Autism Law Summit 2024: ABA in Schools, Treatment Intensity & Adult Coverage

Location: Boise, ID Recap by: Jim Hamilton

The Autism Law Summit is the independent annual conference where ABA providers, attorneys, regulators, and a handful of parents work through the practical law of getting autism services covered. Idaho Insurance Director Dean Cameron welcomed the group to Boise. These are the takeaways I thought would be most useful to our families. The official session decks from the summit library are attached at the bottom of this page and linked throughout.

Why treatment intensity matters

• The requirement to follow the profession's standards comes from parity law itself, not just from the profession. As the official intensity deck puts it: "In determining medical necessity and coverage of services for mental health conditions (including autism), health plans are to rely on generally accepted independent professional medical or clinical standards of care," and "NOT payers, managed care orgs, private companies, or individuals" (p. 5).
• For ABA those standards are the CASP practice guidelines, which describe two scopes of service: comprehensive treatment, roughly 30 to 40 hours a week, and focused treatment, roughly 10 to 25 hours, with more when behaviors put health or safety at risk. On intensity, the deck quotes CASP directly: "Patients should receive treatment at the intensity that is most effective to achieve treatment goals," with adjustments "individualized and based on the patient's response to treatment" (p. 6).
• When a payer cites research to justify cutting hours, ask what kind of research it is. Credible evidence includes direct measures administered to the child, not just indirect caregiver or provider report, and the weight of the whole body of literature matters more than the single study attached to a denial letter. The deck also gives a citable bar for "evidence-based": the NCAEP thresholds of two high-quality group studies, or five single-case studies with at least 20 participants, or a hybrid.
• Statistical significance is not the same as clinical significance (p. 9). What shows a treatment changed a child's life is visual analysis of graphed data and statistics quantifying the direction and magnitude of change for that individual, not a p-value across a pooled sample.
• If a denial letter cites the 2024 JAMA Pediatrics meta-analysis on intervention intensity (Sandbank et al.), the deck answers it point by point on p. 12: the analysis excluded at least seven studies of comprehensive intervention, pooled mostly focused, lower-intensity studies with comprehensive ones, and mixed ABA with non-ABA interventions, which "calls into question authors' conclusions that intervention intensity has no bearing on child outcomes."
• One note on sources: the official file posted by the library covers the panel's opening twelve slides. The rest of the session included a systematic review of early intensive behavioural intervention presented by researcher Sigmund Eldevik and colleagues, with scatter plots of weekly treatment hours against gains in IQ and autism severity scores and a reliable-change analysis at high, moderate, and low treatment intensity.

Coding, units, and "maximum units of service"

• The ABA Coding Coalition publishes free guidance including its Supplemental Guidance article and a Model Coverage Policy, and takes questions through the portal on its homepage. Parents can ask directly, not just providers: per the official update deck, the Coalition answered 282 submitted questions in the past year, about 24 a month. (The AMA's November 2018 CPT Assistant article on the ABA codes is not free to everyone; it is available to APBA members or by purchase from the AMA.)
• Medically Unlikely Edits (MUEs) are "maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service," and they are "not meant to be used as hard caps" (deck, p. 15).
• Many commercial payers mirror Medicare's maximum unit limits, which the Coalition considers less appropriate for ABA than Medicaid's. The Coalition advocates both for payers to use the Medicaid values and for CMS to raise the Medicare limits on some ABA codes, and that argument can be quoted in an appeal.
• The ABA codes are agnostic to diagnosis: nothing in the code set limits them to a particular condition.
• From the Coding Coalition's update: quarterly federal billing edits have been flagging ABA and speech therapy or psychotherapy delivered to the same child on the same day, and reports of those same-day denials are ramping up. As the deck puts it, same-day "is NOT CONCURRENT" (p. 25), so a denial on that basis is worth appealing.
• Supervision billed alongside a technician's session is legitimate for that specific code pair: "The services represented by 97155 and 97153 are separate and distinct, so billing them concurrently does not constitute duplication" (deck, p. 20), and the AMA's CPT Assistant guidance says 97155 is intended to be reported with 97153 when the supervising clinician directs a technician.
• Two billing details that explain confusing statements: a unit is 8 to 22 minutes of service under the rounding rules, and a BCBA modifying protocols or writing notes, even in the child's presence, is indirect time that should not be billed as face-to-face service. If your statements look off in either direction, ask.

