Sacramento — Parents of children with autism are hopeful they have scored a victory this week after Blue Shield of California has agreed to pay for a form of therapy for the developmental disorder that it previously refused to cover.
The announcement that Blue Shield will pay for behavioral therapies for autism treatment – a step that other providers may soon follow – was made Wednesday during a hearing at the Capitol.
The hearing was focused on myriad problems parents faced in seeking coverage for behavioral therapies for their autistic children, but part of the way through, Maureen McKennan of the Department of Managed Health Care that regulates health maintenance organizations told members of a committee about the agreement.
McKennan, the department's acting deputy director for plan and provider relations, said the deal, which was signed Monday and took effect immediately, includes no denial of coverage for behavioral treatments, though medical necessity of treatments still would be considered, broader access to health providers, forbidding interruptions in care and reimbursing a handful of people for previous treatments they received that Blue Shield would not pay for.
Coverage of the treatment – known as applied behavior analysis or behavioral intervention therapies – has been denied by HMOs and health insurers who said it is not medical treatment. Medical professionals and advocates for those with autism have disagreed.
"These treatments are the best treatments we have for autism right now," said Dr. Joshua Feder, an autism expert who is a psychiatrist and assistant professor at UC San Diego. He noted that autism diagnoses have been growing rapidly, from 4 in every 10,000 people in 1990 to 1 in 110 today.
The treatments are highly individualized and often take months of reinforcement. Therapists seek to focus on the environment surrounding a certain behavior – such as what happens before and what happens after successful communication – and use that to reinforce the behavior.
It's an intensive treatment that has been described as rewiring the brain, with a therapist modeling behavior for a child.
But at Wednesday's hearing, parents of children with autism described to lawmakers sometimes years-long endeavors of trying to get such treatment for their children after battling with health providers.
California's insurance regulation is split between two departments, and the agreement applies only to Blue Shield members whose health plans are overseen by the Department of Managed Health Care and affects about 2.5 million people.
The other regulator, the Department of Insurance, has been aggressive in enforcing what regulators with that department believe is a legal requirement that health insurers pay for the treatment.
Senate President Pro Tem Darrell Steinberg, D-Sacramento, who is chairman of the Senate Select Committee on Autism and Related Disorders, said the agreement "sounds very, very positive," though he said the details of it would receive significant scrutiny from the Legislature.
"I'm confident to say progress is being made. The question is, how much progress?" he said.
McKennan said that regulators and Anthem Blue Cross were close to making a similar agreement and that the department was in talks with Kaiser Permanente as well. If all three agreed to the provisions, more than 90 percent of people in California with HMO plans would be covered.
But Charles Bacchi, executive vice president of the California Association of Health Plans, said that the treatment is not a medical service and that health providers are not required by law to offer it. That organization has a lawsuit moving through court to resolve the issue.
Meanwhile, Steinberg has introduced a bill, SB 166, that would mandate providers in California cover applied behavior analysis therapy.
How much the agreement will mean for Blue Shield members remains to be seen, and lawmakers said they wanted to revisit the issue to find out. But Jerry Flanagan, a staff attorney for the group Consumer Watchdog, called the settlement "an exercise in political deflection" for the Department of Managed Health Care and he said the language was not strong enough to ensure there are therapists in the Blue Shield network who actually provide those services.
Flanagan called it "doomed to fail."
E-mail Wyatt Buchanan at [email protected].