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Autistic children of parents on Medicaid may miss out on a needed therapy, lawmakers warn
R.G. Greene was diagnosed with autism spectrum disorder at 3 years old. He struggled to speak. But with help, he learned to talk when he was 5. It was then that R.G. told his father he loved him for the first time.
Rep. Robb Greene, R-Shelbyville, credits his son’s improvement to applied behavior analysis, or ABA, therapy. The therapy helps people — often children with autism spectrum disorder — become independent by learning to control their behaviors.
Last month, the state, through the Indiana Family and Social Services Administration, set new Medicaid reimbursement rates for the services, which go into effect Jan. 1.
But Greene, other lawmakers and service providers still warn the rates are too low and could cause clinics offering the services to close or force them to prioritize care for families on private insurance to stay in business.
The fallout, they say, could leave Hoosier families receiving Medicaid coverage unable to find the same care that altered R.G.’s life.
The need to curtail Medicaid costs
Since 2016, ABA therapy providers have been reimbursed through Medicaid by an office within FSSA for 40% of service costs. But providers have charged disparate fees, resulting in some providers being reimbursed more for the same services.
And as demand for the services has grown, so have the costs.
Federal data shows 1 in 36 U.S. children are now diagnosed with autism spectrum disorder. In 2022, Indiana Medicaid programs provided ABA therapy services to about 6,200 children and young adults each month, according to the agency. The demand resulted in $420 million in annual claim payments to providers in 2022.
“Over the last three years ABA expenditures have increased by more than 50% per year, which is not a sustainable rate,” the agency posted on its website in August.
That standardized rates need to be set is not being questioned. “It doesn’t take a policy wonk in Medicaid to understand that reimbursing 40% of whatever is billed isn’t sustainable,” Green said.
To curtail the ballooning costs, the agency drafted preliminary reimbursement rates for all ABA therapy services in August, at the behest of the General Assembly.
One rate, in particular, drew criticism: a $55.16 hourly rate for registered behavioral technicians. The technicians’ services account for the majority of ABA therapy Medicaid expenditures billed to the agency. In the first quarter of this year, the average reimbursement rate for the service was $97 an hour and ranged from $21 an hour to $800 an hour depending on location, according to the agency.
On Aug. 18, Lt. Gov. Suzanne Crouch wrote a letter to the agency expressing her “significant concerns” with the proposed reimbursement rates, arguing they were too low for providers to continue operating the way they are. In late August, Green authored a letter, signed by a bipartisan group of 13 state senators and 29 representatives, urging Gov. Eric Holcomb to intervene in the matter.
The final rates
Following the pointed criticism, the agency revised its rates, increasing the technicians’ rate to $68.24 an hour. The revised rate was similar to providers’ average operating cost, as determined by a study from two years ago — $68.12 an hour.
Crouch told State Affairs at the time that the new rate was “better than it was.” But many critics said it should still be higher. Green told the (Franklin) Daily Journal the hourly rate should be “in the mid-$70 range,” a sentiment echoed by other lawmakers.
However, despite continued worries, lawmakers on the State Budget Committee unanimously approved the rates in late October.
“It didn’t end the way we would have liked to see it,” Rep. Becky Cash, R-Zionsville, said.
A Family and Social Services Administration spokesperson didn’t immediately respond to a request for comment. The agency has argued the technicians’ rate is higher than what is reimbursed in neighboring Kentucky, Ohio, Illinois and Michigan. The rates will be revisited again in four years, as part of the agency’s long-term plan to review all Medicaid reimbursement rates. The agency also plans to increase rates 2% each year to account for inflation.
With the new rates set to take effect Jan. 1, some lawmakers and providers still predict small clinics that offer individualized care, especially in rural communities, might close as soon as summer.
“If other clinics go out of business or don’t expand or even contract the number of clients they serve, obviously, those families will be out of service,” said Miles Hodge, co-owner of Shine Pediatric Therapy in Indianapolis, an ABA therapy service provider. “Either those families will have to find a new clinic, or they will have to go without services.”
Hodge foresees waitlists for clinics “getting longer and longer,” and children “going without services for months or a year-plus before they are able to get in.” New clinics might be dissuaded from opening because “there’s a lot of startup costs,” and Medicaid historically reimbursed them at higher rates than private insurers, he said.
“They really tried to push it through really quickly before they were able to hear from the people who would be impacted by this,” Hodge said of the agency’s process for establishing the rates.
