Family hits Medicaid roadblocks in getting 5-year-old needed care

A Southwest Florida mom says she’s fighting so her five year old can continue to get the care she needs.

As any 5-year-old does, Sophia Martinez has a lot to say. She’s loves pictures, reading, and anything she can get her hands on.

But her mom, Yashira Martinez, says this not who she was three years ago, “she would head butt the wall, the tile floor, she would pull her hair, bite her hands.”

All because, mom says, she didn’t know how to communicate.

Yashira Martinez sought professional help. Neurologists diagnosed sophia with autism and her doctors recommended applied behavioral analysis therapy or ABA.

Martinez said, “In a matter of I want to say 2 to 3 months, sophia was signing, she wanted a cracker, she’d sign cracker.”

Then she she started talking.

Behavior analyst Lauren Lovell calls sophia’s progress remarkable, “As her communication skills built and went up, those target behaviors went down …now we have a little girl, we have someone we can interact with.”

But getting here has only been half the battle. The other half, getting the therapy Sophia needs covered by her health insurance.

Medicaid covered the therapy for three years, but her family is now having problems getting the treatment approved.

Lovell said, “As a provider it breaks your heart.”

The state is using a new company to approve plans. The family submitted the request in June… and more than one month later, they still haven’t received the green light. So Sophia stopped going in.

“The more time that goes on without children getting services, the more dramatic effect it’s gonna have because the behaviors just get worse,” Lovell said.

Sophia’s been out of therapy for almost 3 weeks and her mom says she’s noticing signs of regression, “I feel desperate, you start panicking … my child needs it, and not just my child, but other children and not only Lee County but it’s the whole state of Florida.”

Lovell added that “it’s a major safety concern, and what we do is considered medically necessary.”

After meeting Sophia last week we reached out to the Florida Agency for Health Care Administration.

And Thursday, her mom tells me they’ve finally been approved after waiting almost two months.

The agency said the average time to process a request is about 12 days, but they couldn’t say the reason for these delays.

They added that they’ve been meeting with the company tasked with review, and ensure they can more quickly respond to requests.