On March 26, 2012, a Florida U.S. District Court judge ordered the State Medicaid agency to “provide, fund, and authorize Applied Behavioral Analysis treatment … to all Medicaid-eligible persons under the age of 21 in Florida who have been diagnosed with autism or Autism Spectrum Disorder as prescribed by a physician or other licensed practitioner.” Historically, the Florida Agency for Health Care Administration (AHCA) denied payment for Applied Behavioral Analysis (ABA) based on ACHA’s determination that ABA is experimental and, therefore, not medically necessary. Based on the evidence presented, including expert testimony and Federal and State Medicaid laws and regulations, the Court found that AHCA’s determination that ABA is experimental was “arbitrary, capricious, and unreasonable” based on the Court’s finding that AHCA had not adequately researched the efficacy of the treatment. The child plaintiffs in the case were diagnosed as having autism or Autism Spectrum Disorder (ASD) pursuant to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screens and were prescribed ABA treatment by a physician. Under Federal Medicaid law (42 U.S.C. § 1396(r)(5)), AHCA is required to cover all services for children found necessary by EPSDT screens and prescribed by a physician or other licensed practitioner within his/her scope of practice, even if the services are not included in the State plan for Medicaid. The Court ordered AHCA to, among other things, notify all community behavioral health services Medicaid providers and all physicians providing EPSDT screens that ABA is now a covered service for Medicaid-eligible children diagnosed with autism or ASD. The case may have implications in other states where ABA is available for children but not covered by the state’s Medicaid program.
Use the link below to review the Court ruling.
FL Ruling Autism Medical Necessity 2012 Mar.mht (114.49 kb)