Kim Dodson, CEO of The Arc of Indiana, a nonprofit that helps people with developmental disabilities, believes some children with autism spectrum disorder in rural communities might go without care if the small clinics close. “As I talk to providers, I think $68 will be difficult,” she said. “We need more providers serving our rural areas and our minority populations, so, for me, that is a huge concern.”
But Dodson is unfazed by some providers leaving the state,especially those who have taken advantage of the state’s 40% reimbursement model. “They can leave,” she said.
What to look for moving forward
Critics of the rates expect to have a better understanding of how the reimbursement rates will affect clinics by summer, when interim committees begin meeting. Their hope is that “you’ll have six, seven, eight, months of information, data,” Greene said.
Greene wants legislators to “make sure that we’re not losing access, we’re not damaging providers, we’re not slipping in terms of our reputation in the state of Indiana for being a place where families with children on the spectrum are supported.”
Greene and Dodson proposed the topic be studied by an interim study committee next year.
“I know what ABA did for my child, and the concern that I have is this is an intervention,” Greene said. “You need to catch your child as quickly as possible when you get that diagnosis, to get them into that intervention and get them the resources to … have a degree of independence.”
Header image: Rep. Robb Greene, R-Shelbyville, is pictured with his son, R.G., at the Indiana Statehouse. (Credit: Robb Greene)
INDIANAPOLIS — Last August, Anne Hathaway’s phone lit up with a call from Gov. Eric Holcomb. Nearly a quarter-century before, Hathaway had recruited the future governor to run for an Indiana House seat in the only race he lost.
With the resignation of Indiana Republican Chairman Kyle Hupfer in hand, Holcomb asked Hathaway to lead the Indiana Republican Party, and in doing so was tapping the first women to hold the role.
For the past 15 years, Hathaway had led the Richard G. Lugar Excellence in Public Service Series, an organization inspired by U.S. Sen. Richard Lugar and created by Teresa Lubbers and Judy Singleton to develop a gender bench for the GOP.
“I encourage women every day to take a risk, be willing to lose; go out of their comfort zones and run for office or serve on a board or commission,” said Hathaway, who serves as Indiana’s national committeewoman on the Republican National Committee, during a recent, exclusive Howey Politics/State Affairs interview.
“I couldn’t continue to do that unless I was willing to do that myself, willing to take the risk, willing to lead by example,” she said, adding, “When the call came for me, I jumped. Yeah, I’m in. Let’s go.”
Holcomb said in making this historic nomination: “Here are several key reasons I believe Anne is the right person at the right time for this role. Anne’s resume of service to the Republican Party is as extensive as just about anyone’s in the country, having served with distinction at the local, state and national levels throughout her entire career. Furthermore, with experience in running campaigns at every level of government, she has the knowledge and relationships to not only keep our party moving forward, but to continue to take it to the next level.”
Hathaway’s roots are in the tiny Illinois town of Galva just north of Peoria. After graduating from high school with a class of 77, and then from the University of Illinois, she decided to spend a year in Washington, D.C., where she began as a typist at the Department of Treasury.
Hathaway served in the White House as assistant and director of scheduling for former Vice President Dan Quayle, was program director for the 2012 Republican National Convention, and was executive director of the Indiana House Republican Campaign
Following Hathaway’s resume is a lesson in stewardship and power.
“Sen. Lugar would be more excited about me being state chair than I am just because, Judy Singleton and Teresa Lubbers were ecstatic,” said Hathaway.
She now helms the party at (or nearing) its historic apex. The Indiana GOP holds all the state constitutional offices, nine of 11 congressional seats, maintains General Assembly super majorities, more than 90% of county offices, and as of the municipal elections earlier this month, 76 mayors. If a Republican is elected governor in 11 months, the party will increase its historic dominance to five consecutive terms.
Hathaway will lead the party through the five-way gubernatorial primary. Following next June’s Indiana Republican Convention, she will head to Milwaukee, where Republican National Chairwoman Ronna McDaniel tabbed her to head the RNC’s Arrangements Committee.
Hathaway has committed to serve only through the May primary. “At that time, she will work together with the gubernatorial nominee and you all to decide who is best to finish out the remainder of the term,” said Holcomb.
Asked if there was a chance to continue as chair beyond the May election, she said, “That’s a conversation to be had.
“I have agreed to stay at least through the state convention. I believe the gubernatorial nominee should have his or her own political partner here. I’m just focused on the time between now and then, she said.
