Mandated Benefits Review by the Pennsylvania Health Care Cost Containment Council
– January, 2008
According to the PA Department of Public Welfare (DPW), Medical Assistance (“MA” -- the
Medicaid program in Pennsylvania) provides coverage of medical and mental health services
to autistic children that include mental health wraparound services (e.g., Behavioral Health
Rehabilitation Services), speech and occupational therapy, shift nursing, in-home personal
care services, diapers, nutritional supplements, and prescriptions. Proponents of HB 1150
(Act 62 of 2008) argued that the MA program and its services fail to serve children with ASD
adequately. In its submission (pages 6 to 11), DPW, which administers the program and
oversees its services, listed a number of points made by an outside panel, Pennsylvania
Autism Task Force Final Report (December 2004). Many of these points were also widely cited
in other official submissions and in many constituent comments.
Some of these points are problematic (see commentary below):

The MA behavioral health system does not acknowledge nor serve the pervasive nature
of autism or pervasive developmental disorder (PDD). The behavioral health system
operates as if autism were a short-term medical condition.
The emphasis on “short-term treatment” is part of the “Wraparound” philosophy.
The MA behavioral health system (Medicaid) was not created for “short-term”
treatments or conditions; it covers children from birth to the age of 21 years.

Medical assistance is provided via a mechanism designed to serve children with mental
illness or mental retardation. As a result, the medical necessity criteria, mechanisms for
providing services, the definition and identification of covered services, service delivery
criteria, reporting standards, and rate structures are grossly ill suited to meet the needs
of children with ASD.
Autism is listed as a “mental illness” in DSM-IV and this permits Medicaid funding
for its treatment. Arguing that “Autism is not a mental illness” serves no purpose
except, perhaps, to jeopardize Medicaid funding for its treatment.

Notwithstanding the fact that autism is a life-long incurable biological disorder, the
current system requires that a psychologist or a psychiatrist reevaluate the child every
four months [changed recently to twelve months] to determine their continued eligibility
for services. Parents find this reevaluation requirement to be medically unnecessary,
needlessly intrusive and demeaning.
Some parents fail to see that their child is getting better in as little as four months,
but many do. If treatment is delivered correctly and consistently, most children with
ASD will demonstrate improvements at four month intervals.

Physicians encourage pharmacological interventions rather than behavioral
interventions because the medical model (for) autism is wedged into the mental health
category and mindset.
Medical treatment of ASD is controversial; behavioral treatment isn’t. Psychologists
don’t prescribe medication & are ideal treatment supervisors for children with ASD.

There is an insufficient number of qualified providers in the Commonwealth and access
to quality services is geographically inconsistent.

Lack of early identification and diagnosis causes delayed interventions and support to
the individual and family members.
Good reasons to enthusiastically support and expand psychologists’ roles in
Medicaid and the diagnosis and treatment of children with ASD.

The intervention approach for ASD children in PA is both inappropriate and inconsistent
with their needs. The program comprises a mental health paradigm with release dates
for services not reflecting the reality or ongoing path of the ASD child.
The treatment outcome data collected by the Institute for Behavior Change for the
past 10 years directly contradicts this uninformed opinion.

With the lack of consistency and coordination between systems, and with the lack of
funding, there is a major concern over how available funding is being used. There is a
need for a seamless, coordinated system with braided funding. The funding should
follow the child instead of each service being funded from its own individual system or
silo.
Medicaid funding is an entitlement for disabled children in Pennsylvania; it does
follow the child. Existing systems can coordinate between each other if they want to.

There is a shortage of trained speech therapists. Since communication deficits are the
main focus of autism as a disability, this severe shortage of speech therapists is a major
problem.

Noted throughout proponents’ submissions was the low reimbursement rates offered to
MA providers, along with stringent program requirements, which resulted in provider
shortages and waiting lists for services. Steven Kossor, Executive Director of the
Institute for Behavior Change in Coatesville, Pennsylvania, and a licensed psychologist
who has been supervising the delivery of Behavioral Health Rehabilitation Services to
children enrolled in Medicaid/MA since 1989, noted that “Medical Assistance payment
rates for these services have remained pathetically low (they were set in 1992 and have
never been adjusted for inflation or any other reason) …”. (Letter to PHC4, Sept. 20,
2007) The observation that low reimbursement rates adversely affect the availability of
providers was repeatedly made in a large proportion of the submissions. See also
Section VIII, A.
Although a lack of funding was a prominent complaint in Pennsylvania’s 1999 Kirk T.
lawsuit that resulted in changes to the training and supervision of treatment staff,
especially TSS, funding remains inadequate. The inadequacy of funding for Behavioral
Health Rehabilitation Services is widely understood throughout the parent and provider
community as the greatest impediment to accessing appropriate, necessary Behavioral
Health Rehabilitation Services.
Unless funding for BHRS is increased (along with requirements for professional
supervision and public disclosure of treatment outcome data), effective BHRS will
remain in short supply.