Phony Autism Settlement Hides the Real Issues

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What’s worse than an insurance company that denies a child access to medically necessary treatments for autism?  A complicit regulator that’s too cozy with the very insurers that they are charged to oversee.

On Wednesday, Governor Brown’s Department of Managed Health Care (DMHC) tried to convince Senate President Darrell Steinberg’s legislative committee that it finally reversed years of discrimination against autistic children and their parents in a settlement with Blue Shield.  But the details of the settlement do not live up to the DMHC’s overheated promises. Kate Movius, in the picture above, and a big group of other parents of autistic kids were on hand to set the story straight.

The settlement gives lipservice to the need for autistic children to get access to an essential treatment for autism — Applied Behavioral Analysis (ABA) — but the details likely provide no real improvements for parents and appear designed to fail.

The DMHC still maintains that ABA providers must be licensed for their services to be covered, even though no ABA specific license exists in California.  Blue Shield still maintains that ABA is not a “health care” service even though volumes of medical literature identify it as a highly effective treatment for autism.

Under the terms of the settlement, care overseen by ABA specialists — certified by the national Behavior Analyst Certification Board, Inc. — will not be covered.  Worse, the settlement gives Blue Shield a pass from abiding by state laws requiring them to have a network of providers, leaving parents to find one on their own — a likely impossible feat for many parents. If parents can’t find a licensed provider to oversee the care, Blue Shield does not have to pay.

In an apparent concession, Blue Shield does agree to pay for care overseen by a licensed supervisor even if the person providing the care directly is unlicensed.  But without a network of licensed supervisors it is unclear how this provision provides any real advantage to parents.

The settlement is chock-full of other loopholes and limitations that play into Blue Shield’s hand, giving them a pile of excuses to cut-off care.

The trouble at the DMHC began under the Schwarzenegger administration, and continues there because the same insurer-friendly regulators are still running the show. Its time for the Brown administration to clean house.

Beginning in March of 2009, the DMHC made a policy change to allow insurance companies it regulates to refuse to pay for ABA. That change was one that was lobbied for by a health insurance industry looking to boost profits and adopted under the Schwarzenegger administration, well known for its partiality to health insurers. Schwarzenegger received $1,349,850 in campaign contributions from health insurance companies as governor.

Consumer Watchdog and co-counsel Strumwasser & Woocher sued the DMHC, in part, over its requirement that ABA providers must be licensed as a condition to be covered under insurance contracts.  The DMHC continues to fight that lawsuit, underscoring its refusal to embrace a systemic fix.

It doesn’t have to be this way. The Department of Insurance, enforcing the same state law as the DMHC – the Mental Health Parity Act – but overseeing a different piece of the health insurance market, unequivocally requires health insurers it regulates to pay for ABA, citing overwhelming medical literature that ABA is the most effective medical treatment for autism, and finding that ABA providers are not required to be licensed as a condition for coverage under insurance contracts.

What’s needed is a clear commitment from the Brown administration that autistic children will get the treatments they need when they need it.  The Blue Shield settlement falls far short. 

Jerry Flanagan
Jerry Flanagan
Jerry Flanagan is Consumer Watchdog's Litigation Director. Flanagan leads Consumer Watchdog’s litigation efforts in the areas of health insurance coverage and access to treatments. He has over 20 years experience working in public interest and health care policy, legislation and litigation.

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