State Rep. Robb Greene, R-Shelbyville, poses for a photo with his son RG, bottom, earlier this year at the Indiana Statehouse.
Submitted photo
State officials have increased proposed reimbursement rates for autism therapy services for children with Medicaid, though some say the increases don’t go far enough.
The Indiana Family and Social Services Administration’s latest proposal is $68.24 an hour for Applied Behavioral Analysis, or ABA, therapy performed by a registered behavioral technician — a 24% increase from the $55.19 per hour originally proposed in September. Registered behavioral technicians, or RBTs, conduct a majority of ABA services.
The rate for therapy delivered by a master’s level board-certified behavior analyst has increased to $110.52, up from $103.77. FSSA also added a larger reimbursement for administrative overhead costs and more money to cover time that supervisors can’t bill for.
Changes to the proposed rates come after public outcry, where providers and state lawmakers reacted with alarm to the first proposed rate standards. More than 40 lawmakers signed onto a bipartisan letter from State Rep. Robb Greene, R-Shelbyville, sharing the impact ABA therapy on had his son RG, who has Autism Spectrum Disorder, urging Gov. Eric Holcomb to reconsider the cuts and invite stakeholders in for a collaborative discussion on the new rates.
Behind the rates
The state pays for coverage of ABA therapy, which can improve social, cognitive and behavioral outcomes in some children with Autism Spectrum Disorder, as well as the overall well-being of the child and their family, according to FSSA.
Medicaid first began covering these services in 2016. Because there was not “meaningful data” on which to set base rates at that time, FSSA has been paying providers a percentage of the amount they chose to bill the state rather than a statewide rate for ABA therapy services, according to the agency.
For the majority of ABA services, the percentage is currently 40%, causing payments to vary widely from provider to provider. Payments currently average $91 for hourly rates but range from $46 to $222 hourly for the same services, according to an Aug. 8 presentation by the Office of Medicaid Policy and Planning.
ABA expenditures have increased by more than 50% per year over the last three years. These costs, which are described as unsustainable, will continue to grow if an ABA fee schedule is not implemented, officials say.
Last year, state officials began to work toward establishing a uniform rate, reaching out to ABA providers and learning how other states reimburse ABA. The goal is to transition to “transparent statewide ABA rates that promote uniform access for families and allow providers to retain a stable workforce, while ensuring sustainability for Indiana’s Medicaid program,” according to FSSA.
The established rates should also cover the cost of providing the service “plus a reasonable overhead,” the agency said.
Federal requirements require the agency to operate a program and set rates reflective of the efficiency, economy and quality of care. The agency has a responsibility to both Hoosiers receiving Medicaid and taxpayers to make sure the program remains sustainable, Michele Holtkamp, director of FSSA’s Office of Strategic Communications and Public Affairs, said last month.
Criticism of the rates
In August, the initial proposed rates came out and the agency received feedback from providers and families. On Sept. 20, the agency announced updated preliminary ABA rates that also reflect a “productivity adjustment” for supervisors to cover time for which they are unable to bill, and include a 20% overhead, rather than 15%.
One organization — Indiana ACT for Families — is still dissatisfied with the proposed rates. Calling the decision “callous,” the coalition of parents, ABA therapists and providers said they fear the new rates will still result in a reduction in services for children with autism. They have been vocal about the proposed changes over the last few months.
“This callous decision will force many centers to close, leaving thousands of Hoosier families stranded and desperate to find the care required for their children who have autism to live a normal life,” the coalition said in news release. “… We ask that (Gov.) Holcomb direct FSSA to reconsider the cuts and have a fulsome discussion with the thousands of Hoosier families who will feel this detrimental impact to come to a reasonable, transparent rate agreement that is fair for all stakeholders.”
State Rep. Robb Greene, R-Shelbyville, also believes the rate is too low and could cause the closure of therapy centers. The rates should be in the mid-$70 range, he said.
State officials say the new RBT rate of $68 is higher than the Medicaid rate paid in Kentucky, Ohio, Illinois, Michigan and Missouri, and is higher than the rate paid in Indiana under the federal TriCare program by $1.
The rate is also in line with both the average and median hourly rates, $68 and $62 respectively, across all states with available data, FSSA says on its website.
Greene, who represents most of southern and western Johnson County and a majority of Shelby County, is also concerned about the data the state used to make to determinations. Officials had used data from other states as benchmarks, but those states haven’t updated these rates in a few years, he said.
“Since the pandemic and inflation, there’s a need to have the most accurate up-to-date data to determine what this rate is from 2024 onward,” Greene said.
Greene also believes the state’s survey of providers did not have a wide enough sample, he said.
James Vaughn, deputy communications director for FSSA, said Wednesday that the ABA rates were calculated using a 7.5% annual inflationary factor. Additionally, all rates on FSSA’s Medicaid rate matrix “include a 2% yearly index that will apply to future years’ rates to address ongoing cost increases between the rate reviews that are conducted every four years,” he said.
Fight goes on
If centers were to close, Greene said children will be pushed into local school systems that may not have the resources available for students with intellectual disabilities. Indiana has been a leader in autism therapy space for years, and Greene would hate to see the state lose its position, he said.
“I think there’s still an opportunity to push FSSA in the right direction here before the year’s out. … I haven’t lost hope that we can get it to a better place,” Greene said.
The updated rate proposal will be before the state budget committee on Oct. 27. The new rates are expected to go into effect in January.