ABA in school settings

The public conference session "Accessing ABA in School Settings" was presented by Dan Unumb, Esq. of the Autism Legal Resource Center, Rebecca Urbano Powell, BCBA, and Emily Ice, PhD. The framing was the clearest I have heard on this topic:

• Education and medical treatment are two different systems with different standards, different providers, and different purposes. An IEP delivers the special education and related services a child needs for an appropriate education. ABA is medical treatment aimed at every impairing symptom. Your child has rights under both, and one does not cancel out the other.
• Because ABA works on the interaction between behavior and environment, and because generalizing skills across settings is genuinely hard for many children, treatment in the setting where a child spends most of the day can be medically necessary. Treatment should not be limited in advance to a particular location.
• The stronger request is not "put ABA in the IEP." It is a request under the ADA and Section 504 for your child's own qualified provider to deliver prescribed, medically necessary care in the school setting, in the same spirit as a student who needs a service animal getting access. The school then owes you an interactive, good-faith process rather than a blanket "no." One honest caveat on the service-animal comparison: service animals have their own federal regulation with a strong presumption of access, while an outside provider request runs through the general reasonable-modification analysis, so expect the district to argue the difference.
• The school's lawful outs are narrow but real: a district can deny an accommodation that would impose an undue hardship or pose a direct threat to safety, and a safety refusal must rest on actual evidence about your child, not speculation or stereotype. What a district cannot lawfully do is refuse to investigate the request at all; when it is on notice, it must undertake a fact-specific investigation of what a reasonable accommodation would be.
• The session's other structural point: a family raising this as an equal-access claim does not have to exhaust IDEA due process first. A Supreme Court decision and a 2023 federal appeals decision both treat a request to bring your own funded provider as an access question a family could raise against any public facility, not a dispute about whether the education offered was appropriate.
• The written legal analysis behind this session, published by the Autism Legal Resource Center, walks through the school, Medicaid, and insurer duties one at a time, including the EPSDT rule that "the state Medicaid program retains primary responsibility for covering and insuring delivery of all medically necessary healthcare service in school settings for Medicaid eligible children" (p. 4). The EPSDT slide in the session deck names Kansas and Missouri among the states where that obligation applies (42 U.S.C. § 1396d(r)(5)).
• The DOJ filing on service animals in schools is where the access framing gets its teeth. It is a brief rather than a ruling, but the government's position is blunt: "it is not for the School Board to survey the universe of possible accommodations or modifications and determine ... the best, or most 'reasonable' (from its perspective) approach" (p. 8), and meeting IDEA obligations does not settle a district's separate ADA obligations.
• To make that request well: identify your child as a person with a disability seeking an accommodation, reference the ADA and any state law or guidance, demonstrate medical necessity with your provider's documentation, define exactly what access you are asking for, and have a funded provider ready to go.
• Individual reasons that support the request include behaviors that are stable at home or in clinic but high at school, skills that are progressing in ABA but not carrying over, safety concerns that IEP goals have not resolved, and behavioral contrast, where behavior improves in the treatment setting and gets worse in the setting with no treatment.
• States are starting to legislate the process. Colorado's statute requires districts to adopt a policy for outside health care provider access, and requires them to report how many requests they approve and deny. Louisiana's law works differently: it prohibits a district from barring a behavioral health provider when the parent requests the service, and it had to be amended to name ABA providers explicitly. And the South Carolina Department of Education issued a memorandum on April 2, 2024 directing case-by-case consideration of ABA access requests and prohibiting blanket denials.
• The single most practical page in the official session deck is the table of eleven standard school objections with rebuttals (p. 36), including the two districts reach for first: progress on IEP goals has no bearing on medical necessity, and adding clinical ABA is not a change of educational placement. Read it with the request process on p. 32 before any meeting with a district.
• Practical advice for the provider who does get in the door: be warm, make clear you are not there to evaluate the teacher's performance, and say out loud that the goal is for the child to become independent so the medical support can step back.

