Medicaid Advocacy

Letter to US State Medicaid Directors

Dear State Medicaid Director,

This past July, the Centers for Medicare and Medicaid Services released a bulletin to states indicating that Medicaid programs across the country must provide “medically necessary diagnostic and treatment services” to beneficiaries with autism under age 21.

While this is an exciting opportunity for children and families, I also recognize that this is a daunting task for many states. Furthermore, CMS is clearly seeking an expeditious response from states to meet the requirement.

A “knee jerk” reaction by many policy makers and advocates has been to mandate Applied Behavioral Analysis (ABA) services as the solution and response to the bulletin. While this is done with good intention, it is very problematic and may actually create more problems than it may solve. We were pleased to see that CMS issued clarification in a frequently asked questions document released recently. CMS emphasized that the directive does not specifically require state Medicaid programs to cover ABA. Rather, that ABA is just one of several offerings that states can choose to provide in order to fulfill their obligations to those on the spectrum.

As you most probably already know, there is no one-size-fits-all approach to supporting and treating children with autism. ABA is clearly effective in modifying behaviors and helping families “normalize” their children’s behaviors. However, that can’t be the sole goal of medical treatment. It is our strong belief that intervention should be seeking to treat the core challenges that underlie the symptoms and behaviors we observe externally. Dr. Thomas Insel, NIMH Director made this point in his December, 2013 Director’s Blog when he stated: "...(I)t is a promise from the NIMH to get beyond diagnostic categories based only on symptoms. Why is this important? For brain disorders, symptoms are generally a late manifestation of a years-long process. In medicine, early detection and early intervention have often been the best ways to improve outcomes." (Dr. Thomas Insel-NIMH Blog-December 2013)

Cutting edge research is showing what we have known for decades – that a developmental relationship-based approach to intervention not only improves external behaviors, but also positively impacts brain functions and improves the core deficits often associate with autism and other developmental challenges.

The International Council on Development and Learning (ICDL) is a not-for-profit that has been operating for over 20 years. The Council brings together professionals from a wide range of fields to work collaboratively to identify strategies to help every child reach his or her fullest potential. The Council has consistently found that a developmental relationship-based approach is the most effective in supporting children with Autism.

The Developmental, Individual-differences, and Relationship-based approach known as DIR® or DIRFloortime® (also known as Floortime™), is the basis of most every developmental relationship-based treatment approach available today. DIR has a steadily increasing evidence-based with more research being released constantly. Just this month, an NIMH funded research project on a DIR program showed very impressive results in improving the functioning for children with autism.

According to the FAQ document released by CMS recently, “CMS is not endorsing or requiring any particular treatment modality for ASD. State Medicaid agencies are responsible for determining what services are medically necessary for eligible individuals.” This then puts the onus on state Medicaid Directors to ensure that their staff understands the various treatment options that are available.

I am requesting the opportunity for myself and/or one of our Council members to meet with you and your staff to discuss DIR and DIR related interventions such as Floortime. These are evidence-based approaches that can make a world of difference for children and families.

I can be reached directly at or 301-678-9325 or your staff can make arrangements through my assistant, Katya Sidor at or 240-600-0047.

Thank you for your time and consideration. For your reference, I have attached links to a few documents that you may find useful.


Jeffrey J. Guenzel

Jeffrey J. Guenzel, MA, LPC

Chief Executive Officer

Links to Attachments:

What is DIR®?

Redefining Autism: The DIR® Model and the DIRFloortime® Approach

DIR® and DIRFloortime®: Evidence-Base Quick Facts

CMS Bulletin 7/7/14

CMS FAQs September 2014