Advocates for Autistic Children Threaten To Sue Over HMO Guidelines

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Responding to reports that the state’s HMO regulators are writing new — and potentially more restrictive — guidelines for who can appeal a coverage denial in autism cases, an advocacy group is threatening to sue Gov. Schwarzenegger’s administration over the hot-button issue.

Harvey Rosenfeld, founder of the Santa Monica-based Consumer Watchdog, is accusing state regulators of trying to make it easier for health plans to avoid paying for costly autism treatments that are medically necessary. Rosenfeld sent regulators a letter this week threatening to sue if that happens.

It’s the latest in a widening fight over who should pay for expensive autism therapies. Like all patients, autistic children have a last-resort appeal process in California if their health plan refuses to pay for certain therapies. Independent doctors retained by the state’s Department of Managed Health Care conduct second opinion reviews. And during the last year they have increasingly ruled in favor of the patients, hitting health plans with the bill.

But advocates for autism patients worry things could change. Regulators at the Department of Managed Health care have acknowledged that they are re-writing the guidelines because health plans like Kaiser Permanente and Anthem Blue Cross have changed the legal language they use to deny autism coverage. Instead of claiming behavior therapies are not “medically necessary,” the plans have begun asserting instead that intensive treatments are educational and “not a health care service.”

Several lawsuits against Kaiser have accused the HMO of illegally denying autism coverage. But a consumer lawsuit against the state would break new ground. Rosenfeld, a public interest lawyer who most famously wrote Proposition 103, said Tuesday that his group’s role was “forcing state government to enforce the law.”

Rosenfeld’s efforts follow reports by the Los Angeles Daily Journal that more than a dozen families of autistic children had their Independent Medical Review quietly suspended in January due to the new legal scrutiny by the Department of  Managed Health Care. The department ultimately allowed those reviews to go forward, but activists are concerned.

Lynne Randolph, a spokeswoman for the department, said in a prepared statement that the department was “evaluating the concerns” raised by Consumer Watchdog. “The issues in these cases are highly complex, as are most issues concerning autism.”

Consumer Watchdog
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