Idaho families face new Medicaid therapy caps and fear worse is coming after Gov. Little proposed eliminating speech, occupational and physical therapy coverage.
BOISE, Idaho — New limits on therapy services for Idahoans on Medicaid took effect this month, and families now fear even deeper cuts could be on the way after Gov. Brad Little proposed eliminating coverage for speech, occupational and physical therapy entirely.
10-year-old twin brothers Charlie and Milo McConnel come to ‘We Are Better Together’ therapy clinic in Meridian once a week. They’ve been coming to the clinic for about three years.
The boys have Down syndrome, and their mother, Julie McConnel, told KTVB about each of her boys’ struggles with different things.
“Charlie has a ton to say, but his speech is really, really hard to understand,” she said. “People would ask him his name… he wasn’t ever able to say his own name in a way that other people could understand. A few sessions here, he was able to have a lot more confidence.”
“For Milo, he’s not a big fan of drawing, and I’ve just seen his ability to spend more time coloring and whatnot has really increased,” she said about Milo’s fine motor skills therapy.
The 10-year-old twins qualify for Medicaid because of their disability. It covers almost the entire cost of each therapy visit for them. McConnel said the services have been transformative.
“It’s been just absolutely indispensable to have access to therapies,” McConnel said.
The McConnel family has tried other providers and even in-home therapy in the past, but the connection the boys have to their therapists at We Are Better Together is what keeps them coming back, and why the boys have made improvements, their mother said. She added that the connection is crucial for therapy like theirs.
“We already drive to Meridian from Nampa to come to this clinic because of these relationships and this quality of service that we’re receiving,” she said.
IDHW caps therapy visits for those on Medicaid at 20 visits per year
But how often the boys can receive that care is now changing.
On Thursday Jan. 8, therapy providers across Idaho received a letter from the Department of Health and Welfare announcing that physical, speech and occupational therapy visits for Medicaid patients would be capped at 20 visits per year. The letter was dated Jan. 8 but made the change effective Jan. 1.
“If they’re coming once a week, all year long, 20 visits is not nearly enough for them,” McConnel said.
Sarah Bergsma, co-owner of Better Together, said providers were caught off guard by the announcement.
“We just had a meeting with them in December, and nothing was announced then,” Bergsma said. “And so it seems a little shocking that we would get a letter and that it would be retroactive.”
The clinic serves about 300 children per week, and 65 percent of them are on Medicaid, she said.
IDHW did not want to go on camera for an interview about the change, but in a statement to KTVB:
“Idaho Medicaid regularly reviews its policies to ensure consistency with best practices. Prior to this change, a provider had to order physical therapy, occupational therapy and speech therapy, but Idaho Medicaid did not authorize that the service was medically necessary before it was rendered. Commercial insurance commonly requires prior authorization after the 1st evaluation and treatment visit and before any follow up therapy. In reviewing other Medicaid programs, states commonly require prior authorization after 15 or 20 visits to confirm that the therapy continues is medically necessary. Idaho’s policy will now align with Medicaid programs in similar states such as Wyoming and Utah. Wyoming requires prior authorization after 20 visits for OT and PT, and 30 visits for ST. Utah requires prior authorization after 20 visits for OT and PT, and 15 visits for ST.”
Additionally, the department said additional visits can be requested.
“Additional approvals beyond 20 visits will be determined though a prior authorization review process to ensure medical necessity. Providers must submit requests using the standard prior authorization form, which identifies the required clinical documentation to accompany the request to demonstrate the continued need for services, progress toward treatment goals and other requirements. Reviews by appropriate clinical professionals consider diagnosis, functional status, response to prior treatment, evidence-based guidelines, and alignment with federal requirements when applicable. Approvals will be issued for a defined duration and number of visits, with ongoing services subject to reauthorization based on updated clinical information.”
At this time, the department said it has “not developed an estimate for potential cost savings from this policy change.”
But Bergsma said the new prior authorization process adds another layer of bureaucracy that could delay care.
“(Before the change) the authorization comes from the physician, now there’s an extra party involved,” Bergsma said. “It has to go to the doctor and to the Medicaid office.”
Bergsma said she understands if the department is reviewing polices and eliminating waste, but worries the new approval process could cause gaps in treatment. She said she is meeting with IDHW on Friday to learn more about the procedures the clinic will need to do, in order to avoid any denials or lapse in care as much as possible. Bergsma said she’s concerned that needing to submit new paperwork every 20 visits for approval could require extra work she doesn’t have the staffing for.
“I’m scared. For a lot of our patients, they require the consistency of therapy, and even a couple week lapse of therapy, if they’re not sure if the paperwork is done, they regress,” Bergsma said.
But the 20-visit cap may be the least of their concerns.
Removing access to these services for Medicaid patients is on the horizon
Gov. Brad Little’s budget proposal for fiscal year 2027, which begins in October, calls for $45 million in Medicaid expenditure reductions, including the complete elimination of Medicaid coverage for speech, occupational and physical therapy.
In his ‘Enduring Idaho’ budget plan for FY27, cuts to Medicaid Little is proposing include: “An additional reduction to hospital rates; an additional reduction to residential habilitation rates; removal of administrative costs for Managed Care contracts; removal of the pharmacy benefit for non-expansion adults on Medicaid; removal of adult dental services; removal of home and community based services; removal of physical, occupational, and speech therapy services; removal of case management support; removal of hospice services; removal of adult prosthetics and orthotics; removal of adult in-home nursing services; removal of adult chiropractic services; removal of adult audiology services; or removal of adult vision services.”
Little claims repealing Medicaid expansion is not something he’s looking at.
McConnel said she was unaware of the proposal until KTVB informed her of it during the interview on Wednesday.
“I’m stunned. I can’t understand the rationale behind that,” McConnel said. “I don’t understand why it’s some of the most vulnerable people in our communities that have to suffer when we’re looking to make cuts.”
Critics of the JFAC process point to last year’s historic tax cuts as a cut to revenue, which put Idaho in this position of having to cut Medicaid.
McConnel said her family cannot afford to pay for therapy out of pocket, which is the same story for many of the other families at the Meridian clinic.
Bergsma said if the elimination takes effect, many families will go without therapy.
“It means that many of our kids won’t get services. It means that I won’t probably be able to stay in business and or employ as many therapists as I do,” Bergsma said.
For McConnel, the stakes are deeply personal. As an older mother, she often thinks about what will happen to her sons when she is no longer around to advocate for them.
“Our fear, too, as parents of children with disabilities, is what happens to them when we’re gone?” McConnel said. “I’m a little bit older mom, so that’s a very real scenario in our life, that I will they will outlive me, and having things set in such a way that they are as well set up as possible so they can have the best quality of life is so important to me.”
The governor’s proposal now goes to the Idaho Legislature, which will ultimately decide whether to adopt it during the current session.
The Department of Health and Welfare did not respond to questions about the proposed elimination of therapy coverage.
Bergsma said providers and families are planning to advocate at the Capitol in the coming weeks.
“A year ago, I would have never seen this coming,” McConnel said.
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