On Monday July 11, the California Department of Managed Health Care (DMHC) reached a settlement with Blue Shield of California, in which Blue Shield agreed to cover applied behavior analysis (ABA) treatment for autism spectrum disorders (ASD).
The agreement stipulates that that Blue Shield will cover ABA treatment for HMO members whose treatment is regarded as “medically necessary” by a licensed healthcare professional. Blue Shield agreed to cover ABA services for a minimum of six months at the treatment intensity (i.e., treatment hours per week) recommended by the member’s physician. ABA services are to be covered as long as they are provided by or supervised by a licensed professional. The settlement agreement (which can be read in its entirety here) orders this coverage to take immediate effect.
Other insurance companies that are speculated to reach similar settlements with the DMHC include Anthem Blue Cross and Kaiser Permanente.
In similar news, the California Department of Insurance (CDI) issued an order on Wednesday July 13, stating that Blue Shield’s refusal to provide coverage for ABA treatment violated the California Mental Health Parity Act. The CDI states that Blue Shield violated this act by refusing to cover ABA treatment based on invalid arguments that ABA is not “medically necessary,” that it is “experimental,” that ABA providers are not licensed, and that ABA is not a “healthcare service.” This order was issued after the CDI received two complaints from parents of children with ASD, for whom Blue Shield denied coverage for ABA treatment that was recommended by the child’s physician.
In response to the CDI’s order, Blue Shield states, “We will cover Applied Behavioral Analysis (ABA) services for our members, subject to appropriate consumer protections, as we seek guidance from the courts regarding what the law requires.”
Only the future can tell what will come of these legal actions. Some advocates are hopeful that these actions will spark ASD insurance reform in California, while others speculate that these actions will not succeed due to various loopholes. I personally feel that this is a step in the right direction, and I look forward to seeing what will happen in the upcoming weeks.
I am interested in hearing what you have to say on the matter. What are your thoughts on Blue Shield’s settlement to cover ABA treatment for ASD?
Buchanan, W. (2011, July 14). Blue Shield to pay for autism behavioral therapy. San Francisco Chronicle. Retrieved from http://www.sfgate.com