Denying Children Medicaid Benefits

Parents who learn that their child has been diagnosed with a debilitating mental health disorder are often times at a loss as to how to proceed. Those who live with mental health conditions often require intensive therapies to mitigate the impact the problem has on their life. Such treatments, while effective, are both time consuming and expensive—costing tens of thousands of dollars. Most hardworking Americans cannot afford to pay for behavioral therapies out-of-pocket, so they will typically turn to private or state health insurance coverage to offset the costs.

State assistance is typically the favored course, and many children who have a disability qualify for Supplemental Security Income (SSI). Through SSI children with disabilities may also qualify for Medicaid, as well. According to the Social Security Administration (SSA), those eligible for SSI for children benefits must be either blind or disabled. The criteria for which are as follows:

• If under 18, whether or not married or head of household, the child has a medically determinable physical or mental impairment or impairments which result in marked and severe functional limitations.
• The impairment(s) has lasted or can be expected to last for a continuous period of at least 12 months or be expected to result in death.
• If the child is blind, he or she meets the same definition of “blind” as applies for adults. Unlike the requirement for SSI disability benefits, there is no duration requirement for SSI blindness benefits.

SSI benefits are a crucial resource for covering the costs of the evidence based treatments available, therapies which could greatly improve one’s quality of life down the road. It is often recommended that a child who is diagnosed with autism undergo what is known as applied behavior analysis (ABA). A therapy which could go on for years and is extremely costly. Fortunately, in 2014 the federal Centers for Medicare & Medicaid Services (CMS) mandated that all states cover all medically necessary care for Medicaid-eligible children with autism up to age 21.

In California and a number of other states, the CMS mandates have allowed for many children with autism to get ABA treatment, saving parents thousands of dollars each year. Unfortunately, some states have not been so eager to follow the directive. In Texas, for instance, children with autism who have qualified for Medicaid and have been given ABA recommendations, are being denied coverage, Disability Scoop reports. This has forced some parents to get private insurance plans for the children, coverage which carry outrageous deductibles.

While both speech and occupational therapy are covered under the Texas Medicaid program, ABA is not currently a defined benefit. ABA claims are denied despite the fact that research has shown that the therapy can greatly improve the life of a person with autism.

“ABA is based on scientific research,” said Dan Unumb, executive director of the Legal Resource Center at Autism Speaks, a national advocacy group for families. “For many kids it takes upwards of 30 hours a week of intensive therapy to achieve desired results. That sounds like a lot, but when you’re looking at a lifetime of consequence, and at the dramatic difference it can make, it makes sense to comply with the law.” 

Stephanie Merritt Driscoll is an attorney in Southern California who focuses her practice as a Social Security Disability advocate.