Nevada’s autism treatment reimbursement rates among nation’s lowest

It’s challenging for autistic children and their families to find services in Nevada, but advocates are hoping a bill introduced in the state Legislature will improve and expand access to effective help.

A shortage of specialized providers in the state has created barriers to treatment and failed to keep up with the number of children identified as autistic who require medical services, according to a state audit released last month.

The legislation, introduced by Senator James Ohrenschall and Assemblywoman Maggie Carlton, focuses on expanding service providers for a therapy called applied behavioral analysis, or ABA, by increasing the rate Medicaid pays for Registered Behavior Technicians (RBT) — paraprofessionals who administer ABA therapy — from $31.30 per hour to at least $48 per hour.

The therapy involves breaking down tasks into steps and coaching kids through them until they no longer need support. It is widely considered the most effective method of helping young children learn life and social skills.

Low reimbursement rates were a major factor in the limited number of providers delivering medical services, according to the state audit. Only about a third of licensed ABA providers served Medicaid children in fiscal year 2020, often citing Medicaid’s low reimbursement rates as a factor. 

Nevada’s rates are considerably lower than the surrounding states except for 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 than Nevada.

If the bill does not make it into law, Julie Ostrovsky,  a member of the Nevada Commission on Autism Spectrum Disorders, said “the clinics that decide to take Medicaid clients as a charitable act, just because it’s the right thing to do, are going to have to take fewer Medicaid kids and more insurance kids to offset those costs.”

Ideally, most children should receive any services they need before they turn 3, an important developmental period, but clinics often are full, Ostrovsky said.

“There is generally a waitlist for services. We wish that weren’t the case,” she said. “If you are not privately insured it is harder to get services. We all know this.”

The state estimates that in 2020 there were only enough providers to serve about two out of every three children who would most benefit from ABA services, and while the number of ABA providers in Nevada significantly increased between August 2019 and October 2020, many children continue to wait several months before receiving treatment, because providers do not have openings in schedules to accept children right away.

Children from low income families are only further disadvantaged. The shortage of ABA providers for children with Medicaid is worse than for children with private insurance, and wait longer for treatment than children with private insurance. 

A survey conducted as part of the state audit found that 55 percent of providers had a 4 month waitlist for their practice, another 18 percent of providers had a waitlist of greater than a year. Some providers have also limited the number of clients they see due to COVID-19, according to the audit.

“We can’t wait two more years,” Ostrovsky said. “There are too many kids who need the benefits and so many parents who have lost their insurance and have lost their jobs. We can’t have an entire generation of kids with autism with no intervention.”

Ostrovsky said advocacy groups and parents are motivated to see the bill passed.

“We’ve already been contacted by parents who want to know who to call and how to support the bill.”

In 2019, legislators introduced a similar bill, however, it was eventually watered down to an audit due to “fiscal constraints.” 

State officials at the time projected the additional Medicaid-provided service would cost $6,027,523 for the biennium, of which $2,145,769 would be the state’s share.

However, the state audit released last month found those estimates were overblown. Nevada Medicaid and Nevada’s Autism Treatment Assistance Program (ATAP) “overestimated the cost of increasing provider rates due to unreasonable assumptions in their calculations,” according to the audit.

In fact, state agencies did not even spend all available funds budgeted for autism therapy. Over the last two fiscal years, ATAP received an additional $5.4 million to eliminate the waitlist families faced, but the full amount went unspent. Still, an ATAP June 2020 report noted that the average wait time for children in the program was 153 days.

And while the state estimates the cost to provide autism therapy for an estimated 2,500 children is $35.7 million annually, since 2017 only about $15 million per year, on average, has been spent.

The audit concluded that despite funds being available, a lack of providers “is the main reason why children wait for treatment services currently.”

“I find it disappointing we couldn’t work together on that Medicaid rate,” said Ostrovsky, who lobbied for the previous bill. “We had certain legislators question whether the rate was actually needed and necessary. The compromise of the audit was good in the sense that the audit proved we were right. ” 

The bill would however come with a price tag in a time of budget shortfalls and an increasing number of people going on Nevada Medicaid.

“They say there’s no money out there so we need that discussion to happen now. We need this to be a priority now. We are forecasting that we need this money and we need to help these kids,” Ostrovsky said.

“I don’t think you can pick which child you are going to help. I don’t see how you can say for the third time ‘no it’s still not the right time.’ I do think it’s going to be a fight but I think there is a way to make it work.”