Service Suggestions

Balancing Fiscal Responsibility with Legal Obligations

A Strategic Framework for Indiana's ABA Services

Date: September 19, 2025

Authored By: Julie McGill, Family Solutions Home Care LLC

Executive Summary

The ABA Working Group was created to address rising Medicaid costs for Applied Behavior Analysis (ABA). But framing ABA only as an expense misses its role as an essential investment in children’s health, family stability, and Indiana’s long-term economy.

This report is not a critique of the state's intent, but an invitation to reframe the conversation. We can build a system that is both compliant and compassionate, one that prioritizes outcomes over paperwork and recognizes the profound, long-term returns of supporting our most vulnerable citizens.

Introduction

Indiana’s ABA spending is being labeled a “cost problem” when it is, in fact, cost avoidance. Untreated or under-treated autism drives substantial lifetime expenses across education, healthcare, and adult services—plus lost earnings for families. Early, medically necessary intervention flips that equation: it lowers special-education intensity, reduces crisis and residential spending, and keeps parents in the workforce. Delays don’t save money; they shift higher costs to schools, families, and future adult systems.

What Federal Law Actually Requires

Under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, children are entitled to medically necessary care to correct or ameliorate conditions—without hard hour caps or arbitrary duration limits. States must also ensure reasonable promptness and real network access. Indiana’s current posture—re-diagnosis requests, credentialing backlogs, rigid testing cycles, and documentation rules that add burden without adding quality—constrains access in ways that can function as de facto denials.

The Compliance Challenge

A recent federal audit found significant improper payments in Indiana’s Medicaid ABA program. But the state’s fixes have made the situation worse. New policies—service caps, mandatory re-testing, and credentialing slowdowns—conflict with the federal EPSDT mandate, which requires timely, individualized care and real access for children.

These changes did not solve the original problems; they created a structural crisis. Administrative hurdles sideline certified therapists for weeks, while a severe workforce shortage leaves families without services. Children are funneled into inappropriate—and often more expensive—settings because flexible, right-sized options are unavailable. On paper, services are “approved,” but in practice, they are out of reach.

Indiana now faces heightened risk of CMS enforcement, repayment of federal funds, court orders, and long-term loss of provider capacity. The initial audit issues were administrative and fixable; the current risks are systemic, immediate, and legally actionable.

Navigating Critical Challenges

1. Demand is real—and accelerating.
   ASD identification continues to climb, pushing more families into a system that was never sized for today’s volume.

2. One-size-fits-all service models.
   Families are routinely funneled into full-day, 1:1 programs even when a clinically appropriate mix (e.g., 10–20 hours/week, small-group transition, or step-down options) would deliver better fit and value.

3. Access is limited by workforce gaps.
   Too few diagnosticians, BCBAs, and trained technicians—especially outside metro areas—translate approvals into long waitlists, canceled starts, and fragmented continuity.

4. Policy and compliance issues.
   Audit-driven fixes (hard caps, rigid reassessment schedules, unclear documentation rules) prioritize paperwork over clinical judgment, invite de facto denials, and heighten legal exposure under EPSDT.

5. Administration is siphoning capacity.
   Cumulative friction—prior auth churn, narrow tool mandates, and slow, individual rendering enrollment—soaks clinical time, deters provider participation, and delays treatment during the most critical developmental window.

The Path Forward

The question facing Indiana is not whether to invest in these children's futures—federal law makes that investment mandatory. The question is whether to invest wisely, early, and effectively, or to pay far more later for problems that could have been prevented.

This report lays out a practical path to contain costs while improving quality and compliance by building on these principles:

1. Align with Federal Law: Policies that impose arbitrary limits or create de facto denials must be reformed. This means embracing the EPSDT mandate by providing all medically necessary care and eliminating administrative bottlenecks that delay or prevent families from accessing services.

2. Optimize Care, Not Ration It: We must design a tiered system that offers the right level of service at the right time. By making group-based care financially viable, we can free up scarce one-on-one therapy slots for children with the most significant needs, while providing a cost-effective, appropriate "step-down" option for others.

3. Strengthen the Workforce: We must streamline provider enrollment, reduce documentation burdens, and stabilize our workforce. A robust network of qualified professionals is the single greatest asset we have in ensuring that approved care is actually delivered.

4. Fiscal Optimization. Leverage FMAP to maximize federal dollars; reduce downstream special-ed, crisis, and adult-services costs; and stabilize the workforce by unblocking provider enrollment (batching, SLAs, provisional approval) while tightening BCBA oversight where risk is greatest.

This analysis presents a different approach—one that recognizes compliance obligations as opportunities rather than constraints. Indiana can strengthen program integrity while improving access to care. The state can leverage federal funding to build economic capacity while reducing long-term costs. Most importantly, Indiana can ensure that children receive the right services at the right time, maximizing both human potential and return on public investment.

 I. The Importance of Addressing Behavioral Health Needs & Developmental Delays

Rising Prevalence and Urgency of Early Action

Autism and related developmental delays are more common than ever, both in Indiana and nationwide. In the past two decades, the estimated autism prevalence in the U.S. has climbed from about 1 in 150 children to roughly 1 in 36 as of 2020, with more recent data suggesting it could be as high as 1 in 31.  Developmental disabilities are defined more broadly (including autism, ADHD, and others) and affect about 1 in 6 children nationwide[1].

These numbers highlight an urgent reality: Indiana faces a growing wave of children who need intensive support. The central policy question is not whether we pay for these needs, but when and how we pay.

Intervening early—ideally before kindergarten—is paramount. Neuroscience and developmental research show that there is a "critical window" in the early years when intensive intervention can rewire developmental pathways[2] leading to better long-term outcomes and significantly lower costs. Waiting to intervene only magnifies these costs, as untreated needs can escalate into expensive special education, psychiatric care, or long-term residential support. Investing in early intervention is not just a matter of compassion; it is a wise economic choice.

The High Cost of Untreated Autism vs. the Early Intervention

Autism spectrum disorder (ASD) is lifelong. When medically necessary services like Applied Behavior Analysis (ABA) are denied in childhood, the costs do not vanish—they shift into adulthood, where challenges are more severe and far more expensive to manage.  The lifetime cost of supporting an individual with autism and intellectual disability is estimated at $2.4 million in the U. S[3]., or roughly $3.3 million in 2025 dollars[4]. Other studies place the range even higher—$2.5–$4.5 million per person [5] (in 2010)—with about 60% of costs incurred in adulthood, once school-based services end.  Costs span many different sectors: health, education, social care, housing, employment, welfare benefits, and labor markets.

ABA Therapy: An Evidence-Based Medical Necessity

Given these stakes, it is crucial to understand that Applied Behavior Analysis (ABA) is not an optional educational service – it is a medically necessary, evidence-based treatment for children with autism. Decades of research confirm its effectiveness in teaching skills and reducing challenging behaviors.

·         U.S. Surgeon General (1999): “Over 30 years of research demonstrate the efficacy of applied behavioral methods in reducing inappropriate behavior and increasing communication, learning, and appropriate social behavior[6]”.

·         American Academy of Pediatrics (AAP): Endorses ABA as a fundamental evidence-based intervention for autism[7].

·         National Academies of Sciences (NASEM): Identified ABA-based approaches as the most effective interventions for improving outcomes in autism.

Clinical studies show that 25–40 hours of ABA per week in the preschool years can produce transformative results: some children become indistinguishable from their peers by elementary school, often able to attend regular classes without one-on-one aides[8].

Crucially, federal health policy also recognizes ABA as a medical necessity for children with autism. In 2014, CMS issued guidance reminding states that Medicaid must cover autism services for children if medically necessary[9]. Indiana is no exception: its own Medicaid policy explicitly states ABA is covered for children with autism when medically necessary[10]. ABA therapy should be considered a doctor-prescribed medically necessary treatment for autism, just like insulin is for diabetes or an inhaler is for asthma. Without this therapy, a child's developmental potential is diminished, severely limiting their long-term independence.

The Case for Early ABA Investment

Early intervention can prevent hundreds of thousands of dollars in special education expenses, emergency hospitalizations, residential placements, and lost family income. By building independence in childhood, ABA sets the foundation for long-term community participation. That is what makes it one of the most cost-effective interventions available to states: Early intervention is a cost-effective strategy that prevents hundreds of thousands of dollars in long-term expenses. By building independence in childhood, Applied Behavior Analysis (ABA) therapy sets the foundation for long-term community participation and reduces the state's fiscal burden.

• Savings on Special Education: Early ABA can significantly reduce the need for costly educational supports. For example, one Texas study found a savings of $208,500 per child over 18 years of schooling for those who received early intervention[11]. These savings are realized because children who receive ABA are more likely to enter general education classrooms and require fewer special education services.

• Impact of Intervention Age: Early intervention's effectiveness is profoundly linked to a child's age, with each year of delay dramatically reducing outcomes. A study on school inclusion rates, a key metric for independence, shows that successful placement in a regular classroom plummets from 45% for children who start intervention at ages 2-3 to near 0% for those who start at ages 5-6. This highlights how delaying care increases long-term costs and state liability as untreated needs escalate into adulthood.

• Preventing Future Costs: CMS recognizes that early intervention by supporting children in developing communication, social, and daily living skills reduces the risk that untreated conditions will develop into more serious and expensive problems, such as psychiatric hospitalizations or lifelong residential care[12]". Children who are prematurely cut off from ABA can experience skill regression, which leads to higher long-term Medicaid spending[13].

Indiana should view funding early behavioral services not as “spending” but as preventive investment, similar to vaccinations or early health screenings. It lowers lifetime costs, strengthens families, and reduces burdens on state systems later on.

Utilization Trends: Need, Not Misuse

Rising spending reflects growing need and improved access, not misuse.

·         A national study[14] of children with autism on employer-sponsored insurance found:

o Annual spending per child with ASD rose 51% (≈$13,000 → $20,000).

o Nearly all growth came from ABA, which increased 376%.

o The number of children receiving services tripled, reflecting ABA’s acceptance as the clinical standard.

·         Indiana’s surge in Medicaid spending on ABA mirrors a statewide increase in autism identification:

o Medicaid ABA spending rose from $14.4M (2017) to $120M (2019), reaching $639M (2023)[15]. This surge shows families are finally accessing evidence-based therapy. The challenge is not cutting access but sustaining it by investing early—when ABA provides the highest return and greatest long-term savings.

This rise in spending reflects a growing need and greater access to evidence-based therapy—not misuse or overutilization. It highlights a simple truth: families are finally receiving the treatment their children require. The challenge now is to ensure that this investment is sustainable. Early ABA is both medically necessary and the most cost-effective way to reduce long-term burdens. The best way to manage rising costs is not by restricting care, but by investing early—when ABA provides the greatest return.

Oversight Challenges Do Not Undermine ABA’s Value

Families and providers alike benefit when Medicaid dollars are spent correctly and services are delivered efficiently. However, a recent HHS Office of Inspector General (OIG) audit highlighted compliance issues in Indiana’s ABA program. These findings reflect administrative shortcomings, not the effectiveness of the therapy itself. An HHS OIG audit estimated $56 million in improper payments in 2019–2020[16], largely tied to documentation and oversight gaps. This coincided with Indiana’s rapid expansion of ABA, with spending rising from $276 million in 2021 to $639 million in 2023[17]—growth that outpaced the state’s monitoring capacity.

Similar audits in other states have flagged incomplete session notes or unclear provider roles. The lesson is clear: the right response is stronger standards and oversight—not cuts to services. Activities sometimes questioned as “non-therapy” in the audit[18], such as eating meals or toileting, are in fact clinically appropriate interventions when properly documented [19] [20]. Excluding such interventions entirely would undermine the very purpose of ABA.

The Fiscal and Legal Imperative for Indiana

Indiana's obligation to provide ABA therapy is not discretionary; it is a binding legal requirement. By accepting federal Medicaid funds, the state is contractually bound to comply with all federal statutes and regulations. At the core of this agreement is the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) mandate, which requires states to provide all medically necessary services to children without unreasonable delay.

This means Indiana cannot selectively deny or restrict a medically necessary service like ABA therapy without risking federal penalties or litigation. Cutting off early ABA is therefore not just clinically harmful—it is fiscally reckless and legally noncompliant. Investing in early ABA acts as a form of preventative fiscal policy that strengthens families, reduces reliance on high-cost adult services, and ensures more Hoosiers with autism can contribute productively to adulthood.

The state has a clear financial incentive to invest in early ABA and a non-negotiable legal obligation to provide it. This is a matter of both fiscal responsibility and a fundamental commitment to Indiana's most vulnerable citizens.

II. The Federal Legal Framework

Medicaid as a Conditional Federal Grant

Medicaid, established under Title XIX of the Social Security Act, provides medical assistance to low-income individuals and people with disabilities. It is a joint federal–state program: the Centers for Medicare & Medicaid Services (CMS) oversee compliance nationally, while states administer Medicaid through CMS-approved state plans.

By accepting federal Medicaid funds, a state enters into a binding contract to comply with federal statutes and regulations. For Indiana, this means covering and ensuring timely access to all medically necessary services for children, with a sufficient provider network to deliver them.

To remain compliant and protect its federal match (FMAP), Indiana must:

• Payment Integrity: Require providers to maintain documentation supporting claims; undocumented claims are improper and subject to recoupment (42 U.S.C. § 1396a(a)(27); 42 C.F.R. §§ 455.18–455.23).

• FMAP Protection: Claim federal funds only for allowable, documented expenditures; CMS may recoup federal dollars for improper claims (42 U.S.C. § 1396b).

• Private Enforcement: Recognize that families can sue under 42 U.S.C. § 1983 to enforce EPSDT, reasonable promptness, and medical necessity.

• EPSDT Mandate: Provide all medically necessary services for children under 21 (42 U.S.C. § 1396d(r); § 1396a(a)(43)), regardless of adult coverage.

• Medical Necessity: Cover services to “correct or ameliorate” children’s conditions; restrictive adult standards cannot apply (42 U.S.C. § 1396d(r)(5)).

• Reasonable Promptness: Furnish services without undue delay (42 U.S.C. § 1396a(a)(8)).

• Network Adequacy: Maintain enough providers to prevent unreasonable delays (42 C.F.R. § 438.206).

• Free Choice of Provider: Allow members to see any qualified provider willing to deliver care (42 U.S.C. § 1396a(a)(23)).

Failure to meet these requirements can trigger federal enforcement, repayment of funds, corrective action plans, or lawsuits by beneficiaries. Accepting Medicaid funding is therefore not just financial—it is a legal obligation and ethical compact to serve the state’s most vulnerable citizens.

EPSDT: A Non-Optional Mandate

At the center of these obligations is the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Codified at 42 U.S.C. § 1396d(r), EPSDT guarantees that all children under 21 receive any service necessary to “correct or ameliorate” a condition.

This standard is intentionally broad: it covers not only treatment but also maintenance and prevention. CMS reaffirmed this in State Health Official Letter #24-005 (Sept. 26, 2024), explaining that EPSDT includes services that:

• Maintain or improve a child’s current condition (p. 7).

• Prevent a condition from worsening (p. 7).

• Preventing the development of additional health problems (p. 7).

Under this rule, coverage cannot be denied simply because progress is gradual, incremental, or focused on preventing regression.

Federal Prohibition of Hard Limits

Federal law prohibits states from imposing arbitrary service caps for children. Under 42 CFR § 440.230(c)–(d), the “amount, duration, and scope” of services must be sufficient to achieve their purpose, and preset limits are not allowed. EPSDT further requires individualized determinations of medical necessity (42 U.S.C. § 1396a(a)(43); 42 CFR § 441.61(b)). CMS confirmed:

• “While services available to adults may include limits… states are not permitted to apply these kinds of limits to any service covered under EPSDT” and

• Hard caps, such as preset limits on ABA therapy hours, violate EPSDT[21]

For one child, 10 hours of therapy may be enough; another may require 40. If a qualified practitioner prescribes more than a preset limit, the state is legally obligated to provide it. CMS has repeatedly reinforced this principle.

III. The Fundamental Difference: EPSDT vs. FAPE

Children with Autism Spectrum Disorder (ASD) often receive services through both the education and healthcare systems. While both are designed to support children, they operate under distinct legal frameworks and standards, which have critical implications for access to care.

IDEA and the Educational Benefit Standard

Under the Individuals with Disabilities Education Act (IDEA), schools must provide a Free Appropriate Public Education (FAPE) ensuring that a child can learn and make progress in school—focused on academics, social skills, behavior, and preparation for life after graduation[22]. An Individualized Education Program (IEP) may include services such as speech-language, occupational, or physical therapy, but these are provided only to the extent that they support meaningful academic progress.

The Supreme Court in Endrew F. v. Douglas County School District (2017) clarified that schools are not required to maximize a child’s potential, but only to provide services “reasonably calculated to enable the child to make progress appropriate in light of the child’s circumstances, but are not required to maximize potential.

• Focus: Educational benefit and access to learning.

• Scope: Services must support access to and progress in the educational environment.

• Limitations: Services do not address all of a child's behavioral, communication, or medical needs, and support is limited to the school day or year.

Schools provide an important but narrow set of supports. For example, a school may offer limited speech therapy to aid classroom participation, but it does not replace medically necessary therapy a child needs at home or in the community.

Medicaid and the Medical Necessity Standard (EPSDT)

By contrast, the Medicaid program, through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, operates under a broader "medical necessity" standard. It requires coverage of treatments that improve, maintain, or prevent the worsening of a child's physical or mental health condition, regardless of academic impact.  It is focused on functioning and independence across all areas of life.

• Focus: Health, development, and functional independence across all settings.

• Scope: Services must be individualized to the child’s clinical needs, not capped, or limited to what the school provides.

• Obligation: States must provide the “amount, duration, and scope” of services necessary for each child, even if those services are not offered to adults.

EPSDT’s medical necessity standard guarantees care that is comprehensive, continuous, and responsive to a child’s health and developmental needs. It is not limited by the school calendar, academic benchmarks, or educational eligibility rules. This distinction is critical: while schools support learning, Medicaid ensures children receive the medically necessary treatment required to build independence and prevent long-term disability.

Why Schools Cannot Replace Medicaid Services

Getting services at school does not erase the state’s duty to cover medically necessary treatment under EPSDT. Evidence-based guidelines show most children with ASD benefit from 30–40 hours of ABA per week, with 10–25 hours as the minimum for progress[23]. Yet schools may provide only 1–2 hours weekly, narrowly focused on academic benchmarks. Services stop at dismissal, during breaks, and over summer times when regression risk is greatest.

Beyond the service gap, Indiana's schools are simply not equipped or funded to provide the full range of behavioral health treatments that children with ASD require.

Indiana's Special Education Staffing Gap

Indiana schools face severe staffing gaps, with special education consistently one of the hardest-to-fill areas. The U.S. Department of Education has officially listed special education as a statewide shortage area for the 2024–25 school year[24]. This is a persistent and acute problem:

•         In late 2024, Indiana reported more than 1,300 total educator vacancies[25], with 287 open special-education teaching roles on the state’s Educator Job Board[26].

•         By September 2025, the state's Educator Job Board showed 245 open special education teaching roles and a total of 1,164 educator vacancies statewide[27].

The Indiana Department of Education has acknowledged this crisis, launching programs such as I-SEAL. Despite programs like I-SEAL, which aim to accelerate special-education licensure, this persistent staffing crisis severely limits schools’ ability to absorb intensive behavioral health needs[28]. This staffing reality reinforces the need for Medicaid-covered, medically necessary services under EPSDT rather than shifting the burden of care to the education system.

  Financial Burden

The cost of educating students with disabilities is significantly higher than for their peers, straining school budgets that rely heavily on state and local revenue. According to a 2024 national analysis by Bellwether Education Partners, districts spent an average of $13,127 per student on special education, with the majority of that cost falling on local communities. This is a reality reflected in state-level data, such as New Hampshire's 2023–24 school year, where the average cost per pupil with an IEP was $49,812—over $31,093 more than students without IEPs[29].

The federal government, through the Individuals with Disabilities Education Act (IDEA), only provides a fraction of the funding needed to meet these costs, leaving schools to divert general education dollars to cover the shortfall. Forcing schools to absorb additional Medicaid-level healthcare costs would stretch these limited funds far beyond their intended purpose, making a sustainable policy impossible.

The Funding Structure Problem

Healthcare (EPSDT) and education (FAPE) differ not only in purpose—medical necessity versus academic progress—but also in how they are funded. When Medicaid fails to provide medically necessary services, the costs often shift onto schools. Because schools rely primarily on state and local dollars and already face staffing and budget shortfalls, this shift results in unmet medical needs, compromised educational quality, and long-term harm to children and families.

Medicaid: A Federal–State Partnership

• Structure: Medicaid is a leveraged funding mechanism designed as a joint federal–state program to sustainably finance intensive healthcare. For every state dollar spent, the federal government contributes additional funds through the Federal Medical Assistance Percentage (FMAP).

• FMAP Formula: Federal law sets FMAP between 50% and 83% depending on state per-capita income (Social Security Act § 1905(b)).

  • Example: If Indiana’s FMAP is 65%, the federal government pays 65 cents of every Medicaid dollar, while Indiana pays 35 cents.

• Indiana’s Share: Indiana’s FMAP has consistently been in the mid-60% range, meaning the federal government covers nearly two-thirds of costs[30].

School Funding: Primarily Local

• Structure: Indiana’s K–12 schools are funded mainly through state income and sales taxes plus local property taxes. School funding depends heavily on local tax capacity and restricted state aid, making it structurally unsuited to absorb the cost of clinical healthcare.

• Federal Role: Federal dollars accounted for just 13% of total school funding in 2021–22[31]. Federal contributions vary widely: as low as 1.4% in some districts and as high as 32% in others, depending on local wealth and eligibility for targeted programs.

• Restrictions: Federal aid is often limited to narrow purposes. For example, the Individuals with Disabilities Education Act (IDEA) authorizes reimbursement of up to 40% of excess special education costs. Yet Congress has never fully funded IDEA, leaving state and local governments to absorb the shortfall[32]

The Inevitable Trade-offs

Schools were built and funded to educate, not to deliver clinical interventions at medical intensity. Federal law recognizes this distinction: EPSDT requires states to cover medically necessary healthcare precisely because schools cannot fill that role.

When Medicaid denies or restricts services, the trade-offs are immediate:

• Larger class sizes.

• Fewer special education teachers.

• Reduced programming for all students.

• Greater regression for children with ASD.

Examples

• A school may provide speech therapy to aid classroom participation, but Medicaid must cover therapy needed for communication at home and in the community.

• A school may decline intensive ABA if a child is making minimal academic progress, but Medicaid must cover it if clinically necessary to “correct or ameliorate” developmental challenges.

Medicaid and schools serve different purposes, funded through different systems. For children with autism, Medicaid must ensure access to medically necessary treatment, while schools focus on education. One cannot substitute for the other.

IV. State's Obligation for Actual Access

Under federal law, a state's obligation for providing Medicaid services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit goes far beyond simply having a service on the books. The mandate requires states to ensure actual access to comprehensive, medically necessary care for all children under the age of 21.

This obligation is a cornerstone of the Medicaid program and is based on the principle that children's health problems should be addressed as early as possible, before they become more serious and costly.

There are 4 core components of a state's obligation for actual access under EPSDT:

1. The "Correct or Ameliorate" Standard

EPSDT requires states to provide "necessary health care, diagnostic services, treatment, and other measures... to correct or ameliorate defects and physical and mental illnesses and conditions."

• Broad Comprehensive Coverage: This standard is broader than the one for adults. Medicaid must cover all medically necessary services for children, even if the service isn’t typically provided to adults. Services must be sufficient in amount, duration, and scope to meet the child’s needs.

  • Service Scope (42 C.F.R. § 441.50–.62): States cannot arbitrarily limit amount, duration, or scope if more is clinically necessary.

• Habilitative Services: The "ameliorate" clause is particularly important for children with developmental disabilities, as it requires coverage for services that may not cure a condition but can help the child acquire, maintain, or improve skills and functional capacity. This includes services like Applied Behavior Analysis (ABA) and other rehabilitative therapies.

2. Timely and Unobstructed Care

States must not only cover services but also ensure that children can actually get them in a timely manner.

• Reasonable Promptness (42 U.S.C. § 1396a(a)(8)): Services must be delivered in a timely manner.  This includes making necessary referrals without delay and following up to ensure the child receives a complete diagnostic evaluation and treatment.

• Actual access: A service is not truly available if children cannot get it due to system barriers, even if it is technically covered.  Services are functionally denied when families face waitlists of months, lack of nearby providers, or burdens like repeated re-diagnosis.

Examples of barriers that violate this obligation:

• • Long waitlists at providers.

  • Lack of qualified providers in rural or underserved areas.

  • Administrative delays requiring redundant evaluations.

  • Travel or transportation issues without reasonable support.

3. Effective Outreach and Provider Network

The state has an affirmative obligation to both inform families about the EPSDT benefit and ensure an adequate network of providers—including medical, dental, behavioral health, and other necessary services—so that all children can actually access care. This obligation is grounded in 42 U.S.C. § 1396a(a)(30)(A) and 42 C.F.R. § 438.206.

Key Responsibilities:

• Informing Families: States must effectively inform all Medicaid-eligible children and their families about the availability of EPSDT, including the full scope of services and how to obtain them. This must be done in a way that is accessible to people who are blind, deaf, or who do not speak English.

• Facilitating Access: States must use outreach, referrals, and care coordination to help families navigate the system and receive services without unnecessary hurdles.

• Monitoring Access: States must actively monitor wait times, service availability, and network adequacy to prevent delays and ensure timely care.

• Provider Sufficiency: States are responsible for maintaining adequate provider networks and ensuring that managed care plans do not erect administrative barriers that functionally block care.

Examples of such barriers include:

• • Duplicative or unnecessary diagnostic paperwork

  • Excessive prior authorization requirements

  • Delays in provider enrollment

  • Low reimbursement rates leading to provider shortages.

• Payment and Provider Participation: Reimbursement rates must be sufficient to attract and retain providers, ensuring that Medicaid children have access comparable to the general population. Inadequate rates that make services practically unavailable constitute noncompliance with federal law.

States must do more than list services as “covered.” They are legally required to guarantee access in practice, remove administrative barriers, maintain sufficient providers, and ensure families are informed; failure to do so risks EPSDT violations, CMS enforcement, and legal liability.

4. De Facto Denials: Key Points for Compliance

A service that is technically “approved” but cannot be accessed in practice constitutes a de facto denial, which federal law explicitly prohibits under EPSDT. Under 42 U.S.C. § 1396d(r), states are required to provide all medically necessary services to correct or ameliorate children’s physical and mental conditions. Simply listing a service in policy or approving it on paper does not satisfy this obligation.

CMS guidance confirms that services approved but inaccessible due to provider shortages, low reimbursement rates, excessive waitlists, or administrative hurdles violate the EPSDT mandate. States cannot satisfy their federal obligations merely by maintaining policies that appear compliant while allowing systemic barriers to block actual care delivery.

Indiana’s ABA Policy: A Case Study in EPSDT Risk

Indiana’s February 2025 Medicaid policy for ABA therapy illustrates these challenges. The state introduced a tiered coverage model by ASD severity and a 36-month lifetime cap on comprehensive therapy. While intended to manage costs, the policy ties therapy hours and total duration to administrative rules rather than the child’s individual clinical needs. EPSDT requires coverage based on medical necessity, sufficient in scope, duration, and amount to correct or ameliorate conditions. Arbitrary hour limits and lifetime caps risk denying children the therapy needed for meaningful developmental progress, creating functional barriers to care and resulting in de facto denials. Cost containment alone cannot justify restricting medically necessary services under EPSDT.

Court Precedents Supporting EPSDT Enforcement & Legal Risk

The legal risk to Indiana is substantial. EPSDT lawsuits, typically brought under 42 U.S.C. § 1983, can compel comprehensive, system-wide reforms through federal court oversight. Outcomes of such cases often include:

·         Mandatory system reforms enforced through court-approved consent decrees.

·         Ongoing judicial oversight to ensure state compliance.

·         Significant legal costs from protracted litigation

·         Potential federal funding sanctions for continued non-compliance

Multiple court decisions confirm that children have enforceable rights to medically necessary services, and that arbitrary limits or administrative obstacles can violate EPSDT. These precedents define states’ obligations and clarify what constitutes a functional denial of care:

·         Foundational Principles of EPSDT Enforcement: These cases establish the core legal framework for a state’s obligation under EPSDT.

o Collins v. Hamilton, 287 F.3d 482 (6th Cir. 2003): This case established that EPSDT provisions create enforceable rights for beneficiaries under federal law (42 U.S.C. § 1983).

o John B. v. Menke, 176 F. Supp. 2d 1017 (M.D. Tenn. 2001): Reaffirms that children have an enforceable right to medically necessary EPSDT services and that states must provide actual access, not just coverage on paper.

·         Access-to-Care Violations: These cases define what constitutes a failure to ensure adequate access to care, often due to systemic issues.

o Arkansas Medical Society v. Reynolds, 28 F.3d 750 (8th Cir. 1993): Found that a state's low reimbursement rates that cause provider shortages violate the federal access-to-care requirement.

o M.J. v. District of Columbia, 401 F. Supp. 3d 1 (D.D.C. 2019): Reiterates that states must ensure actual access to services, not merely "on-paper" coverage.

o S.D. ex rel. Dickson v. Hood, 391 F.3d 581 (5th Cir. 2004): Held that delays and administrative hurdles that block medically necessary services violate EPSDT rights.

·         Violations from Administrative Obstacles and Service Limits: These precedents specifically address how administrative actions and policies can create illegal de facto denials.

o Miller v. Whitburn, 10 F.3d 1315 (7th Cir. 1993): Ruled that states must provide timely access to services; procedural obstacles that prevent children from receiving care can constitute de facto denials.

o Westside Mothers v. Haveman, 289 F.3d 852 (6th Cir. 2002): Found that arbitrary therapy caps that ignore individualized needs violate EPSDT, as children must receive services determined by their clinicians.

o Ekloff v. Rodgers (D. Ariz. 2006): Struck down blanket therapy caps, emphasizing that EPSDT guarantees individualized determinations of medical necessity.

o R.C. v. State of Oregon, 166 F. Supp. 3d 1210 (D. Or. 2016): Confirmed that administrative delays and barriers can amount to de facto denials.

o Rosie D. v. Romney, 410 F. Supp. 2d 18 (D. Mass. 2006): Held that a state's policy limiting ABA therapy and other intensive services for children with autism violated EPSDT.

o Moore v. Reese, 637 F.3d 1220 (11th Cir. 2011): Ruled that arbitrary reductions in medically necessary services violate EPSDT and require an impartial review process.

o Katie A. v. Bonta, 481 F.3d 1150 (9th Cir. 2007): Emphasized that states must ensure timely access to all medically necessary services, including behavioral health, and that delays are a violation.

·         The Reality of Service Delivery: This case provides a powerful real-world example of how a state's failure to ensure practical access can lead to severe consequences.

o    O.B. v. Norwood, No. 16-2049 (7th Cir. 2016): The court affirmed that a state must ensure the actual provision of services, not just authorization, after a ventilator-dependent child, approved for home nursing, was kept in the hospital for nearly a year due to the state's failure to ensure the care could be delivered.

These cases highlight that the state's failure to provide EPSDT-mandated services is not merely a policy dispute; it is a violation of federal law that can be challenged in court. These lawsuits, often brought under 42 U.S.C. § 1983, can compel the state to change its entire system of care.

More fundamentally, the current system exposes Indiana to the moral and legal failure of denying medically necessary care to children with autism during their most critical developmental window—precisely what EPSDT was designed to prevent.

5. Oversight and Reporting

CMS is not a silent partner in this process. They are actively involved in monitoring states to ensure children actually receive EPSDT services[33]. Federal law requires more than coverage—states to make medically necessary care accessible in practice, and CMS holds them accountable.

CMS Mechanisms of Oversight:

1.   State Plan Review: CMS reviews every state Medicaid plan, including how children will access care, reimbursement rates, provider networks, and administrative processes. Approval alone is not enough; CMS expects active enforcement and monitoring.

2.   Program Monitoring: Both fee-for-service and managed care programs are scrutinized. CMS examines provider availability, wait times, geographic access, and timely authorizations, ensuring that services are not just approved on paper but actually delivered.

3.   Quality Measurement and Reporting: States must report annually (CMS-416) on screenings, treatments, and access to specialty services[34]. CMS uses audits, data analysis, and site visits to identify gaps or delays.

4.   Corrective Action and Enforcement: When states fail to meet requirements—due to delays, workforce shortages, or administrative barriers—CMS can demand Corrective Action Plans. Persistent noncompliance can trigger financial penalties, reduced federal funding, or other enforcement actions.

The Centers for Medicare and Medicaid Services (CMS) provides rigorous and continuous oversight of state healthcare programs. The state’s role is active, not passive. Indiana is legally required to ensure that children on Medicaid receive comprehensive care, not just that it is available on paper.

The choice is clear: continue a system that violates federal law and forfeits resources, or fulfill EPSDT obligations, strengthen Indiana’s healthcare infrastructure, and ensure children with autism can access the care they need, when they need it.

