Coverage for Autism Therapy Prompts State Mandates and Lawsuits Against Blues Plans
By LisaAKAmom
09-03-08
Coverage for Autism Therapy Prompts State Mandates and Lawsuits Against Blues Plans
tinyurl.com/633wek
Reprinted from The AIS Report on Blue Cross and Blue Shield Plans, a hard-hitting independent monthly newsletter on business strategies, products and markets, mergers and alliances, and financing of BC/BS plans.
An explosion in the number of children diagnosed with autism has led to lawsuits against Blue Cross and Blue Shield plans and other carriers over health insurance coverage for controversial therapies. Concerns over autism therapy also have prompted several states, such as Arizona, Florida and Pennsylvania, to enact new autism benefit mandates, forcing Blues plans to revise coverage policies.
On July 1, the father of a 7-year-old with autism filed a lawsuit against Blue Cross Blue Shield of Michigan to force the insurer to reimburse about $8,000 paid for therapy, according to one of the family's attorneys, John J. Conway of Detroit. Another suit over autism therapy coverage was filed in April against WellPoint, Inc. subsidiary Anthem Blue Cross and Kaiser Permanente in California.
Autism is a baffling and costly developmental disability that affects about 1.5 million Americans, according to the Autism Society of America (ASA). The disorder is marked by impaired social interaction and communication, and engagement in repetitive behaviors. The condition is on a continuum of "autism spectrum disorders" that includes Asperger syndrome. Autism has become a hot-button issue as its prevalence has increased dramatically in recent years and as some critics have linked childhood vaccines to the condition. According to the federal Centers for Disease Control and Prevention (CDC) in Atlanta, the incidence of autism has almost doubled since 2000, now affecting about 1 in 150 American children. Autism cases in Michigan have skyrocketed from 4,700 in 2002 to 11,000 in 2006, according to CDC.
Treatment of autism can be expensive. The ASA estimates that the lifetime cost of caring for a child with autism ranges from $3 to $5 million.
During a hearing scheduled for Oct. 22 in the U.S. District Court for the Eastern Division of Michigan, Southern Division, the court will consider a motion to certify the Michigan Blues suit for class-action status. Certification as a class would broaden the suit "to represent other potential claimants in the same situation" as his client, explains Conway.
At issue in the lawsuits against the Blues plans is an intensive one-on-one therapy called applied behavioral analysis (ABA). A full course of ABA therapy costs upwards of $90,000, according to Conway.
Conway says the Michigan Blues plan sent hisclient's family "a pretty bare-bones, perfunctory denial that says, 'Our in-house people think [ABA] is experimental.'"
Michigan Blues spokesperson Helen Stojic declines to comment on the specifics of the lawsuit filed against the plan. But, she says, "Blue Cross Blue Shield of Michigan understands the concern and is very sympathetic to the challenges of families dealing with autism. However, the push to expand employer insurance coverage — through the courts or legislation — comes at a time when many employers are seriously struggling to pay for their existing coverage."
Conway says that ABA is endorsed by the American Academy of Pediatrics, the U.S. Surgeon General, the Association for the Science of Autism Treatment and the New York State Department of Health, among other authorities, and notes that ABA therapy is covered by Blue Cross and Blue Shield of Minnesota.
"Applied behavioral analysis isn't experimental to Blue Cross and Blue Shield of Minnesota," he says. "They pay for the treatment in Minnesota, so we don't know why kids covered in Michigan don't get it, even though they're both covered by Blue Cross entities — same therapy, same medical cases."
Ginny Calega, M.D., vice president of medical management and policy at Pittsburgh-based Highmark Inc., says that the evidence on ABA is not all that clear-cut.
"When you look at the clinical literature around applied behavioral analysis, it's very difficult to compare one study to another," she tells The AIS Report. "They tend to be small populations and have highly individualized needs. When you look at effectiveness and outcomes, it's really difficult to compare study to study because the parameters are different.
+ Read more: tinyurl.com/633wek
To read the rest of this report online browse here www.sarnet.org/lib/todaySAR.htm
tinyurl.com/633wek
Reprinted from The AIS Report on Blue Cross and Blue Shield Plans, a hard-hitting independent monthly newsletter on business strategies, products and markets, mergers and alliances, and financing of BC/BS plans.
An explosion in the number of children diagnosed with autism has led to lawsuits against Blue Cross and Blue Shield plans and other carriers over health insurance coverage for controversial therapies. Concerns over autism therapy also have prompted several states, such as Arizona, Florida and Pennsylvania, to enact new autism benefit mandates, forcing Blues plans to revise coverage policies.
On July 1, the father of a 7-year-old with autism filed a lawsuit against Blue Cross Blue Shield of Michigan to force the insurer to reimburse about $8,000 paid for therapy, according to one of the family's attorneys, John J. Conway of Detroit. Another suit over autism therapy coverage was filed in April against WellPoint, Inc. subsidiary Anthem Blue Cross and Kaiser Permanente in California.
Autism is a baffling and costly developmental disability that affects about 1.5 million Americans, according to the Autism Society of America (ASA). The disorder is marked by impaired social interaction and communication, and engagement in repetitive behaviors. The condition is on a continuum of "autism spectrum disorders" that includes Asperger syndrome. Autism has become a hot-button issue as its prevalence has increased dramatically in recent years and as some critics have linked childhood vaccines to the condition. According to the federal Centers for Disease Control and Prevention (CDC) in Atlanta, the incidence of autism has almost doubled since 2000, now affecting about 1 in 150 American children. Autism cases in Michigan have skyrocketed from 4,700 in 2002 to 11,000 in 2006, according to CDC.
Treatment of autism can be expensive. The ASA estimates that the lifetime cost of caring for a child with autism ranges from $3 to $5 million.
During a hearing scheduled for Oct. 22 in the U.S. District Court for the Eastern Division of Michigan, Southern Division, the court will consider a motion to certify the Michigan Blues suit for class-action status. Certification as a class would broaden the suit "to represent other potential claimants in the same situation" as his client, explains Conway.
At issue in the lawsuits against the Blues plans is an intensive one-on-one therapy called applied behavioral analysis (ABA). A full course of ABA therapy costs upwards of $90,000, according to Conway.
Conway says the Michigan Blues plan sent hisclient's family "a pretty bare-bones, perfunctory denial that says, 'Our in-house people think [ABA] is experimental.'"
Michigan Blues spokesperson Helen Stojic declines to comment on the specifics of the lawsuit filed against the plan. But, she says, "Blue Cross Blue Shield of Michigan understands the concern and is very sympathetic to the challenges of families dealing with autism. However, the push to expand employer insurance coverage — through the courts or legislation — comes at a time when many employers are seriously struggling to pay for their existing coverage."
Conway says that ABA is endorsed by the American Academy of Pediatrics, the U.S. Surgeon General, the Association for the Science of Autism Treatment and the New York State Department of Health, among other authorities, and notes that ABA therapy is covered by Blue Cross and Blue Shield of Minnesota.
"Applied behavioral analysis isn't experimental to Blue Cross and Blue Shield of Minnesota," he says. "They pay for the treatment in Minnesota, so we don't know why kids covered in Michigan don't get it, even though they're both covered by Blue Cross entities — same therapy, same medical cases."
Ginny Calega, M.D., vice president of medical management and policy at Pittsburgh-based Highmark Inc., says that the evidence on ABA is not all that clear-cut.
"When you look at the clinical literature around applied behavioral analysis, it's very difficult to compare one study to another," she tells The AIS Report. "They tend to be small populations and have highly individualized needs. When you look at effectiveness and outcomes, it's really difficult to compare study to study because the parameters are different.
+ Read more: tinyurl.com/633wek
To read the rest of this report online browse here www.sarnet.org/lib/todaySAR.htm
Messages posted for this Topic
I agree...this is something that is much
By LisaAKAmom
09-04-08
Needed. I can remember fighting with the insurance and the school district over who's responsibility it is to provide speech services and how much.
I know we have all been there.
I know we have all been there.
Yes
By Motherof4
09-03-08
With so many different causes and contributing factors, it really is hard to come up with a one-size-fits-all treatment plan. Still, with treatments like ABA, which are helpful for a large number of ASD patients, it would be sensible for companies to cover them in every state, not just in one or two.
