A therapy for children with autism must be covered by public insurance companies, a California appeals court has ruled. Applied Behavior Analysis — or ABA — “is a system in which every moment and action by the child is monitored and rewarded by the therapist on a one-to-one relationship for periods of 35, 40 hours a week,” plaintiffs’ attorney Fred Woocher said. The case, brought by Consumer Watchdog and Strumwasser & Woocher LLP, sought to extend insurance coverage for the treatment to families with public health insurance. Insurers often deny claims involving applied behavior analysis, according to the lawsuit.
You may find more detail in a press release from Consumer Watchdog:
In a complex opinion issued yesterday, the California Court of Appeal ended the Department of Managed Health Care's (DMHC) discriminatory practice of allowing HMOs to deny treatment for autistic children of state employees and low-income families enrolled in the Healthy Families program on the basis that such treatment can only be administered through state-licensed providers.
The case was brought by the non-profit Consumer Watchdog and Strumwasser & Woocher LLP.
The treatment at issue, known as Applied Behavioral Analysis (ABA), has been found to be the most effective treatment for autistic children, as yesterday's opinion acknowledged. After the lawsuit was filed, the California Legislature agreed with Consumer Watchdog by passing a law in 2011 clarifying that HMOs and health insurers must provide coverage for ABA for children enrolled in private health insurance plans and that such treatment could be provided through providers who are certified by a national board, but not state-licensed. However, the Legislature did not include public employees and Healthy Families enrollees.
The remaining issue to be decided by the Court of Appeal was whether the DMHC could allow HMOs to deny ABA for children enrolled in public health plans if an ABA provider does not hold a state license. As Consumer Watchdog and Strumwasser & Woocher LLP pointed out in the lawsuit, no state licensing currently exists for ABA therapists. [emphasis added]
The Court of Appeal agreed with Consumer Watchdog and Strumwasser & Woocher LLP, stating that the "DMHC cannot uphold a denial of coverage for ABA. . . on the basis that the therapist is unlicensed, even when the plan is exempted from the requirements of the ABA statute."
Read a letter from public employee unions, including the California Profession Firefighters, urging Governor Brown to end the DMHC's discriminatory rule now barred by the court decision: