To Whom It May Concern:

We are reaching out on behalf of ourselves and other licensed psychologists in the state of Colorado who specialize in providing comprehensive psychological evaluation services for autism spectrum disorder (ASD). More specifically, we hold strong values for increasing equitable access to underrepresented and marginalized communities and have built our practices to ensure that individuals with medical Medicaid are served. Currently, in the state of Colorado, all autism evaluations are covered under HealthFirst Medicaid (medical) as ASD is considered a neurological pervasive (lifelong) developmental disability. However, beginning July 1, 2023 the Colorado Department of Health Care Policy & Financing(HCPF) intends to move all ASD evaluations to be billed through the individual RAEs (county behavioral health Medicaid). This change is directly related to the newly formed Behavioral Health Administration and their strategic plan.

There are a number of reasons why we have banded to together and are seeking additional advocacy for the devastating ripple effect this will cause the community. With the new prevalence rates of autism (1 in 36), psychological assessment services are increasingly of need. They allow individuals to access a medical diagnosis that then allow intervention services, educational services, and state/federally funded resources to be accessed.

1. The RAEs require lengthy and prohibitive pre-authorization paperwork for evaluation services (the authorizations are routinely denied despite documented medical necessity). This will create an incredible barrier to services to an already underserved population. Additionally, it seems ill-informed to move ASD evaluations to the behavioral health side of Medicaid as ASD is a neurological (medical) disorder while the most efficacious intervention for ASD such as Applied Behavior Analysis (ABA) therapy will remain with HealthFirst Medicaid. Fragmented services (particularly for complex neurobehavioral disorders) cause confusion and delays.

2. The reimbursement rates for evaluations through the RAEs is far below community standard and unsustainable. The years of specialized training necessary to be qualified to complete ASD testing and the increased costs to running an assessment practice do not allow for equitable compensation. As it stands, Medicaid pays out about 50% of what is billed. This will create a mass exodus of specialty trained providers currently providing ASD evaluations to the Medicaid community. Many private practice clinicians and small group practices have already indicated that they will not credential with the RAEs to provide ASD evaluations should this change occur for the reasons listed above (requirement of pre-authorizations and low reimbursement rates).

3. With only a few providers left to provide ASD evaluations should this change take effect, individuals and their families would be unable to access medically necessary treatment and intervention, creating a gatekeeping effect and barrier to services. In 2022, there were 1.73 million individuals covered under Medicaid in Colorado. The waitlist for children to access an ASD evaluation at Children’s Hospital Colorado is currently 2+ years. There are already too few providers to meet the needs of the ASD Medicaid community and this change would force the majority of providers to no longer provide these services. It is important to note that Medicaid requires a revaluation every 2-3 years to ensure access to ABA services. So this move could cause further lapses of services, because families will be unable to access a timely follow-up evaluation.

4. There is already a shortage of skilled Medicaid providers for the population we specialize in (neurodiverse youth/young adults with complex mental health and/or behavioral concerns). This becomes more concerning when we think about serving our Spanish speaking population. By the end of this decade, 1 in 4 people in Colorado will be Latino/a/e. Currently there are approximately 1.23 million people in Colorado who identify as Hispanic/Latino/a/e. 53% of these speak Spanish to some degree (many monolingual and some bilingual). Across metro Denver, there are less than 5 bilingual and bicultural licensed clinical psychologists who have private practices specializing in Spanish assessment for ASD with the 98% of their Spanish speaking caseloads covered by HealthFirst Medicaid. Spanish speaking families frequently travel from all over Colorado to ensure that they receive culturally and linguistically responsive and appropriate assessment services. Health care disparities already exist and current the prevalence rates (1:36 kids with autism) are specifically related to minority populations identified with an intellectual and/or developmental disability. This will result in further marginalization and reinforce systemic barriers.

5. Most psychologists doing this work are credentialed with HealthFirst Medicaid and not any of the RAEs. Therefore, all psychologists willing to provide ASD evals will have to become credentialled with all 4 RAEs before providing any ASD evaluations, which means best case scenario it will take 4-6 months before the majority of psychologists will be able to be credentialed and able to provide ASD evals. This will significantly impact families seeking treatment and keeping current services.