Senior reporter and columnist Brian Howey sat down for a 45-minute, wide-ranging interview with Hathaway where she discussed what it means to make history as the first female state Republican chair, how her work at the Lugar Series prepared her for this new role, the Republican party’s diversity programs and other topics. Read the full conversation on State Affairs Pro here.
Gov. Holcomb taps Boone County Council president to serve out remainder of Comptroller Tera Klutz’s term
Republican Elise Nieshalla, president of the Boone County Council, will serve out the remaining three years of State Comptroller Tera Klutz’s term.
Gov. Eric Holcomb announced the appointment of Nieshalla, a real estate investor, on Tuesday. As state auditor, Nieshalla will oversee the balancing of Indiana’s checkbooks and payment of all state employees.
“My appreciation runs deep for the strong financial standing of our state and the integrity in which the State Comptroller’s Office is run,” Nieshalla said in a statement. “It is truly my privilege to receive Gov. Holcomb’s appointment to serve our great state and local units of government by upholding the highest standards of fiscal responsibility and offering tremendous Hoosier service.”
Earlier this year Klutz announced she would resign Nov. 30, roughly a year after she was reelected. Klutz, who was first appointed by Holcomb in 2017, is the fourth state auditor in a row to not finish their term, enabling the sitting governor to choose a replacement.
Nieshalla was already well-known within Republican circles. She previously ran for treasurer in 2022 against three other Republicans, losing to current Treasurer Daniel Elliott at the state Republican convention. At the time, the convention loss of Nieshalla and other Republicans more closely aligned with the party establishment was seen as a rebuke of the Holcomb wing of the party.
Nieshalla, who lives in Zionsville, is also president of the Indiana County Councils Association and the chairwoman of the Association of Indiana Counties’ 2023 Legislative Committee. She has a bachelor’s degree from Oral Roberts University and a master’s degree from Indiana University.
She’ll be sworn in on Dec. 1 and will serve until at least the 2026 election when voters will have the option to choose the next state comptroller.
Holcomb praised Nieshalla in an emailed statement.
“Elise is a dedicated and proven public servant who has committed much of her professional life to bettering her community through service,” Holcomb said. “She has shared her financial expertise to help steer and shape the bright future of Boone County which gives me great confidence she’ll do the same serving Hoosiers as our next State Comptroller.”
On Tuesday, Indiana lawmakers returned to the Statehouse for Organization Day, the ceremonial start to the legislative session, ahead of what legislative leaders are saying should be a low-key, short session.
“We’ll probably take a pretty measured approach on what we address … , maybe fine tune some things,” House Speaker Todd Huston, R-Fishers, said during an Indiana Chamber of Commerce legislative panel on Monday. “Short sessions are supposed to be for emergency items only.”
Not only will 2024 be a non-budget-writing legislative session mandated to end by mid-March, but this session also falls in the midst of a heated Republican gubernatorial primary. There’s no obvious assumed winner who can lead policy discussions ahead of the election, nor has Gov. Eric Holcomb laid the groundwork for any major policy changes in his last legislative session.
Plus, recent criminal corruption charges against a former lawmaker — and the potential for other lawmakers to be charged in connection with the case — has put a cloud over the Indiana General Assembly.
Still, some minor bills are expected to move, and something can always pop up. Here’s a breakdown of some of the issues State Affairs expects to be debated, and three that probably won’t move.
Both Huston and Senate President Pro Tem Rodric Bray, R-Martinsville, said they want to limit the situations in which schools allow third graders to advance to fourth grade when they fail the IREAD-3, the state’s reading comprehension test.
During the 2021-2022 school year, more than 18% of students failed the test because they were not reading at a third grade level.
“When you pass that kid on, and they aren’t prepared to succeed, you’re not doing that kid a favor,” Huston said, following his Organization Day speech in which he laid out his caucus’ priorities.
Huston’s goal is to make Indiana the No. 1 state in the nation for third grade reading proficiency by 2027.
Democrats cautioned that it may be too soon to make major changes to how IREAD scores are handled in Indiana. During the 2023 legislative session, lawmakers passed a science of reading bill.
“We need to make sure that schools have the opportunity to train their teachers, to implement these strategies across the board before we start throwing new legislative hurdles in the way,” said Sen. Andrea Hunley, D-Indianapolis. “We have to give [new recommendations] time to work before we start, say, failing all children or retaining a whole class of children.”
Continuing to re-think K-12 education
Last legislative session, lawmakers passed a bill seeking to expand work-based learning in high school, but Huston emphasized during his Organization Day speech that legislators can still do more to transform the K-12 school system.
