Our Medicaid Committee is prioritizing work to address barriers encountered in the Medicaid prior authorization process. Our committee meets regularly with the Department of Health Services on matters specific to speech and hearing, in addition to quarterly meetings with the Department of Health Services and other therapy associations. In February our Medicaid Committee presented two major areas of concern 1) extensive information required when a Medicaid-covered individual is simultaneously receiving ABA and speech/language services and 2) extensive information required for adjudication of AAC/SGD services that often does not reflect best practice in this specialty area. 

WSHA provided supporting documentation that speech/language and ABA services are not duplicative. ABA services should not be interpreted as a substitute for the skills warranted by a speech/language pathologist, i.e. clinical training/competencies in evaluation and treatment of communicative and feeding/swallowing disorders, in the provision of services for this neurodiverse population. In the future the ABA plan of care will not be required with submission of speech/language Medicaid prior authorization requests when the SLP attests that contact has been made/collaboration with ABA provider has occurred. SLP must document date, method, and outcome of attempts to obtain the ABA plan of care and collaboration efforts with the behavior management provider in Section IV – items #16 and #17 of PA/TA. Treatment should not be delayed because of unsuccessful attempts to obtain the ABA plan of care.  

WSHA’s review of returned PAs indicates clinical treatment for severely involved users of AAC/SGDs has been limited and restricted by reviewers’ requirements which do not reflect best practice. WSHA

emphasized the number of providers and clinics offering AAC/SGD specialty services continues to shrink for the Medicaid population. Low reimbursement and extensive and inappropriate information required for adjudication of AAC/SGD services will continue to put pressure on the already limited number of providers and clinics. DHS acknowledged training with reviewers is ongoing. Reportedly reviewers have been advised to pose less and more precise questions when prior authorization (PA)s are returned for information and when information is not provided in the original submission, however some type of objective data is needed to determine improvement. Reports of functional progress provided by caregivers or communicative partners, advancement on developmental stage of language acquisition, increased pragmatic use of language, and/or objective data can be used to document progress. Remarks made by reviewers indicating evaluation for AAC/SGDs can readily be obtained through a vendor promoting such devices versus a SLP with expertise in this specialty area were refuted. Training required for comprehensive assessment such as matching features to needs and skills of communicator, assessing use of AAC in various settings, providing language development training for immediate and long-term needs, was highlighted as medically necessary. 

If you are a Medicaid provider and have questions, concerns, or experience to share please reach out to our committee at WSHA@badgerbay.co