The mother of a 6-year-old boy from Lexington County who was diagnosed with autism three years ago recently filed a federal lawsuit against the director of the South Carolina Medicaid agency for the department’s alleged failure to adequately pay for treatment.
Identified in the lawsuit as Z.M., the child’s pediatrician recommended in 2015 that he receive dozens of hours of therapy each week, including six consultation hours of applied behavior analysis therapy.
But the lawsuit alleges that Medicaid’s reimbursement rates for applied behavior analysis, or ABA, are so low that Z.M.’s parents cannot find a provider willing to offer the therapy their son needs. The lawsuit calls South Carolina’s rate “among the worst in the nation.”
Z.M’s lawsuit contends he has been kept waiting more than two years for medically necessary treatment. His parents cannot afford to pay for the therapy themselves, the lawsuit explains.
“ABA treatment is critical at Z.M.’s age to make a behavioral impact on his adult life,” the lawsuit argues. “Without ABA, Z.M. faces serious harm, including regression of his skills and increases in potentially dangerous behaviors as he approaches adolescence.”
Joshua Baker, named as the defendant in the lawsuit, was appointed as the director of the S.C. Medicaid agency by Gov. Henry McMaster last year. Baker previously served as deputy chief of staff under former Gov. Nikki Haley.
A spokeswoman for the S.C. Department of Health and Human Services would not comment on pending litigation.
Criticism surrounding South Carolina’s ABA reimbursement rate pre-dates Baker’s appointment.
The agency recently increased its rate to about $31 an hour for this therapy, but last year the department paid about $17 an hour.
The new rate falls far short of most other states.
Lorri Unumb, vice president for state government affairs at Autism Speaks, a national advocacy group, calculated the average rate among 30 states is about $44 an hour.
Both North Carolina and Georgia pay closer to $50, she said.
ABA providers have no incentive to do business in South Carolina if the Medicaid agency won’t pay them competitive rates, she said.
“Thirty-one (dollars) is still significantly below what seems to be a national average,” Unumb said.
The plaintiff is seeking class action status for the lawsuit. Hearings have not yet been held.
“If a judge feels that access to ABA is actually inhibited in South Carolina, then they’re going to direct the agency to take whatever steps necessary to increase that access,” Unumb said.
An estimated one out of every 59 children have an autism spectrum disorder, according to the Centers for Disease Control and Prevention. Autism is more common among boys than girls.