Medicaid and ABA

From the IHCP: “Effective February 6, 2016, applied behavioral analysis (ABA) therapy is covered for the treatment of autism spectrum disorder (ASD) for members 20 years of age and younger. ABA therapy is the design, implementation, and evaluation of environmental modification using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement, and functional analysis of the relations between environment and behavior. Coverage applies to dates of service (DOS) on or after February 6, 2016, for all IHCP programs, subject to limitations established for certain benefit packages. ABA therapy is available to members from the time of initial diagnosis through 20 years of age when it is medically necessary for the treatment of ASD.”

There have been several tweaks to the program of ABA in Indiana Medicaid since this information was released a while back. We have recently been successful a getting the Psychologist (HSPP) requirement removed from the program, so that BCBAs can commit to treatment with families in the manner we already do. This change is going into effect in the beginning of 2018.

Traditional v. MCE

Depending on who you chose to manage your medicaid benefits, you may have Traditional or MCE coverage. We breakdown the differences below. It is important to note that not all medicaid benefits and implementation is handled the same.

All providers rendering services to Hoosier Care Connect members must enroll with theĀ Indiana Health Coverage Programs (IHCP) and with one or more of theĀ managed care entities (MCE). To be reimbursed for services rendered to members in Hoosier Care Connect, IHCP-enrolled providers must be contracted with the managed care plan in which the member is enrolled.

The four MCEs are:

Anthem, CareSource, MHS, and MDwise

Hoosier Care Connect operates under a risk-based managed care (RBMC) service delivery system in which the State pays contracted managed care entities (MCEs) a set monthly fee for each member enrolled in the MCE’s plan. This fee, called a capitation premium, covers the cost of care for services covered under the MCE program and incurred by IHCP enrollees in the MCE plan. The MCE assumes financial risk for services rendered to members in its plan. It is important to families to note that each MCE is given flexibility on several aspects of its implementation of its services, including its network.

Each MCE maintains its own provider and member services units. Each MCE pays claims, performs prior authorization (PA), and is responsible for subrogation activities. Several of the MCEs insist they have adequate network coverage and are not accepting new facility providers, while others are actively building their networks for their consumers.