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Thursday, July 14, 2011

Blue Shield to Cover ABA in CA -- Sometimes

Wyatt Buchanan reports in The San Francisco Chronicle:

Parents of children with autism are hopeful they have scored a victory this week after Blue Shield of California has agreed to pay for a form of therapy for the developmental disorder that it previously refused to cover.

The announcement that Blue Shield will pay for behavioral therapies for autism treatment - a step that other providers may soon follow - was made Wednesday during a hearing at the Capitol.

The hearing was focused on myriad problems parents faced in seeking coverage for behavioral therapies for their autistic children, but part of the way through, Maureen McKennan of the Department of Managed Health Care that regulates health maintenance organizations told members of a committee about the agreement.

McKennan, the department's acting deputy director for plan and provider relations, said the deal, which was signed Monday and took effect immediately, includes no denial of coverage for behavioral treatments, though medical necessity of treatments still would be considered, broader access to health providers, forbidding interruptions in care and reimbursing a handful of people for previous treatments they received that Blue Shield would not pay for.

Coverage of the treatment - known as applied behavior analysis or behavioral intervention therapies - has been denied by HMOs and health insurers who said it is not medical treatment. Medical professionals and advocates for those with autism have disagreed.


California's insurance regulation is split between two departments, and the agreement applies only to Blue Shield members whose health plans are overseen by the Department of Managed Health Care and affects about 2.5 million people.

The other regulator, the Department of Insurance, has been aggressive in enforcing what regulators with that department believe is a legal requirement that health insurers pay for the treatment.

California Healthline follows up:
In related news, California's Department of Insurance on Wednesday issued a cease-and-desist order calling for Blue Shield to stop denying coverage for the behavioral autism therapy (Payers & Providers. The order contends that Blue Shield's denials violate the 1999 California Mental Health Parity Act, which requires insurers to provide the same level of coverage for certain mental health conditions as they do for physical conditions., 7/14).

DOI said it issued the order after the parents of two children with autism requested the department's assistance in responding to Blue Shield's denial of coverage for the behavioral therapy (Central Valley Business Times, 7/13).

According to a DOI spokesperson, the order does not take effect immediately. An administrative law judge will need to review the order and Blue Shield potentially could appeal the judge's ruling (Payers & Providers, 7/14).

In a statement, Blue Shield said that it will begin covering behavioral autism treatment in all cases "until the underlying legal issues are resolved in court."

The insurer added that it already has complied with DOI's request to cover the therapy for the two children whose families had requested DOI's assistance (Payers & Providers, 7/14).

See coverage from KABC Los Angeles: