At least four Blues plans are in legal or regulatory hot water over their refusal to cover the cost of applied behavior analytics (ABA) — a common form of treatment for children with autism spectrum disorder — in their standard policies. The controversy could reach a climax in 2014 when the health reform law will require health plans to cover behavioral therapies on par with other medical treatments in all policies.
Previous posts discussed cases in California. This report mentions two others:
• Blue Cross Blue Shield of Michigan: A federal judge in Detroit recently granted a motion for class certification in a suit filed by the families of children denied ABA therapy coverage, according to plaintiffs’ attorney John Conway. The suit alleges that the Blues plan “has illegally characterized ABA therapy as ‘experimental,’” he says, “even though it is validated by overwhelming medical and scientific authorities.” Conway says the Michigan plan has faced similar legal actions more than once already, including paying out a $1 million settlement and a $125,000 settlement just last year.
Michigan Blues spokesperson Helen Stojic says that the ruling is “a decision to continue the case and is not a ruling on the merits of the case.” She adds: “We believe that we have been more progressive than other Michigan insurance companies in addressing autism. In 2009, we became the first insurer in the state to offer businesses with our coverage the option to purchase coverage for autism treatment programs that provide intensive early intervention. To the best of our knowledge, we are the only insurer in Michigan to offer this coverage option to businesses.”
• Empire Blue Cross and Blue Shield of New York: A federal judge also refused to dismiss a class-action suit against Empire. “Empire is committed to keeping abreast of the medical research regarding treatment for autism, including ABA therapy,” Kweskin says. “Decisions regarding whether therapies for autism are medically necessary are made by a review committee, the members of which include physicians and other experts.”
Specifically, she adds, “when considering a claim for ABA therapy, Empire takes into account all information that is submitted to support the claim, including any medical records, correspondence and therapy session notes.” Also, she says, “Empire is aware of laws enacted in New York regarding coverage for autism therapies, and is in full compliance with all of these laws. While Empire has been sued regarding coverage for ABA therapy, the laws, members’ policies and facts in each case are different.”
