States and Insurance

At the Los Angeles Times, Duke Helfand and Alan Zarembo follow up on the agreement between the California Department of Managed Health Care and Blue Shield of California and Anthem Blue Shield (Kaiser is considering):

One autism activist said the agreements give insurance companies a loophole by narrowly defining who can deliver the services.

Kristin Jacobson of the Alliance of California Autism Organizations said California has a shortage of licensed professionals who can provide the therapy.

The agreements, she said, are "not going to resolve the issue for the vast majority of people who need the services."

The therapy is often prescribed for up to 40 hours a week and can cost $70,000 a year or more per child in some cases.

California requires insurers to provide the same level of benefits for mental disorders, including autism, as for physical ailments. But the law does not specify what type of therapy to use.

A bill now being considered by the Legislature would do just that, naming applied behavior analysis as a covered therapy. Regulators and insurers said the new agreements were meant to help families in the short term.

While admitting no violation of law, the insurers said the settlements resolved the dispute for now. Anthem said the agreements would "reduce uncertainty for families trying to access behavioral and medical treatments for autism and related disorders." A Blue Shield spokesman said its settlement protects consumers while various legal issues are resolved.

Audrey Lee, who heads the group Los Angeles Families for Effective Autism Treatment, said six months of treatment is only the beginning for most children. Her son, now 5, has been receiving the behavioral therapy for nearly three years.

In her case, as with many others, the state Department of Developmental Services pays for it — at least for now.

"People don't have confidence that the state of California is going to take care of them," Lee said. "Parents see insurance as the wave of the future as far as funding."

The Sacramento Bee editorializes:

Senate President Pro Tem Darrell Steinberg, who chairs the select committee on autism, is carrying Senate Bill 166, which would settle the dispute by requiring that companies provide the coverage. Insurance companies remain opposed, as does the California Chamber of Commerce, contending that the bill would add to insurance costs.

Those costs are not trivial. The Department of Managed Health Care estimates the therapy runs $50,000 to $70,000 a year for a single child. An analysis of Steinberg's bill estimates its implementation might increase insurance premiums by a combined $222 million a year. But the therapy also can lower long-term costs by helping individuals live more normal lives and reduce their dependence on state services.

As the issue is fought out in the Legislature and in courts in California and other states, the U.S. Department of Health and Human Services is determining whether the therapy is covered under the Affordable Care Act of 2009.

While all that is being sorted out, Blue Shield has done the right thing by reaching an agreement. Other health care providers should follow.

Meanwhile, in Michigan, a press release from a law firm:

In a case brought by families having a child with autism spectrum disorder against Blue Cross Blue Shield of Michigan, Judge Stephen J. Murphy, III, today entered an Order granting Plaintiffs' Motion for Class Certification. The families filed suit against Blue Cross over its policy of denying applied behavior analysis (ABA) therapy to children with autism. The suit alleges that Blue Cross has illegally characterized ABA therapy as "experimental," even though it is validated by overwhelming medical and scientific authorities.

Today's ruling means that the case will proceed on behalf of thousands of families who have Blue Cross insurance and who have a child with autism. The Order was issued in the case of Potter v. Blue Cross Blue Shield of Michigan, No. 10-cv-14981 (E.D. Mich)

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