Woes for Autism Waiver at Hi-Line Home Programs

Hi-Line Home Programs, Inc. is an organization designed to serve individual and family development in communities across Montana. The program serves people primarily with developmental disabilities through education, support services, adult living support and a key part of those services are assisting with federally funded waivers from Medicaid to pay for care.

Called the Children’s Autism Waiver Services, the program works to fund interventions for Autism Spectrum Disorder (ASD). That waiver program was affected by recent legislative cuts and the elimination of the Autism Diagnosis Observation Schedule Assessment Site in Miles City, which was hosted by the Developmental Education Assistance Program.

According to Denise Herman of Hi-Line Home Programs, the waiver provides Medicaid funding to help pay for a three-year intensive early intervention program for preschool-aged children with ASD. The catch is that these children must go through an intensive evaluation and diagnosis assessment and be certified by a Board Certified Behavior Analyst (BCBA) before they can receive the waiver from Medicaid. With the closure of the assessment site, now each specialist must be visited individually for completion of the assessment, adding time and money to the process.

According to Herman, the diagnosis system has fallen apart in Montana, due to budget cuts and a sense of over-regulation on the part of the Center for Medicaid and Medicare Services (CMS). In the past, if a child was referred to Hi-Line Home for a developmental disability they were sent to an Evaluation and Diagnosis Clinic in Miles City.

There the child would be screened by a series of medical doctors, occupational therapists, speech therapists and a psychologist or counselor to determine the full spectrum of behaviors. In that screening, the specialists would evaluate for any type of disability from autism to muscular dystrophy. This allowed the team to refer the child to the proper care program. Some could end up working with Hi-Line Home and some could go to Shriners’ or Shodair Hospitals for other treatments if a different diagnosis was determined.

According to Herman, that program came under scrutiny by CMS and was found to be out of compliance and was put into a remediation program while the State developed a plan to become compliant. Jon Ebelt, a spokesman for the Montana Department of Public Health and Human Services (DPHHS), responded to an email from the Courier confirming the closure of the clinics by the 2017 legislative session. DPHHS said the closures were the result of, “significant budget cuts to DPHHS, including DDP [Developmental Disabilities Program] from the regular 2017

legislative session and special session.”

Since the clinics were labeled out of compliance, two independent companies out of Great Falls had submitted to take over the evaluations, but after three years of negotiating with CMS, both companies withdrew their applications citing CMS’s overbearing procedures involving providers who diagnose ASD benefiting from the treatment of those same patients, according to Herman.

DPHHS did not directly respond to questions about the failed plans to take over centralized diagnosis clinics but did address CMS concerns of providers in eastern Montana being involved in both the diagnosis and treatment of patients, which CMS believes is a conflict of interest.

DPHHS responded to questions about the company’s contract withdrawal stating, “The Department’s requirements, including the requirement for multi-disciplinary evaluation team members to be independent from the delivery of approved services, were clearly stated in the RFP. The responders to the RFP attested to their ability to meet this requirement upon submission of their proposals.” Hi-Line Home Programs in Glasgow, however, felt the restrictions were unreasonable due to the lack of providers in the region. According to Herman, the idea that the sole provider in the area could make a diagnosis and then not be involved in the ongoing treatment was an unrealistic requirement in small, rural eastern Montana communities.

Following the consult of the evaluation and diagnosis clinic, a child referred for ASD would then be certified by a BCBA to receive the Medicaid waiver. Adding to the program's accessibility problems, in the last regular legislative session lawmakers sided with the Montana Department of Labor in enacting new licensing requirements for BCBAs that adds a level of state certifications on top of the already-existing federal requirements. According to Herman, this means that those professionals are currently unable to work with the Medicaid waiver recipients. Many are in regulatory limbo due to the new law, further hindering the treatment of those using the Medicaid waiver.

Without the Clinics and BCBAs, a diagnosis requires independent evaluations from the same specialties as before, but this time working independently and with little collaboration or training in ASD. In some cases, this can delay diagnosis by several months to years and ultimately impede early intervention. “A diagnosis will get them the other therapies they need,” explained Elissa Erickson, who also works at Hi-Line Home Programs, and who believes early intervention can have major impacts on the development of a child with ASD.

According to Herman and Erickson, 67 percent of children who receive any early intervention will not require special education services in school. That can save the school district up to $20,000 a year per child throughout their school career according to Hi-Line Home Programs, although Bob Connors, the superintendent of Glasgow Schools, said it was difficult to determine a dollar figure for special education costs due to fluctuating costs per district. In the case of the three-year intensive Autism Program, cost is roughly $30,000 a year, meaning the program could more than pays for itself.

In their email response, DPHHS acknowledged the value of early childhood intervention, and downplayed the lack of access stating: “[C]hildren seeking Autism intervention can have their physician or other practitioner request services through the Medicaid EPSDT [Early and Periodic Screening, Diagnostic and Treatment Services] Prior Authorization & Certificate of Medical Necessity form.”

According to Herman and Erickson, that is not always as easy as it sounds. Many times, providers will look to delay diagnosis to avoid the perception of a hasty diagnosis or a stigma, which may follow a child for life. The unintended side effect, however, is that a child with ASD may not receive the intervention they require in a timely manner, which according to Herman, could have lasting impacts and costly consequences.

The other obstacle to diagnosis in eastern Montana stems from a lack of providers. Because a diagnosis requires occupational therapists, speech therapists, and primary care providers, as well as a BCBA, to all agree in concert the process can easily run into a road block, which could derail the diagnosis at any point. The other delay comes in the form of simply getting an appointment with each locally. In some cases providers are as far away as Billings, meaning the process can take a significant amount of time and money. That time, according to Herman and Erickson, can again delay intervention, and currently no real solution exists for northeast Montana.

DPHHS did say that children with ASD in eastern Montana qualify for early intervention under “Part C,” and that those services are administered by a contractor known as Developmental Education Assistance Program (DEAP), which covers the 17 most eastern counties in Montana. Hi-Line Home Programs also covers Part C services for developmental disabilities in toddlers, but they say that the Children’s Autism Waiver going away has impacted many of their young children who are in the Part C services.

DPHHS did add, “The Autism SPA [State Plan Amendment] is available for children up to age 21. Children with an ASD diagnosis may qualify for other services administered by the Department’s Health Resources Division, Children’s Mental Health Bureau or Developmental Disabilities Program.”