Nebraska senators hear concerns about spending, access for autism services

The Nebraska Legislature’s Health and Human Services committee heard about challenges facing applied behavior analysis therapy, which helps children with autism, in a hearing at the state capitol on Friday.

Applied behavior analysis therapy, or ABA, teaches children with autism about emotional regulation, communication and other life skills. Throughout the year, Nebraska Department of Health and Human Services officials have rolled out changes to the program under Medicaid with the aim of making it more sustainable.

The department updated definitions that included a new cap of 30 hours per week for a child receiving services and a requirement to meet with parents at least two hours a month.

Officials also reduced the amount Nebraska pays to providers under Medicaid. Before the rate changes, the state paid $36.11 per 15 minutes of ABA therapy. With the new rates, it pays $18.70 for treatment from a registered behavior technician (RBT) and $22.72 for a board certified behavior analyst (BCBA) — a 48% decrease and 37% decrease, respectively.

The reasons behind the decision include a nearly 1,800% increase in the total amount Nebraska paid under Medicaid from 2020 to 2024, as well as a comparison that showed the state was far ahead of what neighboring states paid, said Matthew Ahern, deputy director for DHHS Medicaid and Long-Term Care.

“In our rate studies, when we looked at comparable states that had reductions, they have not seen reductions in the amount of services being provided,” Ahern said. “When we have comparable states that have rates at or below ours, they are not necessarily having access that's below ours, either.”

One factor that contributed to the ABA rate increases was the overall rate increases in the state for Medicaid behavior health rates, Ahern said. Another was the expansion of telehealth, bringing in more providers from out-of-state, with the right certifications to practice in Nebraska.

State Sen. Brian Hardin, chairman of the committee, asked Ahern if out-of-state providers potentially saw a chance to take advantage of the higher rates in Nebraska with the expansion of telehealth during the COVID-19 pandemic.

“Well, I would say that there were people that looked at the circumstances and made decisions,” Ahern said. “Now in terms of what their motives are, I can't speak to that, but it was a perfect sort of storm to take advantage of the situation in front of them.”

Ahern added that many of the providers who entered the state with telehealth have since set up physical locations in the state. There is currently a requirement for registered behavior technicians to work with children in person, while board-certified behavior analysts may supervise through telehealth.

Amy Nordness, who has a doctorate in communication disorders and is associate dean and director of Munroe-Meyer Institute at the University of Nebraska Medical Center, said MMI is looking at ways to keep providing quality care while adjusting for the rate cuts, including adjusting how many patients it takes from various insurance plans, reducing salaries and increasing how many patients BCBAs take on.

“We're not really trying to make money as a unit at UNMC. We need to cover our costs, though,” Nordness said. “For example, we have a clinic on 50th and Ames in Omaha that's 90% Medicaid clients. It wouldn't be sustainable if we're taking a hit on 90% of our services.”

In addition to costs, Nordness said MMI’s waitlist to get a diagnosis, which is needed before starting ABA therapy, could be anywhere from nine months to a year. Then, there could be another wait to access treatment.

“There are greater services for young children in the metro area, so we do not have as long of a wait list for toddlers,” Nordness said. “But once those kids are school age, we're finding it could be years waiting for services.”

Munroe-Meyer did not work with DHHS on the rate cuts, but it has been working with the Medicaid officials on best practices for ABA. Nordness said the rate cuts will be a challenge, but MMI doesn’t want it to impact the quality of care it provides.

“As a part of UNMC, member of the University of Nebraska system, when a challenge comes up, we try to learn what we can and adjust and do the best we can, and then train others how to manage that,” Nordness said.

MMI aims to keep services at 18 to 20 hours per week for a child, with a maximum of 22 hours a week. Corey Cohrs, CEO of ABA provider Radical Minds in Omaha, said his practice aims for a 20 hour weekly cap on services.

Cohrs also said he’s heard from families who say other providers have only offered them 40 hours a week for care as a basis, which doesn’t fit every child' s needs.

“Those rates did attract more providers, but they also shaped delivery models that emphasize billing over outcomes,” Cohrs said. “We saw hours expanded to 30 to 40 hours a week by default, supervision billed heavily but often remote or perfunctory, and services pivoted to group or in-home sessions, more to fill staff schedules than to reflect individualized client need.”

Kristen Rose, public policy and legislation chair for Nebraska Counseling Association and a former ABA provider, said rural areas of the state are seeing a shortage of ABA providers, especially ones who live in the communities.

She heard from a registered behavior technician in Sidney who had to drive two hours to a patient to provide two hours of service, and then drive two hours back — and she wasn’t reimbursed for travel time. That provider was hired by an ABA company in Omaha, which is six hours from Sidney.

“I've seen a lot of well-intentioned providers come from the eastern side of the state to the western side of the state, and the culture is different, the travel times are different, logistics are very different,” Rose said. “I don't know that they’re necessarily bad actors, but maybe they don't understand everything that may need to go into providing the resources necessary.”

When asked about trying to get more RBTs and BCBAs in rural areas, Rose said people need to have the “heart to be there.”