DHHS issues ‘guardrails’ for serving Nebraska kids with autism as Medicaid costs surge, audits loom

LINCOLN — Spurred in part by the rising costs of services to young Nebraskans with autism, the state on Friday announced new “guardrails” they hope ward off potential misuses of public funds.

Officials with the Nebraska Department of Health and Human Services signaled a couple of months ago they’d be issuing cost controls and guidelines related to applied behavior analysis (ABA) — a Medicaid service area for youths which has seen state expenses over a three-year period skyrocket by more than 1,000%.

While the state has presented no evidence of fraud or abuse by families or providers of Medicaid-covered ABA services, DHHS officials point out that Nebraska pays among the highest provider reimbursement rates in the nation. They say that with ABA usage rising, they wanted to set clearer parameters, expectations and to rein in potential over-authorizations of services. 

As reported previously by the Nebraska Examiner, federal audits and multimillion-dollar fines against other states’ Medicaid-covered behavioral health programs also sparked Nebraska DHHS to examine its own program for income-eligible youths.

“I don’t think we have a clear picture of the amount of misuse happening in the state,” Matt Ahern, DHHS deputy director of Policy and Plan Management, said Friday. “We know it’s been an issue in a lot of other states. It’s a trend.”

He said surging costs are a priority but that his department is driven more by: “What is the clinically appropriate thing to do?”

Potential disruption fuels worry

At issue are ABA services, a widely known therapy shown to help autistic kids function better in society.

Nebraska DHHS probes Medicaid service for autistic youths as costs escalate

Experts say the number of youths affected has grown: One in 36 youths nationally has autism spectrum disorder, a developmental disability with challenges ranging in social communication to repetitive behaviors.

According to state data, Medicaid claims paid to ABA providers in Nebraska has increased from $4.6 million in 2020 to nearly $52 million in 2023. Medicaid-eligible youths who were served during that period grew from 169 to about 1,150, a nearly 600% jump. 

Acceleration continued in 2024, with Ahern calling ABA program costs one of the sharper increases he’s seen across any service line.

Potential disruptions in services to youths on the autism spectrum put families and advocates on edge. Some say taxpayers could pay more in the long run if those affected land in jails or institutions.

Mariel Fernandez, vice president of the Council of Autism Service Providers (CASP), reviewed the guidelines and said she is pleased they appear to keep the path to services clear for young Nebraskans with autism spectrum disorder.

She said the national group appreciated DHHS consideration of public comments and “desire to ensure children and youth have access to medically necessary services” for ASD.

Cathy Martinez, president of the Lincoln-based Autism Family Network, said Friday that families are happy the state heeded red flags raised during a recent public feedback period and made adjustments in areas such as education thresholds for lower-level technicians.

“I am a little concerned, however, with the six-hour per day cap for services,” she said. “Some children need more than that.”

Key clarifications, changes 

Hours of service — among about 10 main areas of change or clarification announced Friday — limit state reimbursement to six hours of direct patient assessment and treatment per day, for a total of no more than 30 hours a week. 

Ahern said Nebraska did not have a cap before. He called the guideline a “soft cap” — meaning a provider can seek permission for reimbursement beyond that limit for medical necessities. That would entail the same process that applies to prior authorization: a review by the “managed care organization” serving as Nebraska’s Medicaid contractor and an appeal if the provider disagrees with the MCO team’s decision.

Leading up to Friday, Ahern said, DHHS had seen requests for reimbursement that surpassed 30 hours a week, “which may or may not have been appropriate.”

He said a cap helps set a boundary for what is typical and out of whack. “We want to make sure everyone is doing due diligence.”

During the month-long comment period, the state fielded more than 300 comments on proposed changes and clarifications. DHHS said they also consulted experts including psychologists, psychiatrists, physicians and organizations that advocate for families and service providers.

Martinez, who has a child with autism, said providers had expressed particular alarm about an earlier recommendation that Registered Behavior Technicians need a bachelor’s degree as well as a year of relevant experience or graduate education.

She said the technicians are on a lower tier of the ABA pyramid, and a college degree mandate would have led to a drop in people available to work with autistic kids.

In response to family and community concerns, Ahern said the education requirement was lessened. He said a college degree for technicians had been on the books before.

Now that will be clarified to say the technicians must be certified by the Behavior Analyst Certification Board and enrolled with Nebraska Medicaid, Ahern said.

Among other worries from providers, according to DHHS documents, is a requirement that a parent or caregiver be engaged in ABA treatment and planning for two to four hours a month.

Final guidelines say caregiver involvement is crucial to treatment success, and that Nebraska Medicaid allows for telehealth flexibility. Coverage for services, however, is not to be denied on lack of caregiver participation alone, Ahern said.

The new guidelines take effect Feb. 7.

A “frequently asked questions” document on the DHHS website notes Nebraska Medicaid’s relatively high rate of reimbursement for ABA services. It encourages providers to “find a reasonable middle ground and close the gap.” 

Said Ahern: “We’re excited about what we were able to put out here.”