Autism: Law Make Insurers Cover Therapy – For Now

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Parents of children with autism lauded the governor's decision to sign into law a bill that requires health insurers to cover behavioral health treatments for their kids, but questions linger about the therapy and whether the coverage will continue after the main provisions of the federal health law go into effect in 2014.

The law, Senate Bill 946, will be in effect only from July 1, 2012, through July 1, 2014. After that, either the requirement will be covered under the federal law or the state will have to decide what to do next.

In his signing message, Gov. Jerry Brown expressed reservations about the law and the therapy, saying, "There are remaining questions about effectiveness, duration, and the cost of the covered treatments that must be sorted out.

"There is still much work to be done," he concluded.

Health insurers' view

The law's chief critics, health insurers, read that to mean the governor questions whether they should cover these costly treatments, while the parents of autistic children and their supporters say Brown's reluctance reflects nothing more than the pressure applied by insurance lobbyists.

"There's not a lot of controversy in medical communities about the effectiveness of the treatment," said Kristin Jacobson, who represents the Alliance of California Autism Organizations, which is made up of about 40 groups. "The insurance industry was very effective in raising concerns, and luckily the governor was able to see beyond that."

The therapy at the center of the debate is called applied behavioral analysis, or ABA, and it's a one-on-one form of intervention that focuses on encouraging appropriate behaviors among children with autism while discouraging destructive behaviors.

Many medical organizations consider applied behavioral analysis the most helpful treatment for autism, a condition that affects 1 child in about 110. While the therapy ranges in price from $36,000 to $75,000 a year, California is the 28th state to require insurers to cover it.

The California trade group that represents health insurers argues the therapy is an educational service, not a medical service, and contends the new law will drive up health care costs by almost $850 million a year.

"Adding more benefits, particularly those that are nonmedical and are high-dollar services, policymakers will have to weigh and measure their desire to make sure people have those nonmedical services with the ability to make coverage affordable," said Nicole Evans, spokeswoman for the California Association of Health Plans.

State, federal rules

The new law, written by Senate President Pro Tem Darrell Steinberg, D-Sacramento, exempts publicly funded health plans such as Medi-Cal and plans that state employees have from covering the therapy.

The mandate intersects with the federal health law because the federal government is putting together a list of benefits that will have to be covered. If behavioral therapy is not included, either it will no longer be required or the state will have to decide whether to continue the coverage requirement.

Jerry Flanagan, staff attorney for Consumer Watchdog, which pushed for the expanded autism coverage, said he expects the federal law to include the therapy as a covered benefit.

But, he said, "if the state ultimately requires more coverage than what's required under the federal rules, then the state will have to pay for it."

Parents of autistic children say California should maintain coverage if the federal government doesn't include it. Otherwise, taxpayers will have to continue to shoulder costs of treatments that should be covered by private health insurers.

San Bruno resident Lisa Valerio, parent of an 8-year-old child with severe autism, has struggled with several different insurers over the years to get his treatments covered.

Insurers seek clarification

Early this year, her son, Nathan, started acting aggressively for the first time, and she realized he needed immediate, intensive ABA therapy. Because the treatment wasn't covered under her Kaiser plan, she turned to publicly funded regional centers, which care for people with disabilities.

"Our state is in such a crisis, why should we be relying on our state to fund these services that are medically necessary?" said Valerio, who has battled Kaiser unsuccessfully for treatments for her son.

Kaiser officials said the health maintenance organization has had a long-standing policy of generally considering ABA to be an educational, rather than medical, service and on that basis hasn't routinely covered it.

SB946 changes that.

"We're working in close collaboration with (state regulators) to implement the bill," said John Nelson, spokesman for Kaiser, which has about 13,500 members in California diagnosed with autism. "But we agree with the governor's signing message in that there are areas that need to be clarified."

E-mail Victoria Colliver at [email protected].

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