EBD Blog

In the Virginia (US) legislature (which I sometimes call the “House of Burgess” for fun), efforts to mandate coverage of intensive behavioral therapy (AKA “ABA,” “discrete-trial training,” etc.) by insurance policies gained a little momentum 16 February when Senate Bill 464 passed by a nearly 2-to-1, bi-partisan margin. Earlier this legislative session, one similar bill (HB 303) was rejected by a narrow vote (4-to-4) in the committee on Commerce and Labor of the Virginia House but another (HB 34) may still be alive (I’m too uniformed about legislative processes to know).

The summary of the just-passed Senate bill, whose chief patron is Senator Janet D. Howell of Reston (VA, US), is as follows:

Requires health insurers, health care subscription plans, and health maintenance organizations to provide coverage for the diagnosis of autism spectrum disorder (ASD) and for treatment of ASD in individuals from age two to six, subject to an annual maximum benefit of $35,000. This requirement does not apply to individual or small group policies, contracts, or plans, and will not apply to the state employees’ health insurance plan until July 1, 2015. This measure will not apply to an insurer, corporation, or health maintenance organization if the costs associated with coverage exceed one percent of premiums charged over the experience period.

Virginians who are concerned about helping young children with Autism to succeed should contant their representatives to urge passage of this legislation. It is not a perfect solution (for example, the coverage is limited to young children only), but this is a situation in which the perfect should not be the enemy of the good.

Senator Howell’s bill has co-patrons, including R. Creigh Deeds, Mark R. Herring, David W. Marsden, J. Chapman Petersen, Richard H. Stuart, Patricia S. Ticer, Jill Holtzman Vogel, and Mary Margaret Whipple. Way to go to them and to every Virginia Senator who voted for the bill: Blevins, Colgan, Deeds, Edwards, Herring, Houck, Howell, Locke, Lucas, Marsden, Marsh, McEachin, Miller (Y.B.), Norment, Northam, Petersen, Puckett, Puller, Quayle, Reynolds, Saslaw, Stosch, Stuart, Ticer, Vogel, Wampler, and Whipple. Thanks.

• HB 34