Objective: To assess the use of Medicaid programs, including waivers, to address the needs of aging autistic individuals. Data sources: We gathered data on Medicaid programs in place between 2004 and 2015 for 50 states and the District of Columbia from the Centers for Medicare and Medicaid Services website, by contacting state Medicaid administrators and advocacy groups, and by reviewing the Medicaid Analytic eXtract Waiver Crosswalk. Study design: This retrospective analysis classified each Medicaid program and documented state changes over time in eligibility criteria: those serving autism spectrum disorder only, autism spectrum disorder or intellectual disability, and intellectual disability only. Data collection/extraction methods: We captured age and diagnosis eligibility criteria for Medicaid programs serving any of the three target groups. Principal findings: A total of 269 Medicaid programs met our criteria and most programs (51%) were 1915(c) waivers. The number of autism-specific 1915(c) waivers grew more than fivefold during the study period, outpacing increases in waivers serving individuals with intellectual disability. Conclusions: States varied in their use of Medicaid to address the needs of the aging autism population. Further study of characteristics of states that changed their Medicaid programs, and of the health care use and outcomes associated with these changes, are needed to identify opportunities to replicate effective approaches to meeting the needs of this population.
With the increase in prevalence of autism spectrum disorder (ASD) over recent years (1, 2), much attention has been paid to U.S. children and adolescents in need of services. However, half a million youths with ASD will age into adulthood over the next decade (3), and many adults are already in need of long-term services and supports. Medicaid is the primary source of health care coverage for these individuals (4), but little is known about the composition of the adult population with ASD enrolled in Medicaid.We examined Medicaid Analytic eXtract data including all individuals under age 65 with claim(s) of ASD (clinical modification code: 299.xx) and a random sample of 3,358,220 Medicaid beneficiaries without ASD or intellectual disability (ID) (317.xx-319.xx) between 2008 and 2012. Figure 1 shows the administrative prevalence of individuals ages 18-64 enrolled in Medicaid, by age category. The numerator includes individuals with 12-month continuous enrollment and either one inpatient or two outpatient visits for which ASD was a diagnosis. The denominator is the sum of the numerator plus the total Medicaid population without ASD in that age group with 12-month continuous enrollment. We assumed that the percentage of Medicaid beneficiaries without ASD with 12month continuous enrollment was the same in each year as in our simple random sample of 3.3 million Medicaid recipients without ASD or ID, ranging from 55% (2008) to 60% (2012).
Importance: Rates of occupational therapy service utilization among people with autism spectrum disorder (ASD) or intellectual disability (ID) have not been explored in population-based samples. Objective: To describe occupational therapy services delivered to Medicaid-eligible persons younger than age 65 yr identified as having ASD, ID, or both and to evaluate demographic factors associated with occupational therapy service utilization in this population. Design: Retrospective, case–control, cohort study using claims records from Medicaid Analytic eXtract files (2009–2012). Setting: Data from all 50 states and Washington, DC. Participants: Beneficiaries identified as having ASD only, ASD+ID, or ID only who were younger than age 18 yr (N = 664,214) and ages 18–64 yr (N = 702,338). Outcomes and Measures: We analyzed Current Procedural Terminology® and Healthcare Common Procedure Coding System procedure codes, Medicaid Statistical Information System type of service codes, and Center for Medicare & Medicaid Services provider specialty codes. Results: Only 3.7% to 6.3% of eligible adult beneficiaries received occupational therapy; in contrast, 20.5% to 24.2% of children received occupational therapy. Significant predictors of service use varied by group; however, differences by race–ethnicity, eligibility on the basis of poverty, and geographic location were observed. Among children, the most frequent billing code was for “therapeutic activities” (43%–60%); among adults, it was “community/work reintegration training” (29%–39%). Conclusions and Relevance: Billed procedure code patterns do not consistently reflect the unique occupational focus that occupational therapy providers deliver to people with developmental disabilities. Disparities in occupational therapy receipt warrant further attention to understand the social and structural factors affecting service delivery. What This Article Adds: Occupational therapy services paid for by Medicaid are used more frequently by children with ASD and ID than by adults with these diagnoses. Greater understanding of the intersectional factors that drive service delivery and disparities is needed.
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