Huston said House Republicans will push to allow state money typically set aside for students pursuing a college education to be used to obtain certificates and certifications for “high demand, high wage jobs.”
“We must continue to adjust the way we think about K-12 education in order to meet the needs of all students, including those who aren’t interested in pursuing a two-or four-year degree,” Huston said. “Let’s use this session to build on skill and work-based learning, and let’s align our funding to this goal.”
This fall the Indianapolis Chamber of Commerce took a delegation of Indiana lawmakers and others to Switzerland to see how the country’s apprenticeship program operates. Expect more changes in the coming years that would enable Indiana’s K-12 system to more closely mirror that of Switzerland’s.
Child care access
During his own Organization Day speech, Bray emphasized a need to expand affordable child care options for young children.
“Day care is a constant challenge from the Ohio River to the Michigan line, trying to find day care at all if you can find it and whether it’s affordable,” Bray said.
He pointed to a legislative study committee on the topic which recommended some minor reforms to the system, such as lowering the age requirement for working unassisted in an infant or toddler classroom to age 18 from 21 and requiring the state to review how it can streamline child care regulations to increase availability.
Don’t expect lawmakers to throw more money at the child care system since 2024 isn’t a budget-writing year.
Health care costs
Lawmakers passed multiple bills during the 2023 legislative session aimed at cutting health care costs, ranging from limiting physician noncompete agreements to creating benchmarks for how high hospital prices in the largest hospital systems should be.
But Bray said he expects lawmakers to offer more legislation on the topic this year in order to help drive down costs long term.
A legislative study committee on the topic backed recommendations to require more disclosures by insurance companies on their “prior authorization” process for medical care, as well as require medical providers to give lawmakers a six-month notice for mergers or acquisitions.
It’s unclear whether legislation on water access will actually pass either chamber, but the topic is almost certain to come up in discussions.
Earlier this year, the Indiana Economic Development Corp. announced plans to pump water from the Wabash River aquifer to the LEAP district in Lebanon. Tippecanoes citizens have been vocal in their opposition to the plan, and just this week the Tippecanoe County Commissioners voted to put a moratorium on high volume water exports.
Legislative leaders say they want to avoid legislating on the issue until they get more data. The Indiana Finance Authority and the Indiana Chamber of Commerce are studying the issue.
“We’re not going to take any other steps until we have an opportunity to study to make sure that there’s ample water for the projects that we’re trying to bring into the state of Indiana,” Bray said, “and we understand just how much is too much to take away from a particular community.”
But, even if leadership would rather wait to address the elephant in the room, lawmakers are almost certain to file legislation.
Issues that won’t move: Gaming
For at least the past two legislative sessions, lawmakers have filed bills to legalize internet casino gaming, or iGaming. It appeared momentum was on proponents’ sides. Until this month.
Earlier this month former state Rep. Sean Eberhart agreed to plead guilty to criminal fraud charges that federal prosecutors say stem from influencing casino legislation in return for the promise of a $350,000-a-year job.
Both Bray and Huston said Monday they don’t expect any gaming legislation to move in 2024.
During Monday’s Chamber panel, Bray said the federal investigation “makes gaming extremely hard to engage in.”
“It taints the Statehouse, it diminishes the confidence that people have in the integrity of the Statehouse, it causes an awful lot of problems and it makes it particularly difficult to engage in that kind of policy,” Bray said.
Issues that won’t move: Marijuana
Lawmakers studied the impact legalizing marijuana would have on the workforce and youth in an interim committee this fall, but the committee never issued any recommendations for legislation.
Both legislative leaders and Holcomb have emphasized their reluctance to legalize marijuana until at least after the federal government reschedules it. Huston reiterated his hesitation on Monday.
“No one has made a compelling case to me yet on why legalizing marijuana or having more people use cannabis in the state of Indiana is a positive thing,” Huston said. “So until I hear that answer, I wouldn’t expect a whole lot of change.”
Likewise, Bray said its passage “seemed unlikely.”
The ceremonial start of the legislative session is just that. Lawmakers won’t start moving bills until they return to the Statehouse in January.
The gist Destiny Wells, the 2022 Democratic secretary of state nominee, announced she is running for the Indiana attorney general’s office next year, hoping to oust Republican incumbent Todd Rokita. Earlier this year Rokita, a vocal supporter of social conservative causes, announced he was seeking reelection. This race could be among the more competitive races …