Federal Judge Rules Florida Medicaid Must Cover Autism Treatment

A recent report issued by the Centers for Disease Control and Prevention (CDC) shows that autism in the United States is more widespread than ever, with 1 out of every 88 children affected by an autism spectrum disorder. Experts agree that early detection and treatment of the disorder, while the child’s brain is less developed, best prevents long-term impairments. However, for poorer autistic children who are covered by their state’s Medicaid program, that treatment may never come since most states’ programs will not cover applied behavioral analysis (ABA), which is considered widely to be the best available treatment. According to U.S. District Judge Joan Lenard, Florida will no longer be one of those states.

Under the state law, Florida’s Medicaid will only fund medical care that is “medically necessary.” The Florida Agency for Health Care Administration had refused to cover ABA, which it deemed “experimental,” even though private insurers in the state were bound by law to cover the treatment. Judge Lenard found the Agency’s conclusion, as well as the process it used to reach the conclusion, “arbitrary, capricious and unreasonable.” Evidence showed that the Agency did not abide by its customary evaluation processes in making the determination and that it omitted studies that concluded ABA is medically necessary.

Judge Lenard found that the lack of coverage left poor children in danger of “irreversible” harm. She stated, “If these children do not receive ABA in the primary years of development, the children may be left with irreversible language and behavioral impairments.” The cost of providing ABA to Florida children covered by Medicaid was assessed at nearly $12 million per year, with the state covering $5 million of that amount and the federal government assuming the balance. Judge Lenard asserted that the cost of providing corrective behavioral treatment to autistic children would ultimately be less than the cost of leaving them untreated.

Some believe that the case will affect other states in addition to Florida since most Medicaid programs do not pay for ABA. With increasing awareness and prevalence of the disorder, it is likely that more parents will be demanding payment for treatment.