 V. Beyond Current or Future Cost-Cutting Narrative – Examine the Economic Benefits

Medicaid is not simply a budget line item; it is a federal-state partnership that multiplies Indiana's healthcare investment and drives economic activity statewide. Every state dollar invested in Medicaid draws down additional federal funding at Indiana’s Federal Medical Assistance Percentage (FMAP) rate, multiplying the impact of state spending. This leveraged funding creates a powerful economic multiplier effect.

The Multiplier Effect: A Fiscal Reality

For Fiscal Year 2025, Indiana's Federal Medical Assistance Percentage (FMAP) is 64.9%[35], This means that for every $1 Indiana invests, the federal government contributes nearly $2, effectively tripling the state’s healthcare spending power. The impact extends far beyond healthcare:

·         Economic Activity: Research shows that each $1 of federal Medicaid assistance generates up to $1.50 in total economic activity[36].

• Job Creation: Studies show each additional $100,000 in federal Medicaid aid creates approximately fifteen jobs over five years, at a cost of roughly $33,000 per job-year[37].

•  The Cost of Cuts: Cutting just $10 million in state Medicaid funding does not only remove Indiana’s $10 million plus the federal match (≈$28.5 million total). Once the ripple effects are considered, it can shrink statewide economic output by tens of millions more.

The American Hospital Association estimates that for every $1 billion reduction in Medicaid spending, Indiana would lose 1,573 hospital jobs, 14,191 total jobs statewide, $1.7 billion in economic activity, and $40.8 million in tax revenue. Cuts to Medicaid ripple through every sector of the state’s economy[38].

How Medicaid Dollars Circulate

Medicaid is a proven economic driver for Indiana families and communities. Dollars invested through the Indiana Health Coverage Programs (IHCP) circulate through our state’s healthcare system and into local communities, producing economic benefits that extend far beyond the initial services. Economists call this the multiplier effect: one dollar of Medicaid spending generates more than one dollar of total economic activity as it is spent and re-spent across the economy through a three-step cycle:

1. Direct Spending: Wages for professionals and staff, as well as payments to clinics for rent and supplies.

2. Indirect Spending: Providers purchasing goods and services from other local businesses.

3. Induced Spending: Individuals employed by Medicaid-funded jobs spending their wages in the community.

This cycle makes Medicaid one of the state’s most reliable job engines. Cutting Medicaid funding does not just reduce care access—it forfeits federal dollars, eliminates jobs, and weakens the state's economy.

FMAP During Economic Downturns

Congress has historically increased FMAP during recessions—such as the 6.2-point boost during COVID-19, which raised Indiana’s federal share to over 71%. According to the Congressional Research Service, these increases helped states avoid damaging Medicaid cuts and had a “statistically robust positive effect on employment.[39]” A federal report on higher HCBS payment rates acknowledged their broader economic impact and cautioned that rolling back these temporary increases too quickly could trigger renewed provider instability, higher staff turnover, and reduced access once the public health emergency ends[40].

Cutting Medicaid does not just reduce care access—it forfeits federal dollars, eliminates jobs, and weakens Indiana’s economy. By contrast, maintaining or expanding Medicaid investment leverages federal funds, strengthens the healthcare workforce, and stimulates growth in communities statewide.

Opportunity Costs for Families and Society

Income losses tied to autism are not one-time shocks; they compound over years, eroding household savings, constraining career progression, and increasing reliance on public supports. The aggregate effect is lower productivity and reduced economic activity across communities.

Best-available estimates place the lifetime societal cost per person with autism near $3.2 million, divided among direct medical (~10%), direct nonmedical (~31%), and indirect (productivity) costs (~59%) [41].  Within the indirect category, losses are borne both by the autistic individual (≈$971,072) and by parents/caregivers (≈$904,595). In other words, the single largest share of economic burden stems from lost productivity across the lifespan.

These opportunity costs manifest in multiple ways:

• Parental earnings losses. Across childhood (ages 2–21), parents forgo an estimated $148,000–$253,000 in earnings[42].  Mothers of autistic children, in particular, earn ~35–56% less per year (≈$14,755 in the original estimate) and are more likely to exit the labor force; one study found 37.6% of mothers stopped working versus 12.1% among parents of children with asthma[43].

• Adult productivity gaps. Employment rates for adults on the spectrum remain low (≈53–61%), leaving substantial workforce potential untapped[44]. Combining caregiver and individual losses yields a lifetime opportunity cost ≈$2.1 million per person, including forgone wages, reduced tax revenue, and higher public spending[45].

High-cost service drivers across the lifespan

When early supports are delayed or unavailable, costs shift into later, more expensive services:

• Psychiatric care: ≈$2,033/day[46] and $20,000+ per hospitalization[47].

• Group homes: ≈$65,000–$120,000/year[48].

• Day services: ≈$25,000–$35,000/year for ~8 hours/day programming[49].

• Residential/supported living: up to $200,000/year in some settings[50].

• HCBS for IDD: $51,000–$70,000/year on average (service-intensity dependent) [51].

• Ongoing personal care and transportation: cumulative costs in the hundreds of thousands over a lifetime.

These represent the opportunity costs of foregone work time, reduced labor force participation, or lower-paying jobs taken to accommodate care needs.

ABA as Workforce Infrastructure

Applied Behavior Analysis (ABA) is more than a healthcare service—it is also workforce infrastructure. Reliable access to ABA allows parents, especially mothers, to remain employed, keep households financially stable, and contribute to Indiana’s economy. When ABA is cut or delayed, families face a double loss: reduced household income and diminished tax revenue for the state. Applied Behavior Analysis (ABA) is not only a clinical service, but also workforce infrastructure. Reliable access to ABA enables parents (disproportionately mothers) to stay employed, maintain household stability, and contribute to the state’s tax base. When ABA is cut or delayed, families absorb a double loss: lower earnings and diminished tax revenues.

Well-documented labor-market impacts include:

• Reduced work hours: Parents of children with autism work an average of seven fewer hours per week than other parents[52].

• Lower maternal employment: Mothers of children with autism are 6% less likely to be employed than their peers[53].

• Lower income: Mothers earn ~56% less/year (≈$14,755 in the original estimate), and household income is lower by ≈$17,800/year versus families without special health needs [54].

• Labor-force exit: 37.6% of mothers reported stopping work altogether (vs. 12.1% of comparison parents) [55].

These pressures reconfigure entire family financial strategies: relocating for services, accepting lower-paying (but flexible) jobs, declining promotions, drawing down savings/retirement, or shifting to part-time work. The cumulative effect is persistently lower lifetime earnings, reduced wealth accumulation, and a narrowed state tax base.

By contrast, early and sustained support allows parents to remain employed, helps children gain skills for independence, and allows parents to remain in the workforce. This strengthens Indiana’s economy by sustaining tax contributions from both parents and, later, from more independent adults with autism.

Return on Investment: Why Early Intervention Pays

Long-term outcomes are strongly tied to communication ability. Fewer than 20% of autistic adults achieve independent living overall; among those with the highest conversational skills, ~45% lived independently, compared with 0% among those with the lowest skills—underscoring the importance of early interventions that build communication[56].

ABA changes the cost curve by building communication, adaptive, and daily living skills during a time of maximal neuroplasticity. The result is lower special-education intensity, reduced crisis utilization, and less reliance on high-cost adult services.

• Upfront investment: Intensive early ABA has been estimated at ≈$83,119 over four years[57].

• Downstream savings: Economic analyses estimate $656,000–$1.3 million in lifetime savings per child, with potential two-thirds reductions in total lifetime costs when intervention is timely and effective[58],[59].

• ROI range: Estimated $1.80–$17.07 returned per $1 invested in early intervention, reflecting avoided special-education, healthcare, and long-term care costs[60].

This investment also has a significant societal impact. As individuals with autism become more independent and productive, they are more likely to gain employment and contribute to the tax base. This shift from a state-supported model to a self-sufficient one benefits everyone, making early intervention not just a compassionate choice, but a fiscally responsible one.

Economic Reality: Investment vs. Cost-Shifting

The financial burden of autism can be immense over a person’s lifetime, but early and sustained ABA therapy offers a significant return on investment by helping children develop skills for greater independence. While the upfront costs of intensive therapy are substantial, they are offset by the avoidance of far greater expenses later in life.

Cutting Medicaid does not create true savings. It shifts costs onto families, schools, and communities while forfeiting federal dollars that strengthens Indiana’s economy. By contrast, maintaining robust Medicaid services like ABA under EPSDT fulfills federal obligations and reduces long-term public spending.

Protecting ABA is therefore not only sound health policy, but it is also sound economic policy. It sustains families, expands workforce participation, and safeguards Indiana’s long-term fiscal health.

VI. Systemic Pressures & Solutions

Medicaid is a powerful tool—but only when funds are used appropriately and Indiana upholds its federal obligations to maintain the match. One core duty is to ensure program integrity through clear rules, timely reviews, and effective oversight. The OIG audit of Indiana's Medicaid ABA program made found nearly all ABA session notes were wrong or unreliable—missing detail, billing non-therapy time, or misclassifying activities making it clear that the state's failures were systemic, not isolated incidents. As program spending surged from $14.4 million in 2017 to $101.8 million in 2020, key oversight failures included a lack of statewide post-payment review, minimal provider guidance, and weak contractor oversight[61]. These gaps allowed improper practices to spread because the state never built in the guardrails to catch problems early.

However, Indiana’s administrative fixes have introduced a series of systemic barriers that delay care, reduce access, and undermine compliance with federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements. These administrative hurdles combined with the existing systemic problems have worsen the state’s compliance.

A Smarter System: Leveraging Data and Education

1. Use Analytics to Identify Risk Factors

A data-driven approach allows the state to pinpoint potential issues by flagging outliers and non-compliant behaviors.

·         Implement a Provider Risk Score: The state should develop a quarterly provider risk score to identify and prioritize which providers to audit. This score would be based on a range of data points, ensuring oversight resources are focused on the highest-risk areas.

• • Billing Patterns: The analytics system should track and flag billing patterns that deviate from clinical norms. These include:

§  High Hours: Providers with a significantly higher-than-average number of hours per child per week compared to their peers.

§  Continuous Sessions: A high number of continuous 8-hour sessions without breaks, which may indicate a lack of therapeutic intensity or a "childcare" function.

§  Overlapping Billing Times: Instances where the same provider bills for services to multiple children at the exact same time.

• • Operational Flags: The system should also monitor operational data that may signal underlying problems:

§  High Turnover: A high rate of Registered Behavior Technician (RBT) turnover or frequent changes in the supervising Board-Certified Behavior Analyst (BCBA) on claims, which can compromise continuity of care.

§  Missing Supervisor: Claims submitted without the supervising BCBA's information, a key compliance requirement.

§  Repeated Provisional Claims: A high volume of claims with a "provisional" modifier (as proposed in the framework) beyond a specified window, indicating potential credentialing issues.

• • History and Compliance: A provider's past audit history should factor into their risk score. This includes whether they have had prior educational interventions, corrective action plans (CAPs) in the last 12 months, or a history of recoupments.

2. Key Documentation for Review

For effective post-payment review, auditors should focus on a core set of documents that provide a complete record of care. This ensures services are medically necessary, properly delivered, and compliant.

• Treatment Plan: Verify the billed services align with the goals and interventions in the most recent treatment plan.

• Progress Summary: Confirm the child is making progress or that services are preventing regression.

• Daily Notes: Check a sample for start/stop times, child response, and data collection to verify session duration and purpose.

• Supervision Logs: Ensure Registered Behavior Technicians (RBTs) are receiving the required oversight from a Board-Certified Behavior Analyst (BCBA).

• Staff Credentials: Verify all staff were appropriately credentialed and within their scope of practice for the dates of service.

• Prior Authorization: Confirm services billed were authorized for the specific dates.

• Assessments: Ensure the most recent assessments used to justify medical necessity are on file.

3. Educate, Correct, and Escalate

The purpose of the audit is not to deny care but to improve the quality of care and compliance. Audits should follow a tiered response system to ensure appropriate action is taken.

• Tier 1: Educational Issues (Fix Forward): For minor, non-willful documentation errors (e.g., missing a signature, an incomplete note), the state should issue an educational notice or a Corrective Action Plan (CAP). The provider is instructed on how to correct the issue for future claims, and no recoupment is sought for the specific claim. The goal is to prevent the same mistake from recurring.

• Tier 2: Recoverable Payments (Claim-Level Recoupment): For more significant, but not fraudulent, errors (e.g., billing for non-billable time like a break, providing services without proper documentation), the state should seek to recover the funds for the specific claims identified. These are honest mistakes that need to be corrected through recoupment.

• Tier 3: Escalation (Pattern of Intent): For patterns of clear fraud, waste, or abuse (e.g., cloned notes, billing for services never rendered, intentional misrepresentation), the case should be escalated to the Program Integrity (PI) unit for further investigation and potential referral for civil or criminal action.

4. The Role of Education and Transparency

To make this model effective, the state must partner with providers, not just police them.

• Publish a concise “ABA Documentation Toolkit” that includes:

  • Transparent, clinically sound guidelines for what constitutes medical necessity and progress, rather than relying on vague phrases like “substantive progress.”

• • A billable vs. non-billable time chart (meals, naps, recess, travel = not billable unless intervention is actively delivered and documented).

  • One-page example notes for each major CPT code (97151, 97153, 97155, 97156, 97154), showing the expected level of detail and how to subtract non-therapy time.

  • Signature and e-signature examples that meet Indiana’s legal requirements.

• Launch Quarterly "Show-Your-Notes" Office Hours: The state should host regular, voluntary sessions where providers can submit anonymized notes for review. This creates a safe space for learning and helps the state understand common pain points in documentation.

• Co-design note templates with a provider–family advisory group and publish:

  • A plain-language FAQ (“What counts as billable ABA time?”).

  • A 10-minute micro-course for staff on documentation dos and don’ts.
    (Matches OIG’s emphasis on clear guidance, limits provider confusion, and minimizes care interruptions.)

• Reform the Audit Documentation Deadline: Instead of a rigid 72-hour turnaround[62]., the state should implement a tiered system: 72 hours to acknowledge a request, 7–14 days for recent or electronically stored records, and up to 30 days for archived documents. This is a practical solution that aligns deadlines with the actual time needed to retrieve records, preventing unnecessary stress and non-compliance.

• Stakeholder Communication Protocol: Implement a protocol for regular, transparent updates to families, providers, and advocacy organizations on progress and issue resolution.

• Independent Quality Assurance: Establish an external review board with family representatives, clinical experts, and disability advocates to provide unbiased oversight.

Why Post-payment Review Works

This approach improves quality and integrity without creating delays or denials over paperwork.

• Keeps Access Open: Families don't face delays or denials. Services continue while documentation is corrected.

• Targets Real Risks: By reviewing actual session notes, the state can identify widespread problems and address them directly.

• Deters Abuse: Providers know that claims will be checked, which discourages inflated billing or sloppy record-keeping.

• Follows OIG Guidance: This model directly addresses the OIG's explicit recommendation for statewide post-payment reviews and better documentation guidance.

Because the state did not build in systematic verification, guidance, or contractor monitoring, OIG concluded that Indiana failed to provide effective oversight of its Medicaid ABA program.  Still, these findings should not be used to condemn Medicaid spending itself—because across Indiana, Medicaid remains a vital investment that sustains providers, supports families, and strengthens the workforce.

The real takeaway from the OIG’s improper payment report is that documentation quality—not fraud or misuse—was the single largest driver of errors. Addressing this means focusing on practical fixes that close documentation gaps, improve clarity for providers, and build an oversight system that strengthens accountability without limiting access to care.

The ABA Provider Crisis: A Barrier to Maximum Return on Investment

Indiana’s challenge is not just meeting CMS compliance or deciding how much to spend—it is ensuring there are enough qualified professionals to diagnose and deliver services, so that approvals don’t turn into de facto denials.

Early intervention cannot generate economic returns for the state if families cannot access services. The shortage of Board-Certified Behavior Analysts (BCBAs) is the single greatest threat to capturing the fiscal and workforce benefits of early intervention.

Early ABA generates 167%–333% returns on investment, but too few providers are available to deliver therapy during the critical early years when interventions are most effective and cost-saving.

Delays in Diagnosis & Treatment

Autism can be diagnosed as early as 18–24 months, many Indiana families do not get a diagnosis until age 4 or later[63]. These delays are not due to parents overlooking signs—research consistently shows that parents often recognize developmental concerns before their child’s first birthday[64]. The reasons are systemic and reflect specific barriers in Indiana’s health care and Medicaid systems.

Evaluation Process Barriers

Obtaining an autism diagnosis requires a comprehensive multi-visit evaluation process that has become a significant barrier to timely care. Specialists report that completing a single diagnostic evaluation typically consumes 3-8 hours per child, with much of this time devoted to documentation rather than direct clinical work[65]. A survey of autism specialists found that 54% cited the time required for report writing and payer documentation as a significant barrier, while 37% identified the evaluation process itself as problematic[66].