6. Despite being providers and stakeholders, no one has been formally notified by HCPF of this change that is planned to take effect July 1, 2023. Most practitioners are scheduled out much further than July for ASD evaluations (due to not enough providers as it stands now). This will leave a tremendous number of individuals who have been already waiting months for medically necessary services with nowhere to go after already waiting for for 6-8+ for their initial appointment.

Allowing this change will adversely impact the current ASD population and will only further create health care disparity for individuals with ASD. We have captured some of the most compelling arguments and concerns for this change (below) which has been decided without any consideration of what this will do to the Medicaid community who desperately need assessment nor discussion with the providers and stakeholders.

“The pre-authorizations required by the RAEs makes accessing testing services impossible for Medicaid members. Even representatives from the RAEs have acknowledged this. If testing for ASD is moved the RAEs and this is not changed then in effect this service will be eliminated for Medicaid members and they will no longer be able to receive diagnosis for ASD. This is concerning for those across the lifespan, but given what we know about early intervention and the importance of early intervention for ASD this is especially concerning for the pediatric population.

We have people drive from all over the state to get testing, which is another concern as we couldn’t serve people outside of the RAEs we are paneled with and those in rural areas would lose access to this service. There are people literally drive 8 hours to access this service.

The reimbursement rate for the testing codes through the RAEs is not sustainable. Honestly, if we are not paid commensurate with what we receive from the state for the testing codes we will likely need to step out of doing this work with the Medicaid population, which is heartbreaking given how long people need to wait for ASD testing in Colorado. We currently evaluate about 40 people per month for ASD and, like most people, are scheduled out. If the reimbursement does not allow for a living wage then I am. sure we would not be the only ones who would need to step back. Testing is an expensive service to provide and we spend hundreds of dollars on protocols for each testing case. When combining this additional cost with the low RAE reimbursement it is not sustainable.”

“We just got yet another RAE rejection for a preauth just today, which keeps our denial rate at 100%. I promise that this client really needs the diagnostic clarity our evaluation would bring them, like all of the other clients we have had preauth rejections for before. I pay my admin team to spend 20-30 min inputting data on these preauth forms, only to have them denied every time.”

“With this change, our practice would not be able to continue providing these families with testing services given the extra administration time needed for authorization and the lower reimbursement rates. We have also experienced significant challenges in the past with getting authorization from the RAEs, as well as actually getting reimbursed properly for services that were authorized and provided. We want to do what we can to help make services more accessible for those that need them most, but this change only puts that population at even more of a disadvantage. ”

“The need for skilled psychologists to provide psychological evaluations is far below what is required to meet the need for ASD testing. Moving ASD diagnostic evaluations to an RAE would limit the number of providers even further, as many providers would not opt to become an RAE provider. We would not choose for our practice to become an RAE due to the very low reimbursement rate as well as the added work for prior authorization for psychological testing. The resulting decrease in experienced Medicaid providers who can conduct ASD evaluations would result an additional barrier to services for people with ASD, as the diagnosis is typically necessary to access services.

Ultimately, this would devastate our practice and leave a marginalized community without access to services in a community in which there are already not enough providers. ”

In summary, the public health impact of the HCPF’s decision to move the ASD diagnostic testing to the RAEs will be immense and devastating for families seeking much needed services. We respectfully and urgently ask that this decision is reconsidered.

Thank you for your time,

Jennifer Paz Ryan, M.Ed., Psy.D. (Bilingual Licensed Psychologist with Elevated Insights Assessment)

Claire Dumke, Psy.D. (Licensed Clinical Psychologist with Insights Colorado Therapy & Assessment)

Kate Colón, Psy.D. (Licensed Clinical Psychologist with Elevated Insights Assessment)

Brian Lopez Ph.D., BCBA (Licensed Clinical Psychologist and CEO of JumpStart Autism Center)