“I’m trying to figure out what next week will be like,” said Lauren Baldwin of Levittown.
Baldwin explained that his 4-year-old son Ryan has flourished since he started Potential in Newtown, a nonprofit that treats autism.
But as of Sunday, Ryan is among thousands of children in Pennsylvania whose families fear Federal Medicare will no longer pay for their center-based applied behavior analysis services due to a new policy of the state.
“I’ve tried calling our insurance, and they don’t cover autism. Medicare is basically all it has,” Baldwin said.
Founder, president and potential CEO Kristine Quinby said that while home care works for some children, others need resources and social interaction at centers like this.
“Yeah, we have other kids here, so it’s like a group, but they’re still 1 to 1, so they get the intensity that is prescribed for them,” Quinby said.
Quinby said without medical assistance, these services could cost families $ 80,000 per year. Even with employer’s health insurance, families could still spend thousands of dollars a year.
“You say children who have commercial insurance will be allowed to have this service, but children who have medical assistance, who have socio-economic difficulties, are not,” Quinby said.
Medicare will still pay for home sessions, but some families say it doesn’t work for them.
The Mitchells of Doylestown have two children at Potential.
“We just have medical assistance. Thanks to the pandemic, we are both unemployed right now,” Jessica Mitchell said.
Jonathan Mitchell added: “We did ABA therapy at home, which the state is trying to prescribe, and for our children it is not working.”
This policy change is unrelated to the coronavirus, but the pandemic is complicating matters.
Employees enter homes, which may not have the same security protocols as the center.
“Our employees feel safe here and our children feel safe here, our families feel safe here,” Quincy said.
Erin James, press secretary for the Department of Social Services, issued the following statement saying in part: “… services will not be interrupted abruptly.” When it is determined that they are medically necessary and clinically appropriate, medical assistance will pay for ABA services. provided in a center-based setting.
Some advocates fear that the wording of the policy could be interpreted and make it more difficult for children to access these services.
Kathy Christou of Croydon, whose son Alexander attends Potentiel, said: “The people in charge of making these laws who make these regulations really need to sit down and think about what they mean for parents and children. people directly concerned. “
“Don’t take this away from the kids, they need it,” Baldwin pleaded.
For more information on the petition, visit https://abaourway.com.
The full DHS statement is below:
On October 19, 2019, the Department of Human Services (DHS) promulgated the Intensive Behavioral Health Services (IBHS) Regulation. The purpose of the IBHS regulations is to codify the minimum licensing standards and program requirements for participation in the Medical Assistance (MA) program and the AM payment terms for agencies that provide IBHS to children, youth and young adults under the age of 21 with mental disorders, emotional and behavioral health needs. IBHS replaces Behavioral Health Rehabilitation Services (BHRS). BHRS will no longer be available after January 17, 2021.
It has been determined that children, adolescents and young adults who currently receive 1: 1 Applied Behavior Analysis (ABA) services at a center have a medical necessity for the services they receive. This determination will not change when BHRS is no longer available and services will not be abruptly terminated. When it is determined that it is medically necessary and clinically appropriate, medical assistance will pay for ABA services provided at a center. To further assist providers, DHS’s Office of Mental Health and Addiction (OMHSAS) will issue guidelines on the process they should use in order to be able to provide and bill for these services when deemed medically necessary.
IBHS regulations do not address payment by commercial insurance for 1: 1 center-based services, and authorized IBHS agencies may continue to provide these services and charge for commercial insurance.
DHS is committed to ensuring that children, adolescents and young adults receive appropriate clinical services to meet their individual needs, and to do so in settings best able to provide a therapeutic environment to meet their needs. these needs. We recognize that changes in regulations and program design can create uncertainty about the continuity of care. The changes implemented by OMHSAS are designed to ensure that services meet minimum licensing standards, provided by trained personnel, and are regularly monitored to ensure the well-being and safety of children and of the young people we serve. ”
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