Comprehensive assessments for toddlers typically span multiple visits, standardized tools, and long, formal reports that are required by payers. Leading clinical guidance and reviews note that these models are time- and cost-intensive, which slows throughput and contributes to backlogs—especially in regions with few specialists. After testing concludes, families frequently wait weeks for final written reports before services can begin, further delaying critical intervention[67].

Diagnosing Specialist Shortage

Indiana faces a critical shortage of qualified professionals for autism evaluations; a problem rooted in a national workforce crisis.

The state’s capacity to meet the rising demand for services is fundamentally broken. A 2023 national study found only 1.0 developmental-behavioral pediatrician (DBP) subspecialist per 100,000 children in the U.S., a workforce described as "markedly inadequate" for current and future needs[68]. The consequences for Indiana families are severe:

• Staggering Wait Times: Families in the United States face significant delays in accessing autism evaluations. Some major diagnostic centers in Indiana have waitlists stretching 12 months[69]. On average nationwide, wait times at specialty centers for comprehensive diagnostic evaluations often exceed four months, with nearly half of those centers not accepting Medicaid[70].

• Loss of Position on a List: When a diagnostician leaves, the waitlist they managed is often disbanded. Families don't just move down the list; they lose their place entirely and must find a new clinic and a new waitlist.

• Rural Disadvantage: The distribution of DBPs is highly unequal, with specialists concentrated in urban areas. This leaves rural Indiana with "DBP deserts," forcing families to travel for hours to reach the nearest qualified provider.

• Medicaid Acceptance Barriers: In a national survey, 30% of specialists cited inadequate Medicaid reimbursement as a major obstacle to care[71]. When rates do not cover the cost of lengthy autism evaluations, many providers limit or stop accepting Medicaid patients shrinking the pool of providers. A nationwide audit showed that 66% of callers with Medicaid/CHIP were denied a specialty clinic appointment, compared to just 11% of privately insured callers[72].

• Unnecessary Re-Diagnosis: Indiana Medicaid often requests updated evaluations for continued service eligibility, even though autism is lifelong. This consumes valuable provider time, worsening waitlists.

The combination of an insufficient workforce, systemic barriers, and an antiquated reimbursement model has created an access crisis that delays care for Indiana's children and places an undue burden on families.

Added Barriers for Rural and Low-Income Families

The systemic delays and shortages disproportionately fall hardest on the families with the fewest resources, turning an already difficult process into an almost insurmountable one. In rural counties, where providers may not exist at all, families must travel for hours for multiple appointments. For hourly workers without paid leave, time away from work means lost income, while arranging childcare for siblings adds more costs and stress.

Documentation Failures & Downstream Policy Reactions

The OIG audit highlighted a critical problem: many children were receiving ABA without a proper, independent diagnostic evaluation or referral. In response, some medical reviewers have begun over-correcting by requiring updated diagnoses — even though autism is a lifelong condition that does not “expire.”

This practice has created unnecessary bottlenecks, delaying access to therapy and straining the limited pool of qualified diagnosticians. A true autism evaluation is not a quick check-box exercise. It requires taking a detailed developmental history, administering standardized tests and direct observations, and providing follow-up with individualized recommendations and resources. Completing this process often takes 3–8 hours[73]  spread across multiple visits. Requiring families to repeat it without clinical justification wastes resources and delays care.

The OIG audit found that 95% of sampled cases had documentation problems, often with multiple deficiencies layered together[74]. The audit found that 61–98 percent of sampled cases included session notes documenting activities that do not qualify as ABA. Providers routinely billed for time spent on meals, naps, recess, or recreational and academic activities without demonstrating how these were tied to treatment goals. In some cases, group activities were billed as one-to-one therapy.

This problem stemmed from vague requirements: Indiana required providers to include a “detailed statement of services,” but never defined what that entailed. Without clear standards or consistent oversight, providers developed their own interpretations of billable ABA. The absence of statewide post-payment reviews during the audit period allowed these practices to spread unchecked.

Provider Enrollment Delays for RBTs

The audit found that 26 percent of sampled cases involved uncredentialed staff delivering ABA services[75]. Rather than addressing supervision gaps or clarifying scope of practice, Indiana responded by requiring every Registered Behavior Technician (RBT) to be individually enrolled and credentialed before they can provide billable services[76].

Enrollment is not a simple verification step. It requires each RBT or BCaBA to undergo the same rigorous process as independent practitioners, including fingerprint-based background checks and obtaining a National Provider Identifier (NPI). While intended to strengthen oversight, this approach is disproportionate to the entry-level responsibilities of these positions and creates significant administrative hurdles. Smaller and rural providers lack the infrastructure to absorb these requirements, which discourages participation and weakens the workforce pipeline.

The unintended consequences are substantial:

• Lengthy processing times: Enrollment through Gainwell frequently takes six or more weeks. During this period, RBTs cannot bill, meaning children cannot receive services from them even when supervising BCBA is ready to oversee treatment.

• High turnover risk: RBTs are entry-level staff with modest wages. Long waits to become “billable” discourage them from staying, leading to high turnover. Providers invest in recruitment and training only to lose staff before they ever work with a child.

• Reduced provider capacity: Agencies hesitate to hire new RBTs because of the administrative delays, further shrinking the statewide provider network. Smaller agencies are hit hardest, as they cannot absorb the financial risk of waiting weeks for staff to become active.

• Service gaps for families: Families are left waiting for therapy to begin, despite having both a diagnosis and a treatment plan. These delays conflict directly with Medicaid’s EPSDT requirement to provide timely, medically necessary services to children.

In practice, this policy functions less as a safeguard and more as a bureaucratic bottleneck. Instead of improving accountability, it reduces provider capacity, accelerates workforce turnover, and delays services for children during critical developmental windows.

Problems with Required Assessments

The audit found that 22 percent of sampled cases lacked valid diagnostic evaluations or treatment referrals, meaning children were receiving ABA without meeting the state’s own eligibility rules. Instead of addressing this gap through clearer standards or stronger enforcement, Indiana imposed a rigid reassessment system that creates new problems without solving the old ones.

Another change triggered by the OIG audit is Indiana's new prior authorization process that mandates the use of three specific standardized assessments—the Vineland Adaptive Behavior Scales, the BASC Parent Rating Questionnaire, and a direct skills tool—every six months. This rigid, one-size-fits-all mandate has eliminated professional discretion[77].  

This mandate is both costly and more restrictive than the professional standard[78].  The mandate's primary issues are:

• Misaligned with Clinical Best Practices: These assessment tools are typically used at diagnosis and for major treatment plan updates, usually every 12–24 months, not twice a year.

• Compromised Data: This frequent re-testing can compromise data reliability through test-retest effects (where individuals remember previous answers), caregiver fatigue (leading to less thoughtful responses), and general practice effects that can invalidate the results.

• Limited and Inappropriate Assessment Tools: The approved list of assessments is heavily dominated by one publisher, Pearson, creating a near-monopoly and restricting clinical judgment. Alternative tools are better suited for non-verbal children, those with complex medical needs, or individuals with atypical communication styles.

While standardized assessment is critical for treatment planning, Indiana’s current model prioritizes rigid paperwork over clinical value.

Financial Impact of Testing on Providers

Indiana creates an impossible situation by mandating extensive assessments that imposes substantial costs while severely limiting reimbursement. Providers must conduct multiple comprehensive assessments but face a restrictive billing cap of only 8 hours total for the entire evaluation process.

• High Material & Labor Costs: Providers face substantial costs from purchasing assessment kits and forms (e.g., Vineland-3: $400–$500 kit + $2–$5 per form; BASC-3 PRQ: $350–$400 kit + $3–$6 per form[79]). The most significant cost is the time spent by a Board-Certified Behavior Analyst (BCBA), whose time is valued at approximately $100/hour. The full set of evaluations can take a BCBA 7 to 10 hours in labor alone[80] [81].

• Restrictive Unit Caps: While providers must complete all three required tools, Indiana caps billing at just 8 hours per year for the entire evaluation process[82]. This forces clinicians to rush or omit elements of the evaluation for complex cases, compromising thoroughness and quality.

• Financial Disincentive: This creates a significant financial disincentive for providers to perform full, accurate assessments. Since a large portion of the work is unreimbursed, providers must either absorb substantial losses or reduce the scope of their evaluations.

·         Opportunity Costs: The excessive time dedicated to redundant assessments takes clinicians away from providing direct therapeutic interventions or family training, which are more effective uses of their time.

This administrative burden limits agencies' ability to serve new children, creating artificial capacity constraints in an already under-resourced system. The result is higher costs, lower-quality evaluations, and unnecessary stress on both providers and families—all without a demonstrated improvement in outcomes.

Correct the Assessment Problem

To fix this, Indiana should reform its prior authorization process to be clinically sound and less burdensome, thereby expanding access to care. This change is not about cutting costs; it's about investing wisely by ensuring that every public dollar and every hour of professional time is spent on the most impactful, evidence-based care.

1. Lift Assessment Unit Caps
Indiana’s low unit caps on assessments violate the EPSDT mandate, which requires coverage for all medically necessary services to “correct or ameliorate” a child’s condition. Assessments required for service authorization are themselves medically necessary and must be fully billable; lifting caps ensures federal compliance while allowing clinicians to perform thorough evaluations at clinically appropriate intervals.

2. Shift to Annual, Clinically Driven Assessments Indiana should replace the semi-annual mandate with an annual review, unless the clinician documents a clear clinical reason to test sooner (e.g., major transition, safety risk, plateau/regression that cannot be explained by session data). Reducing assessment frequency would free up approximately 6-10 hours of highly trained professional time per child each year.   That time moves to direct therapy, supervision, parent training, and onboarding new staff—the work that actually improves outcomes and expands capacity.

Standardized tools are not designed for frequent repetition; overuse produces practice effects and caregiver fatigue, degrading validity.  An annual review aligns with professional best practices, ensuring that assessments are a meaningful tool for treatment planning rather than a procedural hurdle.

3. Allow Provider Discretion

The state's rigid mandate to use three specific assessments every six months creates a significant barrier to care. This policy is financially burdensome, clinically inappropriate, and compromises data reliability.

Instead of a one-size-fits-all approach, the state should allow providers to use their clinical judgment to select assessments from a broad range of evidence-based tools (e.g., Vineland, BASC, VB-MAPP, ABLLS, AFLS, PEAK). This ensures that the right tool is chosen for the right purpose at the right time, leading to more accurate, meaningful treatment plans and more efficient use of clinical time. This shift aligns state policy with professional best practices, putting the child's individual needs at the center of the process.

4. Streamline Inter-Agency Record Transfers

Problems with assessments and unit caps are worsened by systemic breakdowns in transferring records when families change providers. Previous providers, sometimes motivated by competition or administrative friction, may delay, refuse, or intentionally make records transfers difficult forcing new providers to repeat assessments and delaying critical care. Indiana should address this through a two-pronged approach: an immediate policy intervention to ensure timely record access, coupled with a long-term investment in technology to streamline and centralize record transfers.

• Short-Term Fix - Mandate a Transfer Deadline: Set a 3–5 business-day deadline for a previous provider to transfer a child’s most recent and clinically relevant records upon request. This includes the current treatment plan, all recent behavioral and psychological assessments, and the most recent prior authorization approval. The state should enforce this policy with clear penalties, such as payment holds or corrective action plans, for late or incomplete responses.

• Long-Term Solution - Establish a Centralized Portal: For a permanent solution, Indiana should invest in a centralized digital platform for all Comprehensive Diagnostic Evaluation (CDE) results, assessments, and prior authorizations. This single digital solution would simultaneously improve care coordination by preventing unnecessary re-testing and enhance program integrity by allowing the state to automate checks for fraud, waste, and abuse. This digital platform would ensure that a child's complete clinical history is accessible to any authorized provider, eliminating delays and ensuring seamless continuity of care.

1.  Request updates only when truly required

Require an updated diagnosis only when there is:

• A substantial change in presentation (e.g., loss of skills suggesting a different condition),

• A credible question about the accuracy of the original diagnosis, or

• A legal/regulatory trigger (e.g., the original diagnosis was missing, incomplete, or obtained from an ineligible source).

In all other cases, confirm continuing medical necessity through periodic, structured functional assessments—not re-diagnosis.

2.  Use appropriate, purpose-built tools

For initial and ongoing reviews, providers—such as BCBAs—should have the discretion to select and tailor ABA-aligned, function-focused measures to the individual child’s developmental profile, communication style, and clinical needs. Examples include:

• Functional Behavior Assessment (FBA) with direct observation,

• An age-appropriate, objective skills assessment (e.g., VB-MAPP, AFLS, ABLLS-R, PEAK),

• Caregiver/teacher interviews and standardized behavior rating scales when relevant.

• A newly created “Certification of Continued Need for ABA Services Form” to be used to maintain Medicaid or insurance authorization for ABA therapy, document clinical necessity, and provide an official record for audits, reviews, or service continuation requests. A proposed example of this form is included in the Appendix.

3. Outline exactly what documentation must show

Set a single, statewide checklist for re/authorization packets:

• Diagnosis & independent referral on file (no repeat unless the “required” criteria above are met).

• Current assessment summary: behaviors of concern, baseline levels, risks/safety, and learning barriers.

• Individualized treatment plan: measurable goals, mastery criteria, hours requested with justification, service schedule, and parent/caregiver participation plan.

• Objective progress review (each auth period): graphed data or clear metrics tied to goals, explanation of plateaus/regressions, and plan adjustments.

• Session documentation: date, time, location, units, targeted skills/behaviors, procedures used, child response, and rendering/supervising providers (with supervision logs).

Waitlists for autism diagnosis are already long, and every delay means lost opportunities for early intervention. By expanding who can diagnose, clarifying standards, and encouraging team-based evaluations, Indiana can ease bottlenecks while maintaining quality and independence in the review process. By enforcing independence and quality without unnecessary re-diagnosis, reduces denials driven by ambiguity, and keeps the focus on whether the child’s goals and safety needs are being addressed—so care is timely, appropriate, and easier to audit.

This approach addresses the OIG’s findings on outdated and improper referrals without creating new barriers, ultimately saving money long term by ensuring children access ABA services at the point where intervention is most effective.

Waiver Waitlist Barriers

After receiving an autism diagnosis, Indiana families face yet another major hurdle: the long wait to access Medicaid waiver services that fund critical supports. It is estimated that individuals with ID/DD spend 48 months[83] on a waiting list before enrolling in a Medicaid HCBS waiver, a delay that compounds costs and narrows future options.  The Family Supports Waiver is often reported to have a 3+-year waitlist, leaving children without needed services during their most crucial developmental years.

For families who cannot afford to pay out of pocket, this waitlist becomes the only path forward, forcing them to delay care despite an urgent need for early intervention.

The waiver waitlist is not just an administrative backlog—it represents a systemic barrier that compounds the challenges families already face after diagnostic delays, provider shortages, and eligibility hurdles. For many, it means losing irreplaceable time to build the skills and supports their child needs most.

Delays in Treatment After Diagnosis

Even after securing a diagnosis, families encounter additional delays accessing treatment.

A national survey of autism centers found that the leading barriers to care are workforce shortages (69%) and high referral volume (61%)[84]. Indiana's ABA workforce faces severe challenges:

·         Professional Shortages: In 2024, Indiana had over 2,431 BCBA job openings (a 23% increase from 2023) and 226 BCaBA openings (a 151% increase). Despite having 1,538 certified BCBAs and 10,420 certified RBTs statewide, hundreds of positions remain unfilled[85]. Projections have shown an average growth rate for BCBAs of around 22% over the next decade, significantly higher than the overall average for other occupations[86].

·         ABA Clinic Waitlists: Indiana Behavior Analysis Academy (IBAA) in Kokomo reports wait times of 6–18 months on its website[87]. Partners in Autism in Fort Wayne reports a waitlist of 2.5 – 3 years before services can begin as of September 2025.  One-third of families (33.7%) who never received ABA said long waitlist times were the main reason[88]

These delays not only reflect rising demand for autism services but also signals that the current access challenges are likely to intensify if workforce shortages are not addressed.

Solving the  RBTs Credentialing Bottleneck

The OIG audit identified a recurring compliance issue: in 26 of 100 sampled cases, services were provided by uncredentialed or out-of-scope staff. In response, Indiana now requires every Registered Behavior Technician (RBT) to undergo a full, independent credentialing process through its claims administrator, Gainwell. This process includes a separate, state-mandated background check, even after the RBT has already been certified by the national governing body (the BACB) and passed its background check.

This new requirement, while intended to improve oversight, duplicates verification steps and creates a significant administrative bottleneck.

