The Association for Behavioral Health and Wellness (ABHW) has submitted four policy recommendations and a conceptual framework for how payers ought to address autism therapy benefits in the future.
The recommendations and framework were developed earlier in the year by a working group of autism therapy subject-matter experts, assembled by ABHW members. The recommendations provide a snapshot of how health plans view the fraught moment the autism therapy industry faces. This moment includes scrutiny of the industry’s massive growth, as reflected in Medicaid spending data, and a spiraling failure of oversight of these and other programs.
Debbie Witchey, CEO and president of the ABHW, exclusively told BHB that member plans are seeking to take a more active role in autism therapy now that many years have passed since the autism coverage mandates.
“There’s been a lot of pressure on health plans to cover everything, and they didn’t, until recently, have a way to evaluate what was good and bad care,” Witchey told BHB. “I think they have a much better idea of that from the last few years.”
Specifically, the ABHW has been asked on multiple occasions to engage with either officials within the Centers for Medicare & Medicaid Services (CMS) or its contractors to reflect its members’ learnings related to the autism therapy industry. A contractor who Whitchey did not name is apparently working with CMS to develop a “toolkit” to help ensure programmatic integrity related to autism therapy benefit coverage.
The ABHW is a trade association for health plans and focuses on behavioral health issues. It was founded in 1993. Member organizations include Aetna, Optum, Health Care Service Corp, Centene Corp. (NYSE: CNC) and Carelon Behavioral Health
The organization’s recommendations focus on applied behavior analysis (ABA), the foundational service of the industry. Here is a rundown of the organization’s recommendations to the federal government:
—Establish a federal credentialing standard for all ABA providers through the CMS for providers to conform to as a requirement for participating in Medicaid. This ought to require licensure verification and comprehensive background checks. Organizations ought to be credentialed as well.
— CMS should establish standardized supervision ratios and treatment delegation to registered behavior technicians (RBTs). RBTs ought to be required to obtain their own National Provider Identifiers (NPIs) through the National Plan and Provider Enumeration System (NPPES) and enroll as rendering providers.
— Providers and organizations that both diagnose and treat autism ought to be subject to additional and heightened scrutiny and oversight.
— CMS ought to “work with stakeholders to develop evidence-based, standardized clinical and quality measures.”
ABHW will further develop specific policy recommendations and firm up the articulation of its foundational “tenets” that support those recommendations. At the broadest level, these ideas are organized around individualized treatment, the use of validated assessment tools and the standardization of care and quality outcome measures.
Taken together, these recommendations and tenets reflect the ABHW members’ feeling that additional “guardrails” were established in a still nascent industry, Witchey said. These guardrails also take the form of potentially requiring contemplating discharge and step-downs in developing treatment plans, continuous reassessment,
“Another thing that spurred our interest in trying to develop something that’s evidence-based and outcome-based to the extent possible is that we don’t want to just have arbitrary, across-the-board policies put in place,” Witchey said. “For example, there are a couple of states that have just said that they’re not going to reimburse from Medicaid anymore for more than X number of hours a week. … We’re trying to still emphasize this idea of individualized treatment, but that it comes along with ongoing reassessment, and right now there is not really any kind of requirement for ongoing reassessment.”
Payers are taking a more active role in autism therapy and becoming more prescriptive to better manage the exponential increases in these benefits. This incredible rise in spending is the impetus for many of the actions that specific health plans or state entities have taken. It is also the basis for widespread but fairly nonspecific fears of rampant fraud among payers and regulators. At the very least, the industry’s general failure for adequate claims documentation has been laid bare by the HHS OIG reports.
They are also adjusting their approach based on the time passed and learnings accumulated over the years; payers and providers alike face a fundamentally different environment than when state coverage mandates were new, when both payers and providers were rushing to ensure access to services.
“Health plans have been pressured to cover services without asking any questions, and that made more sense because we were still trying to learn what works and what doesn’t,” Witchey said. “Now we have this information, we have this data. Health plans have a much better idea of what the right services are that are really going to help.”
Still, the changes that health plans want to see among their health networks are likely to be seen as stodgy cost-cutting measures, a dynamic that Witchey acknowledged: “As soon as [members] try to implement some changes, it’s automatically ‘they don’t want to pay for these things’ not ‘they don’t want to pay for ineffective services.’”
She also said that members maintain that the present status quo does not serve members and patients well. The structural dynamic that favored making ABA the primary service for autistic patients stifled additional innovation within ABA and the development of its treatments.
That dynamic has slowly accelerated over the years. Several autism therapy providers are becoming or have started off looking more like multispecialty pediatric practices that fuse several different therapy types, including ABA, in one care model, often in one location.
Still others are putting big bets on a new fundamental model for autism therapy.
Healthworx, a venture capital fund affiliated with CareFirst BlueCross BlueShield, invested in a $10 million round raised by McLean, Virginia-based Positive Development in 2024. Care First is a member of ABHW. Positive Development has raised about $95 million in the last few months to propagate its clinical model, which is based on developmental relationship-based interventions (DRBI).
Health plans similarly face uncertainty as the changes to Medicaid rules brought on by the One Big Beautiful Bill Act, economic pressure, funding reductions at the state and federal levels, and the Trump administration’s heavy focus on eliminating fraud, waste, and abuse reworks how healthcare is administered in America. Recently, federal prosecutors announced that it brought charges against two defendants over an alleged scheme to extract $46.6 million out of the Minnesota Early Intensive Developmental and Behavioral Intervention (EIDBI) program in the form of claims that were generated from whole cloth. Prosecutors say this is the largest-ever autism therapy fraud case.
“They (members) do think something has to change; I wouldn’t say they’re comfortable that we need to eliminate the fraud; they just want to make sure that it’s done in a way that’s still focused on the evidence-based approach,” Witchey said.