Hundreds of autistic children in Nevada covered by Medicaid are not getting access to what is considered the most effective therapy for autism, and the Legislature is attempting to change that.
Applied behavior analysis (ABA) therapy is widely considered the gold-standard treatment for autism, but in Nevada, parents face long wait lists and a shortage of providers.
The situation is worse for children from low-income families with Medicaid as their primary or secondary insurance, and those in rural areas. A big reason, advocates say, is the state’s low Medicaid reimbursement rates for Registered Behavior Technicians (RBT), paraprofessionals who administer ABA therapy.
On Wednesday, the Senate Health and Human Services Committee heard Senate Bill 174, which would increase the reimbursement rate for RBT’s from $31.30 per hour to at least $48 per hour as a way of retaining RBT’s and expanding the number of providers who will take Medicaid, eventually leading to the ability to serve more children with autism. The additional Medicaid service is projected to cost $18 million for the biennium. The state’s share of the cost would be $6.4 million.
Nevada’s rates are considerably lower than the surrounding states except Utah. New Mexico, California, Oregon and Washington all pay substantially higher rates, about $44 to $55. Out of all 50 states, only Missouri and South Carolina at $31 per hour, and Mississippi and Utah at $30, have lower rates.
ABA therapy is mostly a one-on-one treatment for autism patients that focuses on promoting appropriate behavior, social skills, communication and emotional expression. Costs per patient can run $30,000 to $60,000 a year.
In practice, applied behavior analysis therapy relies on breaking down a task, like eating dinner or brushing teeth, into small processes so that a child with autism can learn it more easily. Research has shown that intensive ABA therapy can result in better outcomes for children on the autism spectrum, improving intellectual functioning, language development, daily living skills and social functioning.
For many children this means receiving between 25 to 40 hours of ABA treatment every week for at least a few years, but Medicaid data for the 3rd Quarter of 2018 indicate eligible Nevada children receive an average of only seven hours a week.
“I have had parents come up to me and tell me what a difference the Applied Behavioral Analysis therapy has made for their children and the night and day results,” said Democratic state Sen. James Ohrenschall, the primary sponsor of the bill. “But there’s still a lot of kids who aren’t getting this therapy.”
“These changes would not only make the RBT profession more attractive, they would also make Medicaid’s reimbursement rates more competitive.”
The bill would also require auditing of funding and services, including an analysis of the number of providers and the wait times for children to receive ABA services, and an analysis of revenue and expenditures, including any unspent funds.
As of December last year, only about 290 children in the state were receiving ABA services through Medicaid. These numbers indicate a 36 percent increase in access to care since June 2017, but falls far short of the state budgeted caseload of 1,879. Additionally, only some $1 million of the appropriated $42 million was spent by Medicaid through March 2017.
The Legal Aid Center of Southern Nevada, the Center for Autism and Related Disorders, the UNLV Ackerman Autism Center and several other autism advocacy groups spoke in favor of the bill; no one testified in opposition.
During testimony, one man spoke to the reasons people leave their work as registered RBT’s, telling lawmakers he quit his job because of the low pay, choosing instead to drive Uber and Lyft.
“A lot of us who work as RBT’s are in this position where you don’t really make enough to live on so all of us have another job,” he said. “Some of us teach. I drive Uber and Lyft. But it’s just really hard because you don’t want to let these families down, but you’ve still got to support your own family too.”
In his State of the State, Gov. Steve Sisolak pledged an additional $5.3 million in state and federal funding over the biennium to address the wait list for services related to the Autism Treatment and Assistance Program (ATAP), a statewide program created to assist parents and caregivers with the cost of providing autism-specific treatments to their child.
Julie Ostrovsky, a commissioner for the governor’s Commission on Autism Spectrum Disorders, also spoke in favor of the bill.
“Although our government agencies claim to have hundreds of RBT’s on the books, that does not mean they are working the hours needed, or staying on the job for any length of time,” Ostrovsky said, adding that during the commission’s public meetings parents and providers consistently vent their frustrations about the low RBT rates.
“We must provide intervention as early as possible and it must be intensive and consistent. All Medicaid eligible children should have access to what is medically necessary. I know we have limited funds in Nevada, but we should be competitive and give our children a fighting chance at success.”