent psychiatric sample: a randomized controlled     trial. European child & adolescent psychiatry, 28(6), 819– 834.
https://doi.org/10.1007/s00787-018-1247-4

Division of Medicaid Services, Treatment Intervention Advisory Committee, Operating   
Procedures. (2019). Madison, Wi. DHS.

Forward Health Wisconsin (2019). Retrieved from  
https://www.forwardhealth.wi.gov/kw/pdf/2015-55.pdf page 2, on May 24, 2021.

Hartman, Ellie et al. ‘Early Findings from the Wisconsin PROMISE Project: Implications for   
Policy and Practice’. 1 Jan. 2019 : 167 – 181

Hill, T. L., White, T. C., Anthony, B. J., Reaven, J., Harris, B., Reyes, N., & Anthony, L. G.    
(2021). Disparities in autism spectrum disorder diagnoses among 8-year-old children in        Colorado: Who are we missing?. Autism : the international journal of research and   
practice
, 25(1), 102–113. https://doi.org/10.1177/1362361320950058

Inderbitzen, S (2021). Wisconsin based pre-program responses of clinicians and social workers
(version 3) [unpublished dataset]. Inderbitzen Consulting Services LLC.  

Meyer, A. T., Moody, E. J., Keefer, A., O’Kelley, S., Duncan, A., Blakeley-Smith, A., & Reaven,
J. (2020). Effect of Co-occurring Psychiatric Disorders on Treatment of Children  with
Autism Spectrum Disorder and Anxiety. Journal of autism and developmental disorders,
10.1007/s10803-020-04540-1. Advance online publication.
https://doi.org/10.1007/s10803-020-04540-1

Rogers SJ, Estes A, Vismara L, Munson J, Zierhut C, Greenson J, Dawson G, Rocha M, Sugar
C, Senturk D, Whelan F, Talbott M. Enhancing Low-Intensity Coaching in Parent       
Implemented Early Start Denver Model Intervention for Early Autism: A Randomized      Comparison Treatment Trial. J Autism Dev Disord. 2019 Feb;49(2):632-646. doi:     
10.1007/s10803-018-3740-5. PMID: 30203308.

Treatment for Autism Spectrum Disorders. Wisconsin Department of Health and Family  
Services. 632.895(12m)(c)1.(2011).

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive   
behavioral therapy for anxiety in children with autism spectrum disorders: a randomized,  
controlled trial. Journal of child psychology and psychiatry, and allied disciplines, 50(3),     224–234. https://doi.org/10.1111/j.1469-7610.2008.01948.x

 

Photo of Sean Inderbitzen

Sean is a Behavioral Health Therapist, and lives with an Autism Spectrum Disorder. He has a caseload with 33% of his patients that live with ASD and varying comorbid psychiatric conditions. Prior to being a mental health clinician, he was a Vocational Rehabilitation Specialist for Wisconsin Division of Vocational Rehabilitation for 3 years. He was also appointed by Governor Walker to the Statewide Independent Living Council of Wisconsin. He is an incoming member to the Motivational Interviewing Network of Trainers, and provides training on motivational interviewing, ASD and employment, and ASD and comorbid psychiatric conditions. For more info, find him at Seaninderbitzen.com or on LinkedIn.