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A federal appeals court
has upheld a ruling that lower income children with autism in Florida cannot
be denied a costly but effective treatment that can help them lead more functional,
productive, and happy lives. The 11th U.S. Circuit Court of Appeal in Atlanta
has ruled that U.S. District Judge Joan Lenard of Miami was justified when she
ordered the Florida Agency for Health Care Administration (AHCA) to pay for the
treatment. Lenard’s ruling could affect thousands of Florida children with
autism, allowing them to receive ABA (applied behavior analysis) therapy, an
intensive treatment that helps develop and build functional skills.
Applied Behavior Analysis
(ABA) is a scientifically validated and established treatment that focuses on
the principles and techniques of learning theory to help improve social
behavior. ABA therapy helps to (1) develop new skills, (2) shape and refine
previously learned skills, and (3) decrease socially significant problem
behaviors. ABA techniques have been associated with favorable outcomes for
individuals diagnosed with autism and are effective with a wide range of target
skills and behaviors (e.g., communication skills, interpersonal (social) and
play skills, learning readiness, self-regulation, and problem behaviors).
The lawsuit was filed by
Legal Services of Greater Miami on behalf of three children diagnosed with
autism who were denied access to ABA therapy by Medicaid, Florida’s insurance program
for low-income and disabled people. Medicaid called ABA treatment, “experimental,”
and therefore not medically necessary for a child’s treatment. But following a
lengthy trial, Lenard found that “there exists in the scientific and medical
peer-reviewed literature a plethora of meta-analyses, studies and articles that
clearly establish ABA as an effective and significant treatment to prevent
disability and to restore children to their best possible functional level and
restore their developmental skills” and that the state was discriminating against
lower income children by denying access to the therapy. The appeals court,
however, did remand the case to Lenard to clarify that AHCA retains the
authority to determine the medical necessity for ABA coverage on a case-by-case
basis. The appeals court noted that AHCA in its appeal had dropped its claims
that ABA was experimental, but was concerned Lenard's order could be
misinterpreted to require blanket coverage of ABA. In Florida, like many
states, private insurers are required to cover ABA treatment.
“This case will have national impact, because,
while most states mandate that private insurance companies must cover ABA, most
Medicaid programs do not provide coverage,” said Miriam Harmatz, lead counsel
on the case.
Lee A. Wilkinson, PhD,
CCBT, NCSP is author of the award-winning book, A
Best Practice Guide to Assessment and Intervention for Autism and Asperger
Syndrome in Schools, published by Jessica Kingsley Publishers.
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