Coverage for adults

• Many state autism mandates have no age limit at all, and where age caps do exist, the sessions made the case that they cannot survive federal parity analysis: an age cap applied only to a mental health benefit is exactly the kind of limitation parity law prohibits.
• Medicaid is different. The EPSDT benefit that guarantees medically necessary treatment for children runs through age 21, so coverage after that depends on your state plan rather than on EPSDT.
• Parity law reaches Medicaid managed care: if any part of the program is run by a managed care organization, the parity rules come with it.
• When you are arguing for adult coverage, make the policy and cost argument alongside the legal one. Treatment that keeps an adult in a less restrictive setting saves the state money over a lifetime.

The Medicaid settings rule, in plain terms

A panel walked through the 2014 Medicaid settings rule. It was aimed at providers, but the background matters to any family whose adult child may one day rely on a Home and Community-Based Services (HCBS) waiver:

• HCBS waivers are how states fund long-term services for people who would otherwise be at risk of institutionalization. Several million people receive benefits through them.
• Since 2014, a residential setting funded through a waiver must offer real community integration: a legally enforceable lease, privacy and lockable doors, choice of roommates, control over your own schedule including access to food at any time, visitors of your choosing, and a person-centered plan built around the participant's own goals and preferences.
• A setting is presumed to be an institution, and gets heightened scrutiny, if it sits in or next to an institutional building or has the effect of isolating residents from the broader community. The rule is deliberately designed to discourage building new gated, disability-only campuses.
• After a decade spent transitioning existing providers into compliance, the open question the panel kept returning to is how approval will work for newly built communities.

What the payer panel said they want

• Advocate with data, not threats. Speak to the diagnosis, the assessment, and the risky behaviors such as aggression or self-injury, and answer the plan's medical necessity criteria point by point rather than in general terms.
• Reviewers are looking for a documented clinical story. Quantify what is being worked on, why, and how long it took.
• Send a compliment when something goes right. It lands in an employee's file, and it makes the next conversation easier.
• CASP walked through its clinical documentation template in a dedicated session; the deck, Documentation Template Reveal, is available through the ALRC resource library.

The new federal parity rule

A full session walked through the final Mental Health Parity and Addiction Equity Act rule published in September 2024. The slides are in the deck attached below; here is what matters most for families:

• What counts as a mental health condition is no longer up to the plan alone: any condition in the mental, behavioral, and neurodevelopmental disorders chapter of the current ICD or DSM must be treated as one, and the old deference to state guidelines is gone.
• A new "meaningful benefits" standard: if a plan covers a mental health condition at all in a benefit classification, it must cover the core treatments for that condition there too, and federal courts have recognized ABA as a core treatment for autism.
• Plans must prepare a documented comparative analysis of every non-quantitative treatment limitation before imposing it, hand it to regulators within 10 business days of a request, and hand it to you within 30 days of a written request. If you received a denial, they must provide it. A deficient analysis can mean the limitation cannot be applied at all.
• The session's example of what the rule targets: an experimental-treatment exclusion that is written neutrally but applied more stringently to ABA than to comparable medical care.
• The rule phases in for plan years beginning in 2025, with the meaningful-benefits standard and the data-collection requirements following in 2026.
• One caveat learned at the following year's summit: an employer group has challenged parts of this rule in court and enforcement of some provisions is on hold. The parity statute itself and the 2013 rule remain fully in effect, and your right to request the comparative analysis existed before this rule. The 2025 notes cover where things stand.

Where to complain about a self-funded plan

• A useful nugget from the regulators panel: even if your plan is self-funded and therefore outside your state insurance department's usual jurisdiction, you can still file a complaint there, because the department regulates the third-party administrator handling the plan. You will not get a state external review, but the complaint still counts.

These are one parent's notes from a professional conference, shared parent to parent and not legal advice; sessions are cited rather than individual speakers where remarks were informal. Reach out to Jim through the contact form for more information about the Autism Law Summit or help finding any of these resources.