Eleventh Circuit Rules that Florida Medicaid Must Cover Medically Necessary Behavioral Treatment for Children with Autism Disorders

On September 20, 2013, the U.S. Court of Appeals for the Eleventh Circuit upheld a March 2012 ruling by Judge Joan Lenard of the Southern District of Florida on behalf of several Miami parents who had sued the Florida Medicaid agency when they were denied Medicaid coverage of Applied Behavioral Analysis (“ABA”), the single evidence-based effective treatment for autism. The Eleventh Circuit affirmed the District Court’s ruling that the state violated the Medicaid Act when it excluded coverage of ABA therapy that the children need. The court ordered the state to remove coverage restrictions and take steps needed to assure Medicaid coverage of ABA therapy moves forward.

The case was filed by Legal Services of Greater Miami (LSGMI) on behalf of three autistic children residing in Miami. LSGMI has stated that “this case will have national impact because, while most states mandate that private insurance companies must cover ABA, most Medicaid programs do not provide coverage.” The children’s treating physicians explained the extreme disparity between the prognosis of privately insured children with autism, who receive ABA, and those on Medicaid, who do not.  Medicaid argued that the treatment was “experimental,” and therefore not medically necessary for a child’s treatment.

Betsy Havens, an Equal Justice Works Fellow, presented the Plaintiffs’ rebuttal expert. Following a lengthy trial that included a review of high quality scientific literature by LSGMI’s expert, Judge Lenard ruled the therapy had long been regarded as safe and effective by mainstream doctors, and that the state was discriminating against poor children by denying it. In Florida, like many states, private insurers are required to cover behavior analysis.