The Systemic Consequences

This policy, which treats RBTs like high-risk independent providers, has created a structural crisis in the behavioral health workforce.

• Delays in Care: The credentialing process often creates a 4-6+ week backlog before new staff can be added to a provider's roster[89]. During this period, a child cannot receive billable services from that RBT, delaying critical, time-sensitive care.

• Workforce Instability: RBTs are entry-level professionals with a high turnover rate (averaging 65% annually[90]). Approximately 72% of ABA professionals report moderate-to-high burnout levels[91]. Agencies are forced to either absorb payroll costs for weeks without revenue or delay hiring, which discourages new talent from entering the field and contributes to burnout.

• Failed Oversight: This bottleneck does not meaningfully strengthen oversight, because clinical accountability already rests with the supervising Board-Certified Behavior Analyst (BCBA), who is ultimately responsible for the RBT's actions. The state's policy simply adds a layer of bureaucracy that delays care without improving program integrity.

This approach cripples the workforce pipeline, leaving families on long waitlists and preventing approved care from being delivered.

Why BCBA Credentialing Matters More

This bottleneck does not meaningfully strengthen oversight, since clinical accountability ultimately rests with the supervising BCBA. Systemically, BCBA credentialing failures lead to the highest-dollar improper payments because:

1. Every claim under their supervision is tainted if they aren’t properly credentialed.

2. BCBAs are the ones authorizing medical necessity and supervising clinical care.

If Indiana wants to reduce large-dollar improper payments, the priority should be airtight credentialing and oversight of BCBAs, not slowing down RBT enrollments. RBT tracking still has value (audit trail, fraud prevention), but the true financial risk comes when BCBAs are not credentialed or supervising correctly.

Solutions for Streamlining RBT Enrollment

1. Improve Gainwell's Contract to Expedite RBT Enrollment

To address the significant delays in RBT enrollment, Indiana should revise its contract with Gainwell to tie performance directly to a streamlined and efficient provider onboarding process. The current 4-6 week wait for an RBT to become a rendering provider is an unacceptable barrier to care.

• Establish a Mandated Turnaround Time: The contract should require a strict 5–7 business day turnaround for RBT applications. This is a reasonable and achievable goal for an administrative task that primarily involves verification of a professional certification and basic background checks.

• Implement Performance-Based Incentives: To ensure compliance, the contract must include both financial incentives and penalties. Gainwell should receive bonuses for meeting or exceeding these turnaround benchmarks and face financial penalties for delays. This directly links performance to accountability and encourages efficiency.

• Require Dedicated Staffing and Automation: The contract should mandate that Gainwell allocates dedicated staff or implements automated processes specifically for RBT enrollments. This ensures that the review of paraprofessional applications is treated as a priority and does not get backlogged behind the more complex credentialing of fully licensed clinicians.

By treating RBT enrollment as a priority and holding its vendor accountable, Indiana can eliminate these administrative delays and ensure that families receive timely access to the services they urgently need.

2. Batch Processing of Applications
Instead of each RBT having to navigate a complex state enrollment portal individually, the ABA agency submits a group of applications at once. This is typically done through a secure online portal that allows for:

• Roster Uploads: The agency can fill out a spreadsheet (like a CSV file) with all the required information for their new RBTs. This includes basic demographics, their individual National Provider Identifier (NPI), and their Behavior Analyst Certification Board (BACB) certification number. The agency then uploads this single file to the state's system.

• Automated Verification: The state's system processes these submissions in bulk. It can quickly verify the RBTs' credentials against the BACB's public database and check for any flags on federal and state exclusion lists. This is much faster and more efficient than a manual review of every individual application.

This model is a necessary solution for a high-volume, paraprofessional workforce with a high turnover rate. It allows the state to maintain oversight and program integrity by knowing who is delivering care, but it does so without the administrative bottleneck of a full, individual-by-individual enrollment process.

3. Provisional Approval
A provisional approval approach would allow certified RBTs to begin working immediately, ensuring timely care for families while maintaining robust oversight and accountability. It treats RBTs as supervised paraprofessionals, not as independently licensed clinicians, which is a key distinction that makes this model both logical and feasible.

How the Provisional Model Works

The solution hinges on how the state's claims processing system is configured, and it can be implemented with minimal changes.

1. Enrollment: An RBT who has passed their BACB certification and obtained a National Provider Identifier (NPI) can be provisionally approved to begin working for an already-credentialed ABA agency as soon as the IHCP Rendering Provider application is submitted.  approval to begin providing services immediately under the direct supervision of a BCBA.

2. Claims Submission: Claims for services would be submitted using the RBT's NPI in the "rendering provider" field. The claim would also include a specific provisional modifier (e.g., "U9") that signals to the state's claims system: "This service was provided by a certified RBT whose full credentialing is pending." This crucial step prevents the claim from being denied immediately, which is a key barrier in the current process.

3. System Agreement: Indiana Medicaid and Gainwell (claims administrator) would predefine the provisional modifier, configure the system to recognize it, and monitor submission of full credentialing within a set period (e.g., 90–180 days).

4. Background Checks and Compliance: Final verification—background check, exclusion list check, certification status—continues in the background. The RBT's NPI identifies the specific individual who delivered care, and the provisional modifier provides an audit trail. If the RBT fails any review, the state can stop all future claims and claw back payments for services improperly rendered, maintaining program integrity.

This model is a well-established strategy in medical billing and is already used by Managed Care Organizations (MCOs) and other healthcare programs. By leveraging existing billing infrastructure, Indiana can eliminate unnecessary administrative delays and ensure that its focus on compliance doesn't come at the expense of a family's access to timely, medically necessary care.

4. Agency-Led Screening and State Audits
Under this model, the ABA agency would be responsible for conducting all screening and maintaining internal records to demonstrate compliance. This ensures accountability rests with the entity directly managing the staff. Key requirements for the agency would include:

• Background Checks: Agencies must conduct and document criminal background checks for all RBTs prior to service delivery.

• Exclusion List Screening: Each RBT must be screened against federal and state healthcare program exclusion lists to verify eligibility.

• Certification Verification: The agency is responsible for confirming that each RBT holds an active Behavior Analyst Certification Board (BACB) certification and for maintaining proof of it.

• Internal Roster Maintenance: Agencies must maintain a detailed, up-to-date roster linking each RBT to their supervising Board Certified Behavior Analyst (BCBA). This roster would be the primary record for state review.

• Supervision Logs: Agencies are required to maintain documentation of BCBA supervision for each RBT, demonstrating adherence to all required supervision frequency and format.

State Oversight and Auditing

This model does not diminish the state's authority; it simply shifts the oversight from a time-consuming pre-approval process to a more efficient, post-service auditing function. The state would maintain full program integrity by:

• Auditing Powers: The state retains the ability to conduct audits of an agency's internal rosters, supervision logs, and other records to verify that care is being delivered by qualified, supervised RBTs.

• Claims Accountability: Claims would be submitted with the BCBA or the agency listed as the rendering provider, ensuring a clear, auditable chain of responsibility for services rendered.

• Financial Safeguards: If an agency is found to be out of compliance, for instance, by having non-certified RBTs on staff or failing to provide adequate supervision, the state can deny claims or claw back payments, ensuring accountability without burdening individual RBTs with the enrollment process.

This approach keeps accountability where it belongs—on the supervising BCBA and the agency—while still giving the state a clear way to verify who delivered care.

The current rendering provider process adds unnecessary checks that delay care for families without improving oversight. Indiana has better options for oversight and accountability that meet OIG expectations without forcing families to wait weeks for care.

Addressing Over-Utilization Stressors

The discussion around the cost of behavioral health must acknowledge a key, practical reality: while ABA therapy's primary purpose is medical, its intensive, structured schedule can have a powerful, secondary effect of functioning as childcare. Understanding ABA program costs requires examining the full spectrum of factors that drive service hours beyond strictly clinical need. While ABA is a medically necessary intervention, its intensive, structured schedule can inadvertently function as childcare or support for families, creating incentives for overutilization. Multiple systemic pressures contribute:

• School-day and coverage gaps: Before- and after-school hours, breaks, and summers often lack reliable supports, precisely when regression risk spikes and families need coverage to maintain employment.

• Limited alternative resources: Specialized childcare, respite, and therapeutic programs equipped to support children with autism or complex behavioral needs are scarce and often unaffordable. Families and providers alike may rely on ABA to fill these gaps.

• Financial and workforce pressures on families: Without accessible alternatives, families may face impossible choices: high out-of-pocket costs for care, a parent leaving the workforce, or accepting higher-hour ABA schedules for coverage rather than therapeutic benefit.

• Provider incentives and scheduling pressures: With limited capacity, providers may favor full-time, high-hour cases to maximize revenue, fill schedules efficiently, or meet productivity expectations, which can encourage approval of more hours than clinically necessary.

• Billing and reimbursement structures: Medicaid and private insurance often reimburse based on hours delivered, creating a financial incentive for agencies or practitioners to request or approve higher service levels.

• Administrative and compliance drivers: Excessive documentation requirements, prior authorization processes, and rigid hour caps can paradoxically lead providers to over-request hours to avoid denials or repeated submissions.

These overlapping pressures mean that overutilization can result from a combination of family necessity, provider incentives, and system design. Policy solutions should ensure that service hours are determined by clinical need, not by convenience, financial pressures, or administrative inefficiencies.

Incorporating Shared Savings Models

To reduce overutilization and promote fiscal responsibility, Indiana should consider piloting shared savings arrangements with ABA providers. This model aligns financial incentives with positive clinical outcomes, rewarding efficiency without compromising the quality of care.

• How It Works: Under this model, the state and providers would share any Medicaid savings generated when a child's ABA hours are delivered below a pre-determined average or benchmark, while still achieving their clinical goals. This approach incentivizes efficiency, rewarding providers for helping children "step down" from intensive services when clinically appropriate.

• Aligning Incentives with Outcomes: A shared savings model encourages providers to deliver effective, outcome-focused therapy rather than simply maximizing billable hours. This shifts the focus from service volume to a child's long-term progress, creating a financially sustainable and fiscally responsible system.

Children Between School Readiness and Intensive Therapy Needs

A significant group of children with autism spectrum disorder (ASD) falls between two extremes: they are not developmentally ready to succeed in a traditional school setting, yet they also do not require—or benefit from—intensive, full-day one-on-one therapy. This “in-between” population is one of the most underserved groups in Indiana’s current system.

Current Medicaid service structures are built around two poles: a full-time school day or a 40-hour intensive ABA program. With demand exceeding capacity, providers may prioritize full-time, high-hour cases, which can pressure families to select higher-hour programs simply to secure any services at all. Families are forced into an “all or nothing” choice that often does not reflect their child’s actual clinical needs.

The result is inefficiency, lost opportunities to serve more children, and drives over-utilization, leaving the state to pay for services that are not medically necessary.

Over-utilization should be addressed through targeted oversight, clear distinctions between care and therapy, and waiver pathways that match clinical need, not through blunt caps that violate EPSDT. Indiana has both a legal duty and a fiscal incentive to get this right: ensuring medically necessary ABA is always provided, while building alternative habilitative services that prevent misuse, sustain the workforce, and protect Medicaid’s integrity.

A Three-Tiered Model for Therapeutic Care

A responsible, cost-conscious strategy must acknowledge this middle-ground population and design more flexible service pathways. We propose a three-tiered approach that utilizes Medicaid's existing framework to serve this population effectively and efficiently. This model is based on Applied Behavior Analysis (ABA) therapy, with each tier representing a different intensity level.

1. Tier 1: Intensive ABA (Highest Intensity): This level of care typically involves 30+ hours/week with a 1:1 staff-to-patient ratio. It should be reserved for children with the most significant clinical needs, particularly those newly diagnosed or exhibiting severe behavioral challenges.

2. Tier 2: Transitional Group-Based Care (Moderate Intensity): This middle tier would provide moderate-intensity therapy with a targeted 1:2 or 1:3 staff-to-patient ratio. It's designed for children who have made progress in 1:1 therapy and are ready to learn and generalize skills in a small-group setting. This model is not only clinically appropriate but also more cost-effective than full-time 1:1 care.

3. Tier 3: School Readiness Waiver (Low Intensity): Delivered through a Home and Community-Based Services (HCBS) waiver, this tier serves as a "prep to school" program. It would be a low-intensity, group-based model with a 1:6 or 1:10 staff-to-patient ratio. Designed for children who need minimal behavioral support, this waiver would help them build fundamental group skills and acclimate to a structured social environment, serving as a fiscally responsible, pre-educational intervention. This approach leverages existing waiver programs to fill a critical gap without over-medicalizing the child's needs.

By designing a clear, tiered system, the state can ensure that children receive the right level of service at the right time, thereby reserving intensive resources for those who need them most and optimizing the entire system for both clinical effectiveness and fiscal responsibility.

Group ABA Therapy: A Flawed Reimbursement Structure

Indiana's reimbursement structure for Applied Behavior Analysis (ABA) therapy creates a major disincentive for providers to offer effective group-based care. While individual and group sessions are complementary, with group settings offering a natural environment to practice social skills, the current financial model makes offering high-quality group therapy nearly impossible.

The core issue is a dramatic disparity in reimbursement rates. A provider is paid $68.24 per hour for individual ABA, but only $19.48 per hour for group ABA[92]. This 72% drop-off forces a provider to serve at least four children just to financially break even with a single one-on-one session, even though managing a group is far more complex and resource intensive. This economic distortion is counterproductive and leads to a system that is both clinically and fiscally unsustainable.

This flawed policy has a direct, negative impact on care delivery in the state.

Contradicts Clinical Best Practices

The current rate structure incentivizes large groups (4+ children), which directly contradicts clinical best practices. Leading professional organizations like the Council of Autism Service Providers (CASP) and the Behavior Analyst Certification Board (BACB) emphasize that clinical efficacy is maintained when therapist-to-child ratios are low (ideally 1:2 or 1:3) [93]. These smaller, clinically appropriate groups are the most effective way to teach skills like turn-taking and peer interaction.

The policy also ignores the real-world complexities of group formation. Providers must match children based on developmental levels and behavioral needs, a task made even more challenging when the financial incentive pushes for larger, less clinically effective groups.

Limits Access and Worsens Waitlists

By making effective group therapy financially unviable, the system limits providers to serving one child at a time. This significantly reduces the overall number of children who can receive services from a given staff member, worsening waitlists and restricting access to care. The data confirms this failure, with utilization for group ABA codes at less than 1%[94].. This shows that the current reimbursement model fails to provide a valuable, lower-intensity option, unnecessarily driving more children into more costly one-on-one services.

A Proposed Rate Structure to Align with Clinical Practice

To make a tiered system work, the first step is to restructure group ABA therapy reimbursement rates, so they align with clinical best practices. This adjustment would remove the systemic barriers that currently prevent the delivery of high-quality, cost-effective care.

Raise the Group Rate: Group ABA therapy is rarely used because the current reimbursement—only $4.87 per unit—is based on an unrealistic average group size of 3.5 children. Clinically effective groups are much smaller, typically 2–3 children with compatible goals. At today’s rate, however, providers earn less than they would for individual sessions while managing far more complexity.

For example, serving three children together generates just $14.61, compared to $17.06 for one child individually—despite requiring triple the workload in planning, data collection, and behavior management. The current structure effectively penalizes providers for delivering the more complex, skill-intensive model of care. This is economically irrational and clinically unsustainable.

By substantially increasing the group therapy reimbursement rate, Indiana could make small, clinically appropriate groups financially viable. This reform would incentivize providers to deliver group services that align with best practices, improving access to high-quality ABA while also supporting long-term cost efficiency for the state.

Staff-to-Patient Ratio

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The School Readiness Medicaid Waiver

Under federal law, states may provide autism-related supports through optional Medicaid programs such as 1915(i) state plan HCBS, 1915(c) HCBS waivers, 1915(k) Community First Choice, and section 1115 demonstrations. Yet Indiana lacks a dedicated service for children who are not ready for a traditional classroom but also do not require intensive, full-day, 1:1 ABA therapy. This "in-between" population is left with an "all-or-nothing" choice that is often clinically unnecessary and financially unsustainable.

The proposed School Readiness Medicaid Waiver would close this gap. Delivered through a Home and Community-Based Services (HCBS) program, it provides a low-intensity, group-based model (1:6–1:10 ratio) focused on preparing children for classroom success, building core social and adaptive skills, and reducing reliance on high-cost intensive therapy.

Why This Model Is Different

The staff would still be overseen by a BCBA, who designs the individualized treatment plans for each child in the group. The direct care staff would be RBTs, providing targeted support for each child, even while they are in a group. Unlike clinical ABA, which is designed for intensive skill acquisition with frequent data collection, this waiver service is structured around therapeutic group experiences that focus on:

• Classroom Readiness: Practicing turn-taking, waiting, following group routines, and peer interaction in groups of 6–10.

