Autism Advisory Task Force in California

A notice from California's Department of Managed Health Care about a meeting tomorrow, February 1, from 10 AM to 4 PM:

The Department of Managed Health Care (DMHC) has convened the Autism Advisory Task Force called for in Senate Bill 946 authored by Senate President Pro Tem Darrell Steinberg (Chapter 650, Statutes 2011). The Task Force is charged with developing recommendations regarding medically necessary behavioral health treatment for individuals with autism or pervasive developmental disorder (collectively referred to as “autism”), as well as the appropriate qualifications, training and education for providers of such treatment.

Specifically, the Task Force will focus on:

• Scientifically validated Interventions that have demonstrated clinical efficacy and measurable treatment outcomes
• Patient selection, monitoring and duration of therapy
• Qualifications, training and supervision of providers
• Provider network adequacy
• Requirements that unlicensed providers must meet in order to obtain licensure from the state.

The 18-member Task Force is comprised of a diverse group of researchers, providers, advocates and experts charged with developing recommendations for state policy makers on behavioral health treatment for people with autism. The names and biographies of the Task Force members. The work of the Task Force will be grounded in evidence-based research about interventions that have measurable treatment outcomes.

All Task Force meetings will be open to the public and information about the meetings, including agendas, meeting schedules and informational materials are available on the DMHC’s website.

Members of the public may attend the Task Force meetings in-person or participate by phone by calling the following toll-free phone number: 1-800-309-2350, Conference ID: 288476 (spells AUTISM). The Task Force meetings will be audio-recorded and those recordings will be posted on the DMHC’s website.
The DMHC will submit the Task Force report to the Governor and Legislature by December 31, 2012, at which time the Task Force will disband.

Radio Report on the California Managed Care Agreement

KPCC-FM reports on the recent California managed-care agreement, and finds that there is much less to it than meets the eye:

http://media.scpr.org/audio/upload/2011/08/09/autism.mp3

More on the California Managed-Care Settlement

Shaun Heasley reports at Disability Scoop:

California officials claimed a win earlier this month after striking deals with two private insurers to cover behavior therapy for children with autism, but now some advocates are calling the settlements a “sham.”

In recent weeks, the California Department of Managed Health Care announced agreements with Anthem Blue Cross and Blue Shield of California under which the insurers said they would provide coverage of applied behavioral analysis, or ABA, therapy.

State officials said the agreements would “provide immediate coverage upfront to potentially thousands of additional children annually” when they announced the plans.

Now, however, some advocates are crying foul. In a joint letter to California Gov. Jerry Brown, six autism and consumer groups said that the settlement reached with Blue Shield — which was soon followed by a similar agreement with Anthem Blue Cross — is inherently flawed.

Specifically, they cite a requirement under the agreements that ABA be administered under the supervision of a licensed provider. This is a problem, they say, because California does not license ABA providers, making finding an approved therapist unlikely for families.

A news release from Consumer Watchdog:

In a letter this week, Consumer Watchdog called on Governor Brown to replace Schwarzenegger-era regulators at the Department of Managed Health Care (DMHC) after DMHC officials misrepresented the details of an autism settlement with Blue Shield at a legislative hearing last week, and then signed a similar settlement with Blue Cross. Ten of eleven top DMHC officials were either appointed by Governor Schwarzenegger or joined the DMHC during the Schwarzenegger administration. Download the letter here: http://www.consumerwatchdog.org/resources/govbrownletter.pdf.

The DMHC misrepresented the settlement over Blue Shield's denial of coverage for a key autism treatment, Applied Behavioral Analysis (ABA), assuring legislators that the deal would provide autistic children the care they need. However, the fine print of the settlement reveals that the settlement is in reality "a sham that provides no solution and continues to allow Blue Shield to violate the law, " according to the letter to Governor Brown from parents of autistic children and consumer advocates. The groups urged Governor Brown to block any additional settlements. However, yesterday the DMHC announced it had signed a similar deal with Blue Cross.

In the letter, Consumer Watchdog, the Alliance of California Autism Organizations, Autism Deserves Equal Coverage, the Special Needs Network, Inc., Autism Health Advocates, Autism Health Insurance Project, and Sally Brammell, the mother of an autistic child enrolled in a Blue Cross policy regulated by the DMHC, wrote:

"Remarkably, the agreement appears to have been entered into without discussion or consultation with the Department of Insurance (CDI) or the autism providers or advocacy community, and was misleadingly portrayed in a positive light by DMHC officials at a legislative hearing last week held to review DMHC practices. The same DMHC regulators who folded on access to ABA under the pressure of insurance company lobbyists during the Schwarzenegger administration appear to be responsible for negotiating the settlement with Blue Shield. As Consumer Watchdog warned your staff months ago, the governor's office must be directly involved in establishing the state's autism policy going forward, and needs to replace the current leadership at the DMHC as soon as possible."

