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AIS's Health Business Daily
Featured Story August 29, 2008 Coverage for Autism Therapy Prompts State Mandates and Lawsuits Against Blues Plans 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." Pa. Lawmakers Adopt Mandate Pennsylvania is among about a dozen states that have adopted mandates to address insurance coverage for autism. That state's law requires insurers to cover treatment of autism, specifically including ABA, up to a cap of $36,000 per year until the patient is 21 years of age. Coverage under the law is to be implemented by July 2009. The law excludes self-funded or administrative services only (ASO) accounts, and does not apply to groups of 50 or fewer employees. Calega says that Highmark opposed the mandate and considers ABA unproven and experimental. Nonetheless, the health plan worked with state lawmakers to work out a solution that was in the best interests of all stakeholders, she adds. "Our corporate policy at Highmark is to oppose all mandates," she says. "We do not support any mandates because of the fact that they tend to increase the cost of health care for our members and our employer groups." As it became clear that some sort of mandate would be passed by legislators, "we worked with them to make sure that the appropriate specialists had the appropriate training and provided the appropriate care," she says. Calega says that ABA does not have a standardized treatment plan, and has to be highly individualized for each patient. In addition, she contends, it isn't entirely clear whether autism is best addressed as a health care benefit, a behavioral benefit or an educational issue that is the responsibility of schools. The mandate will result in a 1% to 1.5% increase in health insurance premiums for Highmark members, according to Calega. "It's going to have a fairly significant impact." In March, Arizona enacted a law that required insurers to cover up to $50,000 a year for ABA therapy until age 9, and $25,000 a year for children up to age 16. The law requires insurers to provide coverage for autism for fully insured large groups beginning July 1, 2009, according to Carlos DellaMaddalena, spokesperson for Blue Cross Blue Shield of Arizona (BCBSAZ). "While BCBSAZ opposed the mandate for coverage, we worked with the key stakeholders to develop a solution for the best interests for our customers," DellaMaddalena tells The AIS Report. "BCBSAZ is in the preliminary stages of this implementation process." A law enacted in Florida on May 20 requires health insurance companies to negotiate agreements with the state on coverage of the diagnosis and treatment of autism-related disorders. The law caps coverage at $36,000 a year per child, or $200,000 over a lifetime. The mandate applies only to fully insured large groups, according to Valerie Rubin, spokesperson for Blue Cross Blue Shield of Florida. The law "calls for some level of coverage for autism services," Rubin tells The AIS Report. "Because it's so new, we're reviewing it and will try to determine what it means." California enacted a mental health parity law in 2000 that was intended to require insurers to cover autism and other behavioral disorders the same way they cover any medical condition. Critics charge that health plans are not fulfilling their obligations under the law. |
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