[Note: Shared for #AutisticHistory archive purposes. This is NOT An Autistic Ally.]
Ohio EPSDT lawsuit filed for autism-related Medicaid coverage
September 15, 2015
Earlier this month a federal lawsuit was filed in the United States District Court for the Northern District of Ohio against CareSource, one of the state’s largest Medicaid managed care organizations, for refusing to cover medically necessary applied behavior Analysis (ABA) treatment for children with autism.
The suit was filed by attorneys Richard Ganulin of Cincinnati and Aimee Gilman of Cleveland. By law, Medicaid is required to cover all medically necessary treatments for children under the age of 21 and an estimated one-third of all children with autism receive primary coverage through Medicaid.
The complaint alleges that even though both federal and state courts in Ohio, as well as the state’s own administrative hearing office, have ruled that this care must be provided when medically necessary for a child, CareSource has categorically refused to provide it. The complaint also names the Ohio Department of Jobs and Family Services, the state Medicaid agency which has ultimate responsibility for compliance with federal Medicaid law, as a defendant.
The federal Medicaid act mandates that all states provide Early Periodic Screening Diagnosis and Treatment (EPSDT) services for all Medicaid eligible children under 21 years of age. The broad EPSDT mandate requires that states provide all coverable medical assistance to correct or ameliorate defects and physical and mental illnesses and conditions in these children even if that care is not currently in the state’s Medicaid plan.
“The purpose of the program is to insure that conditions are treated early and that children enter adulthood as healthy and functional as possible,” says Dan Unumb, Executive Director of Autism Speaks Legal Resource Center.
Unumb notes that in the last several years there have been a number of several successful lawsuits by Medicaid families whose children with autism had been wrongfully denied access to medically necessary ABA treatment. In July of 2014, the federal Centers for Medicare & Medicaid Services (CMS) issued a written bulletin specifically reiterating states’ obligation to cover all medically necessary treatments for autism for children and young adults, based on individualized determinations of medical necessity. This may include ABA treatment, speech, occupational and physical therapies, and other therapies and devices depending on the individual needs of the child.
If a Medicaid beneficiary is denied treatment, they have a right to appeal the decision in court. Unfortunately, most Medicaid beneficiaries are low-income and do not have ready access to legal counsel. “It is unfortunate that too often the only way to guarantee access to needed treatment under Medicaid is via the courts, and this is wholly unacceptable,” says Angela Lello, a member of the Autism Speaks advocacy team.
Dan Unumb concurs saying “despite the federal EPSDT mandate, and states’ actions to cover these services in the wake of the CMS guidance, we continue to see court challenges having to be brought against some states by low-income children with autism who can’t get the medically necessary treatment they’re entitled to under the law.” Earlier this year, a Nebraska court ruled that that state’s categorical exclusion of ABA treatment for children with autism violated EPSDT law, and suits are pending in Hawaii and Pennsylvania.
The state’s motion to dismiss the Hawaii case was denied last month and the parties are in settlement negotiations. “We commend the attorneys who are fighting for the rights of these children and with whom we are committed to assuring that children with autism get the healthcare they need when they need it.”
If you or your child are receiving Medicaid and have been denied medically necessary treatments related to autism, contact the Autism Response Team at 888-288-4762 or en Español 888-772-9050, or email via at email@example.com. Remember when making a request for services to insure that all documents you have showing that a qualified healthcare professional has determined the treatment to be medically necessary are included.
If your state does not currently have a coverage plan for the service or if you are advised that what you seek is “not a covered service”, you should include in writing that you are making the request pursuant to EPSDT which requires medically necessary care even if it is not currently a “covered service.”
More With Autism Votes
Autistic people have fought the inclusion of ABA in therapy for us since before Autism Speaks, and other non-Autistic-led autism organizations, started lobbying legislation to get it covered by insurances and Medicaid.
ABA is a myth originally sold to parents that it would keep their Autistic child out of an institution. Today, parents are told that with early intervention therapy their child will either be less Autistic or no longer Autistic by elementary school, and can be mainstreamed in typical education classes. ABA is very expensive to pay out of pocket. Essentially, Autism Speaks has justified the big price tag up front will offset the overall burden on resources for an Autistic’s lifetime. The recommendation for this therapy is 40 hours a week for children and toddlers.
The original study that showed the success rate of ABA to be at 50% has never been replicated. In fact, the study of ABA by United States Department of Defense was denounced as a failure. Not just once, but multiple times. Simply stated: ABA doesn’t work. In study after repeated study: ABA (conversion therapy) doesn’t work.
What more recent studies do show: Autistics who experienced ABA therapy are at high risk to develop PTSD and other lifelong trauma-related conditions. Historically, the autism organizations promoting ABA as a cure or solution have silenced Autistic advocates’ opposition. ABA is also known as gay conversion therapy.
The ‘cure’ for Autistics not born yet is the prevention of birth.
The ‘cure’ is a choice to terminate a pregnancy based on ‘autism risk.’ The cure is abortion. This is the same ‘cure’ society has for Down Syndrome.
This is eugenics 2021. Instead of killing Autistics and disabled children in gas chambers or ‘mercy killings’ like in Aktion T4, it’ll happen at the doctor’s office, quietly, one Autistic baby at a time. Different approaches yes, but still eugenics and the extinction of an entire minority group of people.
Fact: You can’t cure Autistics from being Autistic.
Fact: You can’t recover an Autistic from being Autistic.
Fact: You can groom an Autistic to mask and hide their traits. Somewhat. … however, this comes at the expense of the Autistic child, promotes Autistic Burnout (this should not be confused with typical burnout, Autistic Burnout can kill Autistics), and places the Autistic child at high risk for PTSD and other lifelong trauma-related conditions.
[Note: Autism is NOT a disease, but a neurodevelopmental difference and disability.]
Fact: Vaccines Do Not Cause Autism.