Under pressure from the insurance industry, during the Schwarzenegger administration the DMHC made a policy change to allow insurance companies it regulates to refuse to pay for ABA on the grounds that ABA is "educational" and not "medically effective," and paradoxically on the grounds that ABA providers are not "licensed" even though no such state license exists. The policy change was lobbied for by the health insurance industry, which gave Governor Schwarzenegger $1,349,850 campaign contributions.

The CDI, led by Insurance Commissioner Dave Jones and enforcing the same state law as the DMHC – the Mental Health Parity Act – unequivocally requires health insurers it regulates to pay for ABA, citing overwhelming medical literature that ABA is the most effective medical treatment for autism, and finding that ABA providers are not required to be licensed as a condition for coverage under insurance contracts.

Consumer Watchdog and co-counsel Strumwasser & Woocher sued the DMHC, in part, over its requirement that ABA providers must be licensed as a condition to be covered under insurance contracts. Consumer Watchdog said the fact that the DMHC continues to fight that lawsuit underscores its refusal to embrace a systemic fix.

California Loopholes

To anyone who follows autism politics, it should come as no surprise that the California managed care agreement is less than it appeared at first. At The San Francisco Chronicle, Laura Shumaker quotes Feda Almaliti, founder and executive director of Autism Health Advocates.

Once upon a time, in a room very nearby, a group sat down at a table behind heavy doors. Some in the group were regulators appointed by a governor named Brown, and some were representatives of a major health plan. But no one at that table was a parent whose child needed therapy, no one there would raise real-life issues or concerns. No one would ever say "Nay."

This fairy tale gathering happened last Monday, July 11th. The regulatory agency was the California Department of Managed Health Care (DMHC) and the health plan was Blue Shield of California.

Together they created a fairy tale settlement agreement because many families in the Land of California have been trying to get insurance coverage for their children with autism. These parents didn't want fairy dust or dolphin therapy. They want their insurance provider to cover the most effective and well-studied studied therapy available for their children, Applied Behavior Analysis (ABA therapy).

Now everyone in the Land of California can read this "settlement agreement." (Here's a link.) It says that Blue Shield will provide ABA to children with autism spectrum disorders. But like in all fairy tale contracts, this one comes with a catch.

They have imposed requirements that can't possibly be met. They have defined the education and certification level of qualified providers at an impossible standard, beyond what is customary in this state. The mythical providers of the therapy they have approved are as rare as unicorns.

...

Postscript: Just before this article went live, the DMHC signed another settlement agreement, this time with Anthem Blue Cross of California. It hasn't been released yet.

But we already know what it says.

POST SCRIPT NUMBER TWO AND HOT OF THE PRESS!

Senator Steinberg has asked the Director of the Department of Managed Health Care to defer settlement agreements until loopholes are addressed.

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)

.

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:

Autism, Managed Care, and California

A press release from Consumer Watchdog:

Autistic children with health insurance coverage regulated under the Brown administration's Department of Managed Health Care (DMHC) are routinely denied access to treatment in violation of state law while children whose policies are regulated by the Department of Insurance (DOI), led by Insurance Commissioner Dave Jones, get the care they need, according to Consumer Watchdog and parents of autistic children testifying today at a Senate hearing in Sacramento.

Consumer Watchdog said the DMHC's willingness to settle an on-going lawsuit brought by the consumer group against the DMHC under the Schwarzenegger administration will be a litmus test of whether the Brown administration is committed to caring for autistic children.

"It is simply outrageous that whether autistic children get the care they need depends on which government regulator oversees their parents' insurance company," said Jerry Flanagan, staff attorney for Consumer Watchdog. "We urge the Brown administration to reverse the Schwarzenegger-era pro-insurer policies that illegally cut off access to needed care and severely undermine the health and safety of some of the state's most vulnerable residents. Beyond the harm to severely ill children, insurers' refusal to provide treatment for autistic kids eventually leaves taxpayers to pick up the tab."

Download Consumer Watchdog's letter to Governor Brown urging him to end the Schwarzenegger-era policies:

http://www.consumerwatchdog.org/resources/autismletter3-9-11.pdf.

Beginning in March of 2009, the DMHC made a policy change to allow insurance companies it regulates to refuse to pay for an essential treatment for autism – Applied Behavioral Analysis (ABA) – on the grounds that ABA is "educational" and not "medically effective," and paradoxically on the grounds that ABA providers are not "licensed" even though no such state license exists.