Medicaid Access Challenges
Most Illinois Families with Medicaid Insurance are waiting to Access ABA Services for their children with autism.
What specifically is stopping families from getting access to ABA today?
Currently, most ABA providers cannot find the licensed professionals Medicaid requires to supervise the behavior analyst (BCBA) they employ. This is leaving families on very long wait lists with most families not finding any approved Medicaid ABA providers in their communities. The behavior analyst is the most common practitioner type that oversees ABA therapy and within commercial employer-based insurance, there is no requirement for them to be supervised. Unfortunately, there is a workforce shortage in all human services industries, and it is very difficult to find the required licensed professionals.
Read more about "Advocacy Action Alerts"
Read more about "Why children enrolled in the state’s Medicaid Health plan are having such difficulties accessing ABA therapy?"
What is the Access Challenge your Family is Facing?
Below are the challenges families have shared with us. We have provided some guidance under each specific challenge, just click to learn more.
Please reach out to your Medicaid managed care plan’s member services listed on your insurance card. Ask for approved Medicaid providers for ABA therapy near your home. ABA may also be called adaptive behavior support services.
As mentioned earlier, the main access challenge is the very limited number of Medicaid-approved ABA providers. If your managed care plan (MCO) could not connect you to ABA providers in your community, please consider filing an appeal with the MCO. At the following link, is a short statement about this challenge you can send with your appeal request. You will find your MCO's contact information for sending the appeal request as well.
It is great you have found an approved provider, but if ABA therapy cannot start in a reasonable amount of time, consider filing an appeal with your managed care plan (MCO). At the following link is a short statement about this challenge you can send with your appeal request. You will also find your MCO's contact information for sending the appeal request.
If your provider is a Medicaid-approved provider and employs a licensed practitioner to supervise the behavior analyst (BCBA), Medicaid should cover services.
If your provider is not a Medicaid-approved provider and does not employ a licensed practitioner to supervise the behavior analyst (BCBA), you could ask your provider to consider requesting a single case agreement from your Medicaid managed care plan (MCO). If a single case agreement is denied by your MCO, please consider filing an appeal. At the following link is a short statement about this challenge you can send with your appeal request. You will also find your MCOs' contact information for sending the appeal request. Link to information.
Some families found ABA providers that met the Medicaid requirements and started ABA therapy. After ABA started, if the provider no longer employed the required licensed practitioner to supervise the behavior analyst (BCBA), your services may have been put on hold. The family could ask your provider to consider requesting a single case agreement from your managed care plan (MCO). If a single case agreement is denied by your managed care plan, please consider filing an appeal. At the following link is a short statement about this challenge you can send with your appeal request. You will also find your MCO's contact information for sending the appeal request.
If your Medicaid managed care plan (MCO) denied your Medicaid approved provider’s authorization because your child did not meet medical necessity for ABA for any reason including based on your child’s age or severity, please consider filing an appeal with your MCO. At the following link is a short statement about this challenge you can send with your appeal request. You will also find your MCO's contact information for sending the appeal request.
We would like to hear about the challenge your family is facing accessing ABA therapy within your Medicaid insurance. Please email us at help@ilasd.com so we can learn more and offer any guidance we can.
A single case agreement could possibly allow your ABA provider to contract with your managed care plan (MCO). ABA providers that are not Medicaid approved or obtained Medicaid approval but no longer employ the required supervisor for the behavior analyst (BCBA) can make a request for a single case agreement. If the single-case agreement is denied, please consider filing an appeal.
Why are children enrolled in the state’s Medicaid Health plan having such difficulties accessing ABA therapy when ordered or prescribed by their physician or psychologist?
Medicaid coverage for applied behavior analysis (ABA) therapy for the treatment of autism spectrum disorder (ASD) is still not accessible to most children throughout Illinois who have the state's Medicaid health plan. The Department of Healthcare and Family Services (DHFS) initiated coverage for ABA therapy in October 2020, however, the coverage has not been accessible due to practitioner supervision requirements that led to only a very few providers being able to deliver ABA therapy services in the entire state.
Action Alerts Will Be Coming Soon.
We will soon be posting advocacy action alerts on opportunities for your family to advocate for change. We encourage families to file appeals with their managed care plans if you are not getting access to ABA services.
Advocacy Action Alerts
Keep up-to-date on our Advocacy Action Alerts.
Share Your Story With Us
Are you waiting for access to an ABA provider under your Medicaid insurance? We want to hear about your family's challenges. Please share your story with us including what city you live in. Visit our contact page or email us directly at help@ilasd.com.
Links to Filing an Appeal with your Managed Care Plan
Here are sample templates for each of the types of access challenges or denials you may be experiencing.
Appeal Template We cannot Find ABA Providers who take Medicaid
Appeal Template We were denied a Single Case Agreement to Start Services
Appeal Template We were denied ABA due to our Child's Age or Severity
Current Approved DHFS/Medicaid Delivery Options for ABA
Current Delivery Options of ABA
Option 1: October 2020, Licensed, Dual Professionals only. Includes social workers and psychologists who are also certified behavior analysts (BCBA).
Option 2: April 2022, Added Behavior Analysts (BCBA) with a requirement they are supervised by a licensed professional. Also added ABA could now be delivered by a state-approved Behavior Health Clinic (BHC).
The Problem: Medicaid providers are mainly attempting to deliver ABA currently under option two above but with the workforce shortages in health care, providers cannot find generally licensed professionals to supervise the behavior analysts.
Future DHFS/Medicaid Delivery Options for ABA
Proposed Delivery Options of ABA
Option 3: On a future date, a behavior analyst will be allowed by Medicaid to deliver ABA without the supervision of a licensed professional.
In January 2023, HFS proposed new rules for Adaptive Behavior Services which is the umbrella service includes two treatment services: ABA therapy and Developmental Therapy. In this link to the Register, please see pages 337 to 343.
The Problem: There are restrictive treatment limitations based on age and severity that will impact many looking to access services and overburdensome certification requirements for center-based service delivery options which will impact families greatly who want out-of-home ABA services. Read the Coalition's comments on these proposed rules below.
View Our Public Comments on DHFS/Medicaid Proposed Rules for Future Delivery Options
In February 2023, the Coalition provided public comments on the access challenges within Medicaid's Proposed Rule for ABA.