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Sunday, November 28, 2010

Texas Denial

As the Fort Worth Star-Telegram reports, prosecutor Leticia Martinez and her husband Jeffrey Cureton have run into a loophole in the Texas mandate.

Undeterred, Martinez appealed, pointing out that autism is classified as a serious mental illness, that ABA is medically necessary and that Texas law says it has to be covered.

But the third-party administrators, HealthSmart and Managed Health Network, denied her appeal, saying self-funded plans are not subject to state law and ABA is considered "educational," which is excluded from her plan. In February, Martinez appealed to PEBC [Public Employee Benefits Cooperative] Executive Director Diana Kongevick, who sent Martinez a letter four months later upholding the denial.

"No medical plan covers everything," Kongevick said in a recent phone interview. "That doesn't mean one thing is more important than another. But we couldn't afford in this country to have everything covered, period. It is just not going to happen."

Meanwhile, in the midst of the appeals, Cureton was appointed a federal magistrate judge for the Northern District of Texas -- a position that also offered a self-funded insurance plan but no coverage for ABA.

"I was surprised when I got this appointment that ABA was not covered under any of the federal health benefit plans," he said.

Deeia Beck, executive director of the Office of Public Insurance Counsel, a state advocate for insurance consumers, is among those who believe that self-funded insurance plans should also cover the therapy.

"People often believe state plans have better coverage than private plans and this is an example where, clearly, this is not the case," she said. "ABA therapy has been shown to be extremely effective and that is why it's mandated. It distresses me that other plans do not include that mandate."

A sidebar explains that ABA is the treatment of choice:

For many families, the cost is offset by a program offered by the Texas Department of Assistive and Rehabilitative Services, which contracts with six autism centers statewide, subsidizing the cost of ABA for autistic children ages 3 to 8. But the waiting list is long.
And many insurance companies don't cover ABA. The state mandates fully funded insurance agencies to cover it, but self-funded insurance plans aren't subject to state law and often don't cover it on the grounds that it is "experimental" or "educational."
"I disagree with that," said Dr. Joyce Elizabeth Mauk, CEO of the Child Study Center. "Even the state Legislature has identified it as a medical treatment. It's probably the most studied and most scientifically validated form of treatment for autism."

In Ethan's case, ABA has worked wonders. He no longer just points at what he wants and says "Ma" but now uses words to communicate.

And for parents of autistic children, Le said, those kinds of milestones are priceless.