In a case that could jolt Medicaid programs across the country, a federal judge in Miami has ordered Florida officials to cover behavioral therapy for autistic children.
U.S. District Judge Joan Lenard called the Medicaid program's denial of coverage "arbitrary, capricious and unreasonable, both in its process and in its conclusion."
Her order applies to more than 8,000 low-income children in Florida who are enrolled in Medicaid. In her oral order late Friday following four days of testimony, the judge called it "one of the most important cases I have ever heard."
She issued a permanent injunction giving Medicaid just seven days to notify all physicians who screen youngsters in Medicaid and all community behavioral health programs that the therapy -- called "Applied Behavior Analysis" -- would now be covered.
Lenard's order said that the injunction "is without question in the public interest."
The plaintiffs were children identified by their initials -- K.G., I.D. and C.C. But the injunction applies to all the children on Medicaid for whom the therapy could be beneficial.
The cost of that was estimated at $12 million a year -- of which Florida must pay $5 million, while the federal government picks up the rest. But Lenard said in her order that it is less expensive in the long run to give the children corrective behavioral training than to leave them untreated.
The state Agency for Health Care Administration, which runs Medicaid in Florida, had argued that the treatment was experimental. But testimony indicated that AHCA omitted some favorable studies, and that it did not follow its usual processes for evaluation.
Michelle Dahnke, spokeswoman for AHCA, said late Tuesday that the agency was "reviewing the transcripts and the written order" so that it could offer a response.
The Medicaid program had labeled the treatment "experimental" and denied payment for it, even though commercial insurers in Florida are required to cover it.
"Judge Lenard's order will eliminate this tragic disparity," said lead counsel Miriam Harmatz of Florida Legal Services.
Because most states have a similar disparity, "this case will have national impact," Harmatz said. And sure enough, late Tuesday afternoon, she said the legal services team was being flooded with e-mails from peers in other states.
--Health News Florida is an independent online publication dedicated to the public interest. Editor Carol Gentry can be reached at 727-410-3266.