• Social and Developmental Growth: Supporting communication, coping, and self-regulation in naturalistic settings.

• Fiscal Responsibility: Providing an appropriate step-down service at a fraction of the cost of 1:1 ABA, stretching limited Medicaid dollars further.

This program is not a substitute for medical ABA therapy. Instead, it recognizes that larger group settings, while less clinically precise, have unique therapeutic value for generalization, socialization, and preparing children for school environments.

Why Large Groups Cannot Be Considered “Clinical” ABA
Attempting to bill group-based programs under existing clinical ABA codes is inappropriate for several key reasons:

• Documentation Burden: Clinical ABA requires frequent, individualized data collection and constant adjustment of goals for each child. Tracking six or more children on individualized goals in real time is impractical and produces unreliable data.

• Treatment Fidelity: ABA effectiveness depends on precise reinforcement and error correction. This cannot be replicated in larger groups.

• Medical Necessity Standard: Intensive ABA is justified as a medically necessary treatment for clinical deficits. By contrast, school readiness programs are habilitative and transitional, preparing children for educational settings—not addressing acute medical needs.

A New Funding Model: The HCBS Waiver
Given these differences, the program must be funded through an HCBS waiver, not shoehorned into existing ABA codes. To promote best practices in physical environments, this program should adopt facility standards modeled on Adult Day Services (Category 1), specifically adapted for children with autism spectrum disorder (ASD). Providers that meet these standards would be eligible for enhanced reimbursement.

To balance quality and cost, a two-dimensional rate system is being proposed:

1. Facility Quality Tiers

   • Standard Facility: Meets baseline waiver standards (safety, supervision, structured programming).

   • Enhanced Facility: Offers higher-quality supports with features such as designated functional areas, sensory rooms, specialized layouts, and autism-friendly furnishings that meet space and accessibility standards.

2. Child Need Levels

   • Level 1 (Mild ASD / Support Needs): Primarily social engagement and light behavioral supports.

   • Level 2 (Moderate ASD / Substantial Needs): Targeted support in communication, adaptive skills, and group participation.

   • Level 3 (Severe ASD / High Support Needs): Significant behavioral or communication challenges requiring closer staff monitoring, but not intensive 1:1 ABA.

This new model would create a clear and distinct funding pathway for group-based services, ensuring that children receive the appropriate level of care in the right environment, while also promoting best practices in program design and facility standards.

  Indiana Autism Services: Proposed Group Rates and Savings

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Funding Restrictions and Necessity

Ideally, ABA would be available to all clinically appropriate cases. Given Indiana’s budget constraints, this waiver limits coverage to children already enrolled in Medicaid who (1) have a confirmed diagnosis of Autism Spectrum Disorder and (2) have a documented medical necessity for ABA, with measured outcomes used to inform any future expansion.

This approach leverages federal Medicaid dollars without expanding eligibility. The state’s focus remains on children already served by Medicaid while offering a more tailored, efficient service option. Coverage would continue to be driven by medical necessity, and each treatment plan would document the clinical rationale for a small-group model as the most appropriate and effective intervention—versus 1:1 therapy or school-based services.

Future Consideration: Responsible Expansion
While the initial phase should focus on children already eligible under EPSDT, Indiana could use this waiver as a proof of concept. Once demonstrated to be clinically effective and fiscally sustainable, the model could be responsibly expanded to:

• Other Medicaid populations with similar needs (e.g., children with developmental delays who are not eligible for ABA but benefit from habilitative group support).

• Broader age groups or diagnoses where structured, school-readiness programming reduces reliance on high-cost institutional or crisis care.

By beginning with the population Indiana is already obligated to serve under EPSDT, the state can test and refine the model in a way that meets immediate compliance needs and positions the program for future scalability.

Benefits and Justification

1. Enhancing Clinical Quality and Access

The tiered system ensures that every child receives the right level of care at the right time. By providing a formal step-down option, it creates a crucial therapeutic bridge between intensive ABA and school, preventing regression and ensuring a smoother transition.

• Fills a Critical Gap: The model addresses a significant, unmet need in Indiana’s service array by offering a non-clinical, structured, and behaviorally supportive environment. This gives families a valuable alternative to intensive ABA, which many decline due to cost or intensity.

• Optimizes Resources: Transitioning children who no longer require intensive ABA into structured group programs frees up scarce 1:1 capacity for those with the greatest clinical needs. This improves outcomes while avoiding unnecessary costs and helps reduce long waitlists.

• Aligns Incentives: It removes the current disincentive where providers are penalized for offering group therapy. By aligning payment with best practices, the model makes group services financially viable, ensuring Medicaid dollars are used for medically necessary care.

2. Ensuring Fiscal Responsibility

This model creates a more sustainable system by leveraging federal funding and prioritizing cost efficiencies.

• Cost Savings: The proposed group-based services deliver significant cost savings—approximately 58–74% per child per hour compared to one-on-one ABA. At scale, these savings can be reinvested into reducing waitlists and strengthening other support systems.

• Leveraging Federal Funds (FMAP): Services provided through a waiver qualify for the Federal Medical Assistance Percentage (FMAP). This means each state dollar invested draws down more than two federal dollars, lowering the state’s actual cost share while still providing expanded services.

• EPSDT Compliance: This tiered system helps Indiana comply with the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, ensuring all medically necessary services are provided without blunt caps, reducing legal and financial risk.

• Healthcare System Efficiency: Preventing regression reduces future high-cost interventions, ER visits, or crisis placements.

3. Strengthening the Provider and Family Ecosystem

This program is designed to meet the real-world needs of families and providers.

• For Families: Children get the intensity of therapy that actually matches their developmental stage — no more being pushed into overly intensive programs just because that is what exists helping to make transitions smoother and reducing regression. With tiered models, families do not wait as long for scarce 1:1 slots. Children can move into appropriate group settings sooner and parents can stay employed instead of leaving the workforce.

• For Providers: Providers are not penalized for offering group care — they can diversify services and stabilize revenue streams. Agencies gain a new Medicaid revenue stream that is not entirely dependent on clinical prior authorizations, smoothing cash flow and reducing risk from utilization reviews. It reduces administrative burden by eliminating redundant assessments and provides a clear billing pathway.

• For the Employee: Shifting some RBTs and techs into lower-intensity group settings reduces emotional strain and improves retention. Staff satisfaction improves while still delivering value to families. This professional support can help reduce burnout and turnover, improving workforce stability.

• Economic and Societal Benefits: By keeping parents in the workforce through reliable care access, the state protects its tax base and reduces reliance on other safety net programs. The system also benefits the education and healthcare systems by ensuring children enter school better prepared and reducing the need for costly, high-acuity interventions or crisis placements.

• Public Trust: Families and providers see a system that is responsive, transparent, and designed to meet real needs rather than just cut costs.

A cost-conscious strategy must acknowledge the “in-between” population—children who are underserved by current all-or-nothing models. The School Readiness Waiver provides a scalable, flexible pathway that preserves intensive ABA for the highest-need cases, while extending meaningful, lower-cost support to more families. This three-tiered approach, built on Medicaid’s existing framework, ensures Indiana can deliver care that is both clinically appropriate and fiscally sustainable.

With proper childhood supports and early intervention, more individuals could become productive taxpayers rather than requiring lifelong support services.

 Medicaid: An Investment in Indiana’s Workforce, Economy, and Fiscal Health

Too often, Medicaid is framed narrowly as a social safety net program. In reality, it is one of Indiana’s major economic drivers. Every state dollar invested is matched by nearly two federal dollars, pulling billions into Indiana’s communities. Those funds buy more than healthcare, they create jobs, sustain local providers, and keep families working.

Medicaid’s Long-Term Economic Impact

Early intervention is not just a health strategy—it also strengthens Indiana’s tax base over the long term. When children with disabilities receive timely, effective interventions, it reduces the need for costly special education, increases school readiness, and maximizes the chance that children transition into adulthood as tax-paying workers. The fiscal return is clear: fewer public dollars spent on dependency, and more Hoosiers contributing as productive citizens.

A High-Return Investment

A cost-benefit analysis of early intensive behavioral intervention (EIBI) found that "the economic benefits of early intervention substantially outweigh its costs." Investing in medically necessary ABA during childhood is not just a legal obligation under EPSDT, it is a smart fiscal strategy. Early intervention reduces long-term reliance on adult service systems, promotes independence and productivity, and generates measurable savings for Indiana.

• Generates Education Savings: Medically necessary therapies reduce the need for intensive special education, preparing children to succeed in general classrooms.

• Reduces Adult-Care Costs: Early intervention lowers future reliance on costly Adult Waivers and residential programs by promoting independence. Children who might otherwise require lifelong public support costing over $1 million gain skills for independence and employment.

• Prevents Crisis Care: By funding consistent community-based services, Medicaid avoids costly crisis-level interventions such as hospitalizations and institutional placements.

• Supports Parents: Each year of intensive ABA gives parents an estimated 10 extra work hours per week they couldn’t otherwise work, stabilizing family caregivers and keeping more parents in the workforce.

• Strengthens the Tax Base: Children who receive early intervention are more likely to enter adulthood as employed, tax-paying citizens. This converts a potential need for lifelong public support into a contributing member of the community.

• Creates Jobs: Medicaid supports tens of thousands of caregivers, therapists, nurses, and small business providers. These are tax-paying workers whose wages flow back into the economy through housing, groceries, and local spending. Medicaid spending is not just a cost—it is a circulating investment that multiplies across sectors.

When structured and reimbursed properly, early intervention is a self-sustaining investment: today’s costs generate tomorrow’s savings while building the workforce Indiana needs for the future.

This is fundamentally about Indiana's future: its fiscal health, workforce stability, and commitment to its most vulnerable citizens. The proposed framework provides a practical roadmap to achieve all three simultaneously.

The Stakes

The children entering Indiana's system today will be adults within two decades. Whether they contribute to the economy or require lifelong support depends on decisions made during their most critical developmental years. Federal law already mandates the investment—the only choice is whether to invest wisely now or pay exponentially more later.

This is fundamentally about Indiana's future: its fiscal health, workforce stability, and commitment to its most vulnerable citizens. The proposed framework provides a practical roadmap to achieve all three simultaneously.

A Different Approach

This analysis reframes the ABA discussion from cost-cutting to value creation. Instead of viewing compliance as constraint, it presents federal requirements as leverage for better outcomes. Rather than rationing care, it proposes expanding options through smarter service design.

The result is a system that:

• Meets legal obligations while improving quality.

• Leverages federal funding while reducing long-term costs.

• Serves more families while maintaining program integrity.

• Strengthens the workforce while supporting family stability.

A Model for the Nation

Done correctly, Indiana's reforms could serve as a national model for autism services—demonstrating how states can fulfill federal obligations while achieving fiscal sustainability. The proposed system balances intensive clinical intervention with cost-effective community supports, ensuring every child receives appropriate care while maximizing returns on public investment.

This is not merely a policy adjustment; it is an investment in Indiana's future workforce. Children who receive timely, appropriate intervention become adults who contribute rather than draw from public resources. Parents who can rely on stable services remain productive members of the workforce. Providers operating in a rational system deliver better care at lower costs.

The Moral and Economic Imperative

The children waiting for services today will become adults in twenty years. The question facing policymakers is simple: Will Indiana invest now in their potential for independence and productivity, or will it pay far more later for dependency and institutional care?

The economic evidence is overwhelming. The legal requirements are clear. The moral imperative is undeniable. The only remaining question is whether Indiana will act with the urgency this crisis demands.

The Choice

Indiana stands at a pivotal crossroads. We can continue down a narrow path of administrative over-correction, which attempts to fix one problem by creating a bigger ones creating a burden for families, crippling the RBT workforce, and exposes the state to significant legal liability under federal law.

Or we can choose a different path: one that aligns our policies with both fiscal responsibility and human potential.

The core argument of this framework is simple: early intervention isn’t an expense; it’s an investment. When we invest wisely, early, and effectively in children with autism, we are not just providing a service; we are building a more resilient, productive, and prosperous Indiana. We are leveraging federal dollars to reduce long-term costs in education, adult services, and lost workforce productivity.

The evidence is clear, the tools are available, and the federal partnership is ready. What remains is the political will to choose investment over rationing, compliance over conflict, and long-term prosperity over short-term cost avoidance.

For Indiana's children, families, and fiscal future, there has never been a more important time to respond with intention and not reaction.

For questions about this framework or implementation support, contact Julie McGill, Family Solutions Home Care LLC.

Appendix A:

Certification of Continued Need for Applied Behavior Analysis (ABA) Services

Patient Information

Name: ___________________________________________Medicaid ID: _______________________________________

Date of Birth: ____________________________________Current ABA Provider/Agency: ________________________

Established Diagnosis
☐ Autism Spectrum Disorder (ASD) diagnosis previously established by qualified provider.
☐ Diagnosis remains ongoing and consistent with current clinical presentation.

Clinical Status
Based on review of provider treatment plan, progress data, and patient/family report:

☐ ABA remains medically necessary to address significant deficits in:
☐ Communication
☐ Social skills
☐ Adaptive functioning
☐ Behavior regulation
☐ Other: ________________________________________

☐ ABA services continue to support measurable progress or are needed to prevent regression in skills.

Progress and Goals

Summary of progress since last review (attach provider progress note if applicable): _______________________ _____________________________________________________________________________________________________

Recommended ongoing focus of ABA: __________________________________________________________________ _____________________________________________________________________________________________________

Recommended Service Continuation
☐ Continue ABA at current level of intensity
☐ Continue ABA with modification: ____________________________
☐ Transition/step-down plan recommended: _____________________

Certifying Provider (must be physician, psychologist, or HSPP)
I have reviewed the treatment plan, progress documentation, and relevant clinical information. In my professional judgment, ABA remains medically necessary for this patient.

Name: ___________________________________________ Credentials: ______________________________________

License #: ________________________________________ Signature: __________________________ Date: _________

[1] Centers for Disease Control and Prevention (CDC), Data and Statistics on Autism Spectrum Disorder https://www.cdc.gov/autism/data-research/index.html 

[2] RAND Corporation, "Proven Benefits of Early Childhood Interventions," 2005, https://www.rand.org/pubs/research_briefs/RB9145.html; and D'Agati et al., "EIBI Saves Up to $2,500,000," ABA in Pennsylvania, 2007, https://abainpa.com/aba-save-money.

[3] Buescher, A. V., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. JAMA Pediatrics, 168(8), e14144.

[4] https://www.bls.gov/data/inflation_calculator.htm April 2014 to July 2025

[5] Hall-Lande et al., University of Minnesota, Policy Research Brief on ASD Services ici.umn.edu

[6] Association for Science in Autism Treatment, "Applied Behavior Analysis (ABA)," https://asatonline.org/for-parents/learn-more-about-specific-treatments/applied-behavior-analysis-aba/

[7] Keenan & Dillenburger (2018), Societies – North America autism policy and ABA evidence mdpi.com

[8] Singer, E., Research in Developmental Disabilities cost analysis via Spectrum News thetransmitter.org

[9] CMS, State Health Official Letter (SHO) #24-005: Best Practices for Adhering to EPSDT Requirements. Sept. 26, 2024. https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf

[10] Indiana Medicaid Behavioral Health Services Manual (2023) https://www.in.gov/medicaid/providers/files/modules/behavioral-health-services.pdf

[11] Chasson, Gregory & Harris, Gerald & Neely, Wendy. (2007). Cost Comparison of Early Intensive Behavioral Intervention and Special Education for Children with Autism. Journal of Child and Family Studies. 16. 401-413. 10.1007/s10826-006-9094-1.

[12] Centers for Medicare & Medicaid Services (CMS), State Health Official Letter (SHO) #24-005, Sept. 26, 2024. https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf

[13] Indiana FSSA ABA Working Group, Listening Session Summary (public feedback on ABA policy) in.gov

[14] Grosse SD, Ji X, Nichols P, Zuvekas SH, Rice CE, Yeargin-Allsopp M. Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017. Psychiatr Serv. 2021 Jan 1; https://pubmed.ncbi.nlm.nih.gov/33076792/

[15] WFYI, "Indiana panel to consider ABA therapy cost controls," https://www.wfyi.org/news/articles/indiana-panel-to-consider-aba-therapy-cost-controls.

