A hotly debated bill to require most private insurers to cover behavioral therapy for children with autism is first up in the House chamber on Thursday morning. Concern over costs is once again causing confusion.
HB284, sponsored by Rep. Jim Patterson, R-Meridianville, began as a bill to require health insurers to provide coverage for behavioral therapy.
Alabama is one of five states with no requirement that insurance companies cover applied behavior analysis (ABA), the most common and scientifically supported treatment for autism. In committee, the bill faced stiff opposition from members of the business and insurance communities.
Though it passed the House Insurance committee, HB284 emerged with extra baggage, including caps on coverage, a provision to end coverage if insurance premiums rise beyond one percent, and a mandate to include coverage for children eligible for Medicaid.
That Medicaid mandate, and the costs associated with it, are causing confusion.
Here’s the thing: federal law already requires Medicaid to cover these therapies.
It’s just that Alabama’s Medicaid isn’t in compliance with federal law. Alabama officials are in settlement negotiations right now to fend off a lawsuit from two advocacy groups.
Senator Arthur Orr, R-Decatur, told lawmakers during budget discussions that $11 million from the Education Trust Fund budget has been allocated to the Department of Mental Health for next year to cover autism therapy under Medicaid to avoid litigation.
Officials with the Alabama Disabilities Advocacy Program (ADAP), one of the authors of a February 2016 letter demanding Medicaid cover autism therapies as required by federal law, are unable to talk about any settlement negotiations.
ADAP’s associate director Nancy Anderson acknowledged that they, along with the Center for Public Representation “have been engaged in discussions with state officials since [the letter was sent], and our discussions with state officials have been proceeding apace.”
In the letter, ADAP points out that behavioral therapy should already be covered by Medicaid not only for children with autism, but also for children with severe emotional disorders and intellectual disabilities. The $11 million being placed into the Department of Mental Health’s budget could be enough to cover children in all three categories.
The Medicaid mandate in HB284 “restates existing federal law,” according to Anderson.
In other words, regardless of whether HB284 passes, Alabama Medicaid must pay for autism therapies for eligible children.
So why add a Medicaid mandate to HB284?
Rep. Anthony Daniels, D-Huntsville, said he added the amendment because he is disturbed that Medicaid is “ignoring” federal law.
“It’s very disturbing to me that the Medicaid commissioner is saying we can’t afford to do it when it’s already a mandate and already a requirement,” he said.
Medicaid Commissioner Stephanie Azar could not be reached for comment and a spokesperson for Medicaid said they would not be able to respond to questions from AL.com about the settlement discussions due in part because Governor Kay Ivey has not been briefed about the issue.
Department of Mental Health Commissioner James Perdue did not respond to AL.com’s request for more information.
After the Medicaid amendment was added in committee, lawmakers asked about costs and tried to hold up the bill until those costs could be determined. Daniels said the talk about holding the bill up was ”just an excuse to not do the right thing.”
Medicaid costs are shared with the federal government, meaning for every dollar of Medicaid expenditures, Alabama’s share is about 30 cents and the federal government’s is about 70 cents.
Alabama’s Medicaid agency projected the total cost for Medicaid to cover autism therapy services for eligible children to be between $36.3 and $78.6 million, with the state’s portion falling between $11.3 and $24.4 million.
Daniels has seen Medicaid’s figures, and said he doesn’t believe the numbers are valid. “Medicaid can’t justify dollar-for-dollar amount that they’re articulating,” he said. “I take that with a grain of salt.”
Autism Speaks’ government affairs director Mike Wasmer agrees those cost estimates are much higher than expected. Wasmer said Louisiana’s Medicaid program’s total federal and state costs for ABA therapy were $18.3 million in 2015.
Wasmer said Louisiana has a similar 30/70 split, bringing Louisiana’s actual state costs to around $5 million. Wasmer projected Alabama’s share of Medicaid costs for autism therapy to be around $5.5 million.
Wasmer called Alabama’s Medicaid projections “incredibly inflated” and said they “just simply don’t make sense,” adding these numbers are creating confusion and causing problems. “There should be no fiscal note at all because they’re already obligated under federal law,” Wasmer said.
“I’m concerned that if some legislators who might be sitting on the fence about whether or not to support our bill, if they see this crazy fiscal estimate from Alabama Medicaid, that they’re going to be discouraged from supporting the bill,” Wasmer said.
Before the Medicaid projections were added to the mix, the cost to consumers was already a sticking point. Representatives from Blue Cross Blue Shield of Alabama estimated that insured members could pay an additional $4 every month to offset the costs of coverage for autism therapy.
Patterson disputed those numbers, said costs to insured members rarely exceed $1 a month in states that require coverage of ABA therapy. His examples included Hawaii, Missouri and South Carolina, where costs range from 62 cents a month to a little more than a dollar.
Daniels encouraged advocates to continue calling their representatives and urge them to support HB284 with the Medicaid amendment. “Do right by the people of Alabama and the children of Alabama because they deserve it,” he said.
The House chamber offers live audio at this link when the House is in session. The House is expected to take up the bill at 9:30 on Thursday morning.