The state Agency for Health Care Administration likely will appeal a federal judge’s ruling that requires the Medicaid program to provide a type of intensive treatment to autistic children.
The agency refused to cover the treatment, contending in part that it is experimental and not medically necessary. But Miami federal judge Joan Lenard last month ordered the agency to provide the treatment, known as applied behavior analysis.
“If these children do not receive (applied behavior analysis) in the primary years of development up to age 6 and then to 12 years of age, the children may be left with irreversible language and behavioral impairments,’’ Lenard wrote in a March 26 order.
The agency has started carrying out Lenard’s order but spokeswoman Michelle Dahnke said in an email Thursday that the agency “intends to appeal the ruling” to the 11th U.S. Circuit Court of Appeals.
Dahnke said she could not comment on the grounds for the appeal. Among the issues in the case is the state’s discretion to determine whether Medicaid services are medically necessary and, in a related issue, whether they are experimental.
“Federal courts have repeatedly held that the states can define medical necessity to exclude unproven and experimental treatments,’’ the agency said in a court document filed last month before Lenard held a trial and issued her ruling.
The lawsuit, filed in February 2011, named three children as plaintiffs. Lenard’s ruling applies to thousands of children in the Medicaid program who have been diagnosed with autism or a broader classification of conditions called “autism spectrum disorder.”
Applied behavior analysis is a type of treatment that can include such things as one-on-one therapy sessions and rewards to help correct children’s behavioral problems. Miriam Harmatz, a Florida Legal Services attorney who represented the children in the case against the agency, disputed that the treatment is experimental and said it is already covered in many private health-insurance plans.
By one estimate, including the treatment in the Medicaid program would cost $12.2 million a year though the agency said in the court document last month that the cost could be “significantly higher.”
Harmatz, however, said Thursday that providing the coverage would save money long term because it would help children go to school and later attain jobs. That could help prevent them from needing government assistance in the future.
In the case, the two sides have battled about studies and analyses that evaluated applied behavior analysis. The court document the agency filed before the trial said it is “abundantly clear that AHCA has not acted arbitrarily or capriciously” in deciding against covering the treatment.
Lenard flatly rejected that conclusion.
She pointed to a “plethora” of analyses and studies that shows the treatment is “an effective and significant treatment to prevent disability and restore developmental skills to children with autism and (autism spectrum disorder).”