[16] U.S. Department of Health and Human Services, Office of Inspector General, "Indiana Made at Least $56 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism," December 16, 2024, https://oig.hhs.gov/reports/all/2024/indiana-made-at-least-56-million-in-improper-fee-for-service-medicaid-payments-for-applied-behavior-analysis-provided-to-children-diagnosed-with-autism/

[17] Indiana Capital Chronicle, "Indiana panel to consider ABA therapy cost controls," May 9, 2025, https://indianacapitalchronicle.com/2025/05/09/indiana-panel-to-consider-aba-therapy-cost-controls/

[18] U.S. Department of Health and Human Services, Office of Inspector General, "Indiana Made at Least $56 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism," December 16, 2024, https://oig.hhs.gov/reports/all/2024/indiana-made-at-least-56-million-in-improper-fee-for-service-medicaid-payments-for-applied-behavior-analysis-provided-to-children-diagnosed-with-autism/

[19] Discovery ABA, "How to Address Food Selectivity Using ABA Techniques," https://www.discoveryaba.com/aba-therapy/how-to-address-food-selectivity-using-aba-techniques.

[20] Chung KM, Chung E, Lee H. Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis. J Korean Acad Child Adolesc Psychiatry. 2024 Jan 1;35(1):29-38. https://pmc.ncbi.nlm.nih.gov/articles/PMC10774556/

[21] Centers for Medicare & Medicaid Services. (2024, September 26). State Health Official Letter (SHO) #24-005: Best practices for adhering to EPSDT requirements. U.S. Department of Health and Human Services. https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf

[22] U.S. Department of Education. (n.d.). Individuals with Disabilities Education Act (IDEA). Retrieved October 20, 2025, from https://www.ed.gov/laws-and-policy/individuals-disabilities/idea

[23] Autism Speaks, "Applied Behavior Analysis (ABA)," https://www.autismspeaks.org/applied-behavior-analysis.

[24] U.S. Department of Education, "Teacher Shortage Areas," https://www.ed.gov/teaching-and-administration/professional-development/teacher-shortage-areas

[25] Indiana Capital Chronicle, "Following a nationwide trend, Indiana’s teacher vacancies persist," November 8, 2024, https://indianacapitalchronicle.com/2024/11/08/following-a-nationwide-trend-indianas-teacher-vacancies-persist/

[26] Appleton, Aleksandra. “An Indiana licensing program is ‘putting a dent’ in the shortage of special educators with 600 licensed so far.” Chalkbeat Indiana, 29 Oct. 2024, https://www.chalkbeat.org/indiana/2024/10/29/indiana-special-education-licensing-program-sees-600-graduates/

[27] Nimble, "Job listings for Indiana," https://app.hirenimble.com/jobs/state/in.

[28] WRTV, "I-SEAL program helping fill the shortage of special education teachers," https://www.wrtv.com/news/education/i-seal-program-helping-fill-the-shortage-of-special-education-teachers.

[29] Bellwether Education Partners, "Who Pays for Special Education? An Analysis of Federal, State, and Local Spending by States and Districts," October 2024, https://bellwether.org/publications/who-pays-for-special-education/

[30] Congress.gov, "Medicaid's Federal Medical Assistance Percentage (FMAP)," https://www.congress.gov/crs-product/R43847

[31] USA Facts, "How are public schools in Indiana funded?," https://usafacts.org/answers/how-are-public-schools-in-the-us-funded/state/indiana/

[32] Autism Speaks, "IDEA Full Funding Act reintroduced in Congress," April 3, 2025, https://www.autismspeaks.org/advocacy-news/idea-full-funding-act-reintroduced-congress.

[33] CMS. EPSDT – Early and Periodic Screening, Diagnostic, and Treatment. Centers for Medicare & Medicaid Services. Updated 2023. https://www.medicaid.gov/medicaid/benefits/epsdt/index.html

[34] Centers for Medicare & Medicaid Services. (n.d.). Instructions for form CMS-416: EPSDT participation and screening report. U.S. Department of Health & Human Services. https://www.medicaid.gov/medicaid/benefits/downloads/cms-416-instructions.pdf

[35] The Indiana Department of Education’s FMAP Rates document shows Indiana’s FMAP for Federal Fiscal Year 2025 (October 1, 2024 – September 30, 2025) is 64.90%. https://www.in.gov/doe/files/Federal-Medical-Assistance-Percentage-FMAP-Rates.pdf

[36] Giertz, Seth, and Anil Kumar. "The Local Fiscal Multiplier of Intergovernmental Grants: Evidence from Federal Medicaid Assistance to States." Research Department Working Papers, no. 2112, Federal Reserve Bank of Dallas, Dec. 2021, https://www.dallasfed.org/research/papers/2021/wp2112

[37] Giertz, Seth, and Anil Kumar. Dynamic Estimates of the Multiplier from Federal Medicaid Assistance to States. University of Texas at Dallas & Federal Reserve Bank of Dallas, November 2019 (preliminary working paper). Available at: https://ntanet.org/wp-content/uploads/2020/02/Seth-H.-Giertz-Session1510_Paper3119_FullPaper_1.pdf

[38] American Hospital Association. (2025, June 5). Medicaid spending reductions would lead to losses in jobs, economic activity and tax revenue in states. https://www.aha.org/fact-sheets/2025-06-05-medicaid-spending-reductions-would-lead-losses-jobs-economic-activity-and-tax-revenue-states

[39] Mitchell, A. (2020, May 7). Medicaid recession-related FMAP increases (CRS Report No. R46346). Congressional Research Service. https://www.congress.gov/crs-product/R46346

[40] Friedman, C. (2022). A report on the increased payment rates for HCBS for people with intellectual and developmental disabilities during the COVID-19 pandemic. Journal of Developmental and Physical Disabilities. Advance online publication. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9797883/

[41] Ganz, M. L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatrics & Adolescent Medicine, 161(4), 343-349. https://doi.org/10.1001/archpedi.161.4.343

[42] Hall-Lande, J. et al. (n.d.). A Synthesis of the Evidence to Estimate the Lifetime Costs of Autism Spectrum Disorders. University of Minnesota. Retrieved from https://autism.gatech.edu/downloads/methods-cost.pdf

[43] Cidav, Z., Marcus, S., & Mandell, D. (2012). "Implications of Childhood Autism for Parental Employment." Maternal and Child Health Journal, vol. 16, no. 1, pp. 183-191. https://pmc.ncbi.nlm.nih.gov/articles/PMC3356150/

[44] A.J. Drexel Autism Institute. (n.d.). "Living Arrangements of Young Adults on the Autism Spectrum." https://drexel.edu/~/media/Files/autismoutcomes/publications/LCO%20Fact%20Sheet%20Living%20Arrangements.ashx

[45] Buescher, A. V. S., et al. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. JAMA Pediatrics. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1879723

[46] "State Psychiatric Hospitals: Billing Information." Indiana Family and Social Services Administration, n.d., https://www.in.gov/fssa/dmha/state-psychiatric-hospitals/state-psychiatric-hospitals-billing-information/

[47] Mandell et al., 2005: Psychiatric Services, "Prevalence and Predictors of Hospitalization for Children with Autism Spectrum Disorders" https://www.researchgate.net/publication/5870267_Psychiatric_Hospitalization_Among_Children_with_Autism_Spectrum_Disorders

[48] Autism Housing Network and Mastermind Behavior Services. (2025). Autism and Independent Living Resources. https://www.mastermindbehavior.com/post/autism-and-independent-living-resources-83601

[49] Indiana Health Coverage Programs. (2023, July). DDRS Public Notice July 2023 Rates - RHS Alignment. Indiana Family and Social Services Administration. Retrieved from https://www.in.gov/medicaid/providers/files/DDRSPublicNoticeJuly2023Rates_RHSAlignment.pdf

[50] Knapp et al., Journal of Autism and Developmental Disorders, 2009

[51] Government Accountability Office. "Medicaid: Characteristics of and Expenditures for Adults with Intellectual or Developmental Disabilities" (GAO-23-105457, 2023). https://www.gao.gov/products/gao-23-105457

[52] Cidav, Z., Marcus, S., & Mandell, D. (2012). Implications of Childhood Autism for Parental Employment.

https://pmc.ncbi.nlm.nih.gov/articles/PMC3356150/

[53] Leslie DL, Iskandarani K, Velott DL, Stein BD, Mandell DS, Agbese E, Dick AW. Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working. Health Aff (Millwood). 2017 Feb 1; https://pmc.ncbi.nlm.nih.gov/articles/PMC5819340/

[54] Cidav Z, Marcus SC, Mandell DS. Implications of childhood autism for parental employment and earnings. Pediatrics. 2012 Apr; https://pmc.ncbi.nlm.nih.gov/articles/PMC3356150/

[55] Leslie DL, Iskandarani K, Velott DL, Stein BD, Mandell DS, Agbese E, Dick AW. Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working. Health Aff (Millwood). 2017 Feb 1; https://pmc.ncbi.nlm.nih.gov/articles/PMC5819340/

[56] A.J. Drexel Autism Institute. (n.d.). Living Arrangements of Young Adults on the Autism Spectrum. https://drexel.edu/~/media/Files/autismoutcomes/publications/LCO%20Fact%20Sheet%20Living%20Arrangements.ashx

[57] Janet Cakir, Richard E. Frye, and Stephen J. Walker, "The lifetime social cost of autism: 1990–2029," Research in Autism Spectrum Disorders, vol. 68, 2019, https://doi.org/10.1016/j.rasd.2019.101502

[58] Hall-Lande et al., University of Minnesota, Policy Research Brief on ASD Services ici.umn.edu

[59] Singer, E., Research in Developmental Disabilities cost analysis via Spectrum News thetransmitter.org

[60] RAND Corporation, "Proven Benefits of Early Childhood Interventions," 2005, https://www.rand.org/pubs/research_briefs/RB9145.html.

[61] U.S. Department of Health and Human Services, Office of Inspector General. (2024, December 16). Indiana made at least $56 million in improper fee-for-service Medicaid payments for applied behavior analysis provided to children diagnosed with autism (Report No. A-09-22-02002). https://oig.hhs.gov/reports/all/2024/indiana-made-at-least-56-million-in-improper-fee-for-service-medicaid-payments-for-applied-behavior-analysis-provided-to-children-diagnosed-with-autism/

[62] Indiana Health Coverage Programs (IHCP).  Bulletin BT2024194 (November 29, 2024): Clarifies ABA documentation requirements and updates provider enrollment requirements. https://www.in.gov/medicaid/providers/files/bulletins/BT2024194.pdf

[63] Gordon-Lipkin E, Foster J, Peacock G. Whittling Down the Wait Time: Exploring Models to Minimize the Delay from Initial Concern to Diagnosis and Treatment of Autism Spectrum Disorder. Pediatr Clin North Am. 2016 Oct; https://pmc.ncbi.nlm.nih.gov/articles/PMC5583718/

[64]Zwaigenbaum, L., Bauman, M. L., Stone, W. L., et al. Early Identification of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics. 2015 Oct;. https://pmc.ncbi.nlm.nih.gov/articles/PMC9923897/

[65] Fort Wayne Neuropsychology. (n.d.). Autism spectrum evaluations. Fort Wayne Neuropsychology. https://www.fwneuropsych.com/asdevals

[66] Kraft, C., Badesch, S., Shannon, J., Salomon, C., Seal, M., Chettiath, T., & Taraman, S. (n.d.). Wait times and processes for autism diagnostic evaluations: A first report survey of autism centers in the U.S. [White paper]. Cognoa, Inc. https://www.cms.gov/files/document/wait-times-and-processes-autism-diagnostic-evaluations-first-report-survey-autism-centers-us.pdf

[67] IU School of Medicine. (2024). Early Autism Evaluation Hub System. Children's Health Services Research. Retrieved from https://medicine.iu.edu/pediatrics/specialties/health-services/health-equity-through-autism-research-translation/evaluation-hub

[68] Rebecca A. Baum, Brad D. Berman, Jill J. Fussell, Rohan Patel, Nancy J. Roizen, Robert G. Voigt, Laurel K. Leslie; Child Health Needs and the Developmental–Behavioral Pediatrics Workforce Supply: 2020–2040. Pediatrics February 2024 https://doi.org/10.1542/peds.2023-063678H

[69] WRTV Staff. (n.d.). Indy Clinic Begins Autism Diagnostic Evaluations to Help Cut Down on Wait Times. WRTV. Retrieved September 17, 2025, from https://www.wrtv.com/news/local-news/indy-clinic-begins-autism-diagnostic-evaluations-to-help-cut-down-on-wait-times

[70] Kovic, Y., Dallas, G. D., Andrade, J. L., Lloveras, L. A., Peters, K. P., & Soda, T. (2025). The rapid autism assessment: Reducing barriers to behavioral intervention services. Journal of the American Academy of Child & Adolescent Psychiatry. Advance online publication. https://doi.org/10.1016/j.jaac.2025.01.012

[71] Kraft, C., Badesch, S., Shannon, J., Salomon, C., Seal, M., Chettiath, T., & Taraman, S. (n.d.). Wait times and processes for autism diagnostic evaluations: A first report survey of autism centers in the U.S. Cognoa, Inc. https://www.cms.gov/files/document/wait-times-and-processes-autism-diagnostic-evaluations-first-report-survey-autism-centers-us.pdf

[72] National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Health and Medicine Division; Board on Children, Youth, and Families; Board on Health Care Services; Committee on the Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-Being. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. Washington (DC): National Academies Press (US); 2023 Sep 7. https://www.ncbi.nlm.nih.gov/books/NBK599756/

[73] Fort Wayne Neuropsychology. (n.d.). Components of an ASD Eval. Retrieved September 16, 2025, from https://www.fwneuropsych.com/asdevals

[74] U.S. Department of Health and Human Services, Office of Inspector General. (2024, December 16). Indiana made at least $56 million in improper fee-for-service Medicaid payments for applied behavior analysis provided to children diagnosed with autism (Report No. A-09-22-02002). https://oig.hhs.gov/reports/all/2024/indiana-made-at-least-56-million-in-improper-fee-for-service-medicaid-payments-for-applied-behavior-analysis-provided-to-children-diagnosed-with-autism/

[75] U.S. Department of Health and Human Services, Office of Inspector General. (2024, December 16). Indiana made at least $56 million in improper fee-for-service Medicaid payments for applied behavior analysis provided to children diagnosed with autism (Report No. A-09-22-02002). https://oig.hhs.gov/reports/all/2024/indiana-made-at-least-56-million-in-improper-fee-for-service-medicaid-payments-for-applied-behavior-analysis-provided-to-children-diagnosed-with-autism/

[76] Indiana Health Coverage Programs. IHCP Bulletin BT202558. Indiana (2025, May 8). ABA provider enrollment requirement. https://www.in.gov/medicaid/providers/files/bulletins/BT202558.pdf.

[77] Indiana Health Coverage Programs (IHCP).  Bulletin BT2024194 (November 29, 2024): Clarifies ABA documentation requirements and updates provider enrollment requirements. https://www.in.gov/medicaid/providers/files/bulletins/BT2024194.pdf

[78] Council of Autism Service Providers (CASP). (n.d.). Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder. https://assets-002.noviams.com/novi-file-uploads/casp/pdfs-and-documents/ASD_Guidelines/ABA_Practice_Guidelines_3_0-70a721a1.pdf

[79] Pearson. (n.d.). Pearson Assessments. Retrieved September 16, 2025, from https://www.pearsonassessments.com

[80] Master ABA. (n.d.). How to conduct and document an initial assessment for ABA services. Master ABA. Retrieved September 17, 2025, from https://masteraba.com/how-to-conduct-and-document-an-initial-assessment-for-aba-services/

[81] Journeys DDA. (2019, June 17). Assessment intro + Vineland training [Video]. YouTube. https://www.youtube.com/watch?v=PGUUFUBZDsM&t=2392s

[82] Indiana Health Coverage Programs (2025, February 6). BT202519: IHCP publishes formal FAQ for ABA therapy requirements. Indiana Family and Social Services Administration. https://www.in.gov/medicaid/providers/files/bulletins/BT202519.pdf

[83] U.S. House of Representatives, Committee on Appropriations. (2022). Report to Congress on supportive services for individuals with autism (H. Rept. 117-9). https://iacc.hhs.gov/publications/report-to-congress/2022/report_to_congress_2022.pdf

[84] Kraft, C., Badesch, S., Shannon, J., Salomon, C., Seal, M., Chettiath, T., & Taraman, S. (n.d.). Wait times and processes for autism diagnostic evaluations: A first report survey of autism centers in the U.S. Cognoa, Inc. https://www.cms.gov/files/document/wait-times-and-processes-autism-diagnostic-evaluations-first-report-survey-autism-centers-us.pdf

[85] BACB Certificant Data: Behavior Analyst Certification Board. (2025). BACB Certificant Data. Retrieved from https://www.bacb.com/bacb-certificant-data/

[86] Intellistars ABA. (2025, September 3). The rate of job growth for BCBAs. Intellistars ABA Blog. https://www.intellistarsaba.com/blog/the-rate-of-job-growth-for-bcbas

[87] Indiana Behavior Analysis Academy. (n.d.). Frequently asked questions. Indian ABA. Retrieved September 30, 2025, from https://indianabaa.com/faqs/

[88] Littman ER, Gavin L, Broda A, Hodges AC, Spector L. Barriers to Receiving Applied Behavior Analysis Services in Children With Autism Spectrum Disorder. Cureus. 2023 Nov 9; https://pmc.ncbi.nlm.nih.gov/articles/PMC10710535/

[89] Cube Therapy Billing. (2025). How Can You Overcome Medicaid Credentialing Delays and Speed Up Approval. https://www.cubetherapybilling.com/how-can-you-overcome-medicaid-credentialing-delays-and-speed-up-approval

[90] ABA Matrix. (n.d.). Hiring and retaining talent in ABA therapy. https://www.abamatrix.com/hiring-and-retaining-talent-aba-therapy

[91] Slowiak JM, DeLongchamp AC. Self-Care Strategies and Job-Crafting Practices Among Behavior Analysts: Do They Predict Perceptions of Work-Life Balance, Work Engagement, and Burnout? Behav Anal Pract. 2021 Jun 8; https://pmc.ncbi.nlm.nih.gov/articles/PMC9120306

[92] Indiana Health Coverage Programs. (2023, November 30). IHCP announces fee schedule for ABA therapy services, effective Jan. 1, 2024 (IHCP Bulletin BT2023169). Indiana Family and Social Services Administration. Retrieved from https://www.in.gov/medicaid/providers/files/bulletins/BT2023169.pdf

[93] Council of Autism Service Providers (CASP). (n.d.). Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder. https://assets-002.noviams.com/novi-file-uploads/casp/pdfs-and-documents/ASD_Guidelines/ABA_Practice_Guidelines_3_0-70a721a1.pdf

[94]   Indiana Family and Social Services Administration (FSSA). (2023, August). Applied Behavioral Analysis (ABA) Therapy Services Reimbursement Review ABA Provider Meeting - Rate Methodology / Draft Rates. https://www.in.gov/fssa/files/ABA-Reimbursement-Provider-Meeting-August2023.pdf

Structured Family Caregiving (SFC) Service Definition PROPOSAL

Service Definition (Scope)

Structured Family Caregiving (SFC) is a shared living Medicaid waiver service that enables participants to remain safely in their community by supporting dedicated caregivers who provide daily, non-medical care in a home setting. This person-centered approach preserves dignity and independence while preventing unnecessary institutionalization.

The participant receives individualized care in a home setting of their choice while the Principal Caregiver (family or non-family member) provides daily care and receives financial support, training, and ongoing assistance. The SFC Provider Agency serves as the Medicaid provider, ensuring quality, compliance, and monitoring the caregiving relationship. A key component of this model is the Caregiver Coach, a professional from the agency who provides the Principal Caregiver with financial support, personalized training, and consistent, ongoing assistance. The Caregiver Coach is responsible for monitoring the caregiving relationship to ensure the well-being of both the participant and the caregiver.

This service preserves participant dignity while also protecting caregiver sustainability through structured support and expert coaching.

Goals of the Service

•  Ease the economic pressure on caregivers with financial support, allowing them to focus on the participant's needs.

• Strengthen natural caregiver networks to reduce reliance on institutional long-term care.

• Empower caregivers with individualized training, coaching, and resources to sustain their role.

• Promote continuity of care through trusted, established relationships.

• Ensure participants can remain in a culturally competent, person-centered environment of their choice.

• Promote the participant’s independence and dignity in a setting that protects their choice and self-respect.

• Expand the availability of community-based long-term services and supports (LTSS).
  
  

SERVICE LEVELS

There are three levels of SFC, each with a unique per diem rate. The applicable rate is determined by completion of the SFC/Adult Family Care Level of Service Assessment. The assessment is completed annually to reflect the intensity of caregiver support needs:

• Level 1 – AFC/SFC LOS Assessment Score of 0 - 35.

• Level 2 – AFC/SFC LOS Assessment Score of 36 - 60.

• Level 3 – AFC/SFC LOS Assessment Score of 61+
  
  
  

REIMBURSABLE ACTIVITIES

• Personal Care: Assistance with ADLs such as bathing, dressing, grooming, and mobility.

• Medication Management: Only to the extent permitted under state law (e.g., reminders, cueing, or directed assistance).

• Ongoing oversight: Continuous awareness of participant location and activities

• Cueing and redirection: Prompting for safety, routine tasks, and behavioral support

• Instrumental Activities of Daily Living (IADLs): Assistance with meal preparation, light housekeeping, laundry, shopping, financial management, and phone use.

• Technology support: Assistance with communication devices, telehealth, and social connections

• Companionship & Community Inclusion: Social engagement and participation in community activities.

• Transportation Services: Escorting for necessary appointments, whenever possible, such as transporting individuals to doctor. When provided, such transportation is incidental and not duplicative of any other State Plan or waiver service. Support by a substitute caregiver who has met all principal caregiver qualifications.

• Substitute and Backup Care: Provide temporary care through qualified substitute caregivers to support respite, cover emergencies or caregiver illness, and coordinate care during planned absences such as vacations or personal needs.

• Other appropriate supports as described in the individual’s service plan.

SERVICE STANDARDS

1. Waiver Case Manager Responsibilities

• Assessment & Service Planning: The case manager identifies the participant's initial need for Structured Family Caregiving and conducts annual reassessments to confirm ongoing needs and eligibility.

• Define Services: The service plan must clearly outline the specific services and support that the principal caregiver will be providing.

• Care Plan Development: The case manager facilitates the initial development of the person-centered Care Plan and is responsible for coordinating all subsequent updates as the participant's needs change.

• Caregiver Assessment: Administer caregiver assessment and review the findings to verify the caregiver is capable of meeting the participant's needs.

• Deliver Documentation: Once complete, the case manager is responsible for giving both the final service plan and the Caregiver Assessment to the chosen Structured Family Caregiving provider agency. When a participant transfers between agencies, the case manager must also inform the new agency of the participant’s remaining respite day balance for the current service year.

2. Principal Caregiver Responsibilities

• Caregiver Residency: The principal caregiver must reside full-time in the same home as the participant.

• Home Environment: The living arrangement must preserve all rights and dignity of a private residence, including privacy, comfortable surroundings, and the opportunity for the participant to personalize their living space.

• Care Plan Adherence: Provide all support as identified in the participant’s individualized Care Plan/Service Plan.

• Documentation & Incident Reporting: Keep accurate, factual daily records of care and complete all other reporting requirements set by the provider agency or BDS.

• Collaborate with the Care Team: Participate in care planning meetings and team conferences, sharing observations and feedback.

• Training & Communication: Complete all required training and maintain ongoing communication with the agency, providing updates on participant needs or changes in a timely manner.

• Emergency Preparedness: Create an emergency care plan with the SFC agency, maintain up-to-date emergency contact information, and follow all incident reporting protocols.

3. SFC Provider Agency Responsibilities:

• Credentialing, Compliance, and Documentation Oversight: Ensure the principal caregiver meets all qualifications, maintains ongoing compliance with agency and waiver requirements, and that all required caregiver documentation is accurate, complete, and properly maintained.

• Caregiver Development and Training: Use the Case Manager’s Caregiver Assessment to identify training needs, provide ongoing support, and track progress. Deliver initial and continuing training tailored to lay caregivers to ensure they are equipped to provide quality care.

• Home Safety Assessments: Evaluating the home for accessibility and safety.

• Emergency Care Plan: Develop and monitor an emergency care plan that identifies backup caregivers and outlines procedures for potential absences or emergencies.

• Communication & Visits: The provider agency must maintain regular contact with caregivers to offer guidance, review the participant's status, and provide ongoing support. This includes conducting a minimum of two check-in visits per quarter, with at least one being an in-person home visit. Additional visits will be scheduled based on the caregiver’s needs.

• Incident Management & Collaboration: The agency is responsible for managing the entire process for all reportable incidents, including investigation and follow-up. All communication and collaboration with the Case Manager regarding these events must be documented.

• Stipend Administration: Issuing daily stipends to the caregiver, with at least 60% of the Medicaid per diem rate allocated directly to the caregiver.

• Respite Support: Ensure access to substitute caregivers for up to 15 days of respite per year

4. Caregiver Coach Requirements: The SFC provider agency must employ or contract a caregiver coach to provide caregiver training and support that meets the following requirements:

A. Education/Credentials (one required):

• Bachelor's degree in any field

• Associate's degree in social work, nursing, human services, or related field

• High school diploma/GED plus professional certification such as CNA, HHA, QMA, or CHW

B. Experience (one required):

• Professional Track: 2+ years working with vulnerable populations in professional capacity

• Personal Experience Track: 3+ years as primary caregiver for person with disability, chronic illness, or aging-related needs

• Peer Experience Track: 1+ year peer support, advocacy, or mentoring others 

C. Parents of minor participants and spouses are not eligible to serve as caregiver coaches.

5. Caregiver Training Requirements: The Caregiver Coach must conduct all required training according to the following schedule.

• Initial Training: Prior to starting services caregivers must complete all of the floowing:

  • 1. Core Competencies: Either agency training in the BDS core competencies, successfully pass the Home and Community Support Professional (HCSP) Training Program, or be listed on the HCSP Registry, and must be CPR certified.

    2. Participant Needs: Caregivers must be trained in recognizing and responding to the participant's needs—physical, social, emotional, and behavioral.

    3. Safety Certifications: Caregivers must hold current CPR and First Aid certifications that include an in-person skills assessment.

• Ongoing Training: Caregivers must complete a minimum of 8 hours of continuing education each year, beginning on the caregiver’s official date of hire and renewing annually thereafter.

• Training Topics: Training may include, but is not limited to, the following areas:

1. Safety & Emergency Preparedness (core safety, fall prevention, good body mechanics, safe transfers, transportation safety)

2. Infection Control & Hygiene (personal care, bathing, grooming, adaptive feeding if applicable)

3. Nutrition & Meal Support (basic nutrition, special diets, choking risk foods)

4. Person-Centered Care (dignity of risk, behavioral & emotional support, positive behavioral supports, de-escalation strategies)

5. Communication & Cultural Competency (effective communication with individuals with disabilities, cultural sensitivity)

6. Privacy & Documentation (HIPAA, care planning, daily documentation, compliance)

7. Adaptive Equipment & Home Safety (wheelchairs, lifts, bed rails, household organization)

8. Stress Management for Caregivers

9. Autism & Developmental Disability Support Strategies

10. Dementia-Specific Training (if applicable): understanding dementia, behavioral and psychosocial symptom management, decision-making capacity, and advanced care planning

6.  Respite Services

• • Billed Respite is a formal service where the substitute caregiver is employed and paid directly by the provider agency. The agency then bills Medicaid for the service day. The principal caregiver does not receive their daily stipend for the days that the SFC agency provides respite care.

  • Unbilled Respite is an informal arrangement where a friend or family member chosen by the participant provides temporary care. No compensation is provided, the agency does not bill Medicaid for the service day, and the principal caregiver does not receive their daily payment.

  • Stipend Redirection Respite: is an option available only when the substitute caregiver resides full-time in the same home as the participant. During the respite period, the agency redirects the daily payment to the qualified, co-habitating substitute caregiver. The principal caregiver does not receive a payment for these days. The substitute caregiver must meet all agency requirements, including training and compliance with Structured Family Caregiving policies.

  • Entitlement: Each participant is entitled to up to 15 days of respite per service year. The agency is responsible for ensuring this entitlement is met, either by providing the respite directly or coordinating with an appropriate alternative provider.

  • Planning & Documentation: Timing, duration, and format of respite service blocks must be agreed upon at enrollment and documented in the participant’s file. Participant preferences and desired arrangements must be recorded and reviewed regularly.

  • Accountability & Tracking: The agency remains responsible for ensuring respite is delivered or coordinated according to the participant’s plan, including when an external provider is used. Records must include date, duration, and caregiver providing the service.

  • Flexibility: Respite may be used consecutively or intermittently. The agency may adjust scheduling or duration based on participant needs, staffing, and program requirements.

DOCUMENTATATION STANDARDS

• Each quarter (or more often as determined by the individual's circle of support), the service provider must prepare a progress report and provide this report to the case manager. The case manager will upload the progress report to the document library of the individual in the state's case management system on or before the 15th day of the month following the end of the reporting period. The first reporting period must align with the start of the individual's service plan. 

The progress report must include:

o    Name of the individual served

o    IHCP Member ID (RID) of the individual served

o    Service rendered

o    Date range of services rendered

o    Notation of the ratio for service delivery (if ratio other than 1 staff to 1 individual being served)

o    Name of the provider (and title if applicable)

o    Brief summary of progress towards service plan outcomes

o    Challenges hindering progress towards service plan outcomes, if applicable

o    A positive event that occurred during the reporting period that contributed to the individual's good life

• The provider must maintain all documentation required under 455 IAC 2, plus the following records:

  • • • Accessibility: Upon request, all documentation must be made available to auditors, quality monitors, case managers and any other government entity he provider agency. Records may be stored in multiple locations, but they must be clearly organized and easily linked to the individual to meet compliance standards.

      • Qualifications & Training: All caregiver credentialing documentation, qualifications, and training certificates must be maintained in the employee file.

      • Schedules & Attendance: Records of caregiver schedules and attendance logs.

      • Safety Checks: Completed forms for environmental and equipment safety checks.

      • Daily Caregiver Notes: Daily notes documenting non-medical assistance (ADLs/IADLs), supervision provided, and any observed changes in the participant's condition.

      • Care Plan Compliance: Evidence that services are being delivered in accordance with the Care Plan, including any documented adjustments.

      • Incident Reports: All incident reports and documentation of follow-up actions taken.

      • Quarterly Visits & Coaching: Documentation of quarterly home visits, caregiver coaching sessions, wellness planning, and any use of substitute caregivers.

      • Communication Logs: Records of communication with the participant, family, waiver case managers, and other care team members.

      • Case Manager Collaboration: Evidence of collaboration with case managers, focusing on non-medical updates and resource navigation.

• The principal caregiver must document the following relevant data elements for each service day:

o    Services provided: Specific ADLs, IADLs, and supervision assistance completed

o    Participant engagement: Activities, social interactions, and community participation

o    Health and well-being observations: Mood, energy level, appetite, and notable changes

o    Safety concerns: Environmental hazards, incidents, or risk factors

o    Communication: Interactions with family, healthcare providers, or care team

o    Notable events: Appointments, visitors, community activities, or special circumstances

o    Standards: Documentation must focus on observable behaviors and measurable outcomes  

SPECIAL CONSIDERATIONS:

• Billing Conditions: The SFC agency may bill Medicaid on days when either the principal caregiver provides in-person care or care is provided by a Qualified Substitute Caregiver. A Qualified Substitute Caregiver is an individual whose credentials, training, and background have been verified by the agency, confirming their eligibility to provide compliant services under the waiver.

• Daily Stipend Structure: Agencies receive a per diem payment from Medicaid and must pass a minimum of 60% directly to the caregiver as a tax-free stipend.

• Principal Caregiver Compensation: Receives the daily stipend for any day they provide in-person care or supervise care provided by a Qualified Substitute Caregiver. Stipends are issued directly by the agency and are tax-free to the extent allowed under state law.

• Qualified Substitute Caregiver (Live-In or Temporary) Compensation: When providing approved care, substitute caregivers who meet agency qualifications may receive payment either as a stipend (for live-in arrangements where the principal caregiver’s stipend is redirected) or as a W-2/1099 employee through the agency, depending on the employment arrangement.

• Hospital Care Days: The SFC agency may bill Medicaid for up to five consecutive days per hospitalization. The principal caregiver may receive their daily stipend for these days when providing in-person care to the participant in the hospital. A participant must be back in the SFC home for at least 24 hours before a new hospitalization care period can be approved. Hospital care must be documented and coordinated with waiver case management.

• Relatives and LRIs: Structured Family Caregiving will be reimbursed when provided by a the parent of a minor child participant or the spouse of a participant (also known as a Legally Responsible Individual), Relative or a Legal Guardian, ONLY when all conditions specified in Appendix C-2-d and Appendix C-2-e of this waiver are met.

• Provider Qualifications: The agency must have a current national accreditation or a minimum of three years of experience serving older adults and adults with disabilities, either in Indiana or as a Medicaid-participating provider in another state.

ACTIVITIES NOT ALLOWED:

• Household Limit: No more than four participants may be served in a single SFC household.

• Service Exclusivity: Participants enrolled in Structured Family Caregiving may not receive duplicative waiver services such as Attendant Care, Homemaker Services, Assisted Living, or Adult Family Care waiver services

• Skilled Medical Care: Medical services remain responsibility of healthcare providers and are not covered under the SFC waiver service.

• Caregiver Coaches: Parents of minor participants and spouses are not eligible to serve as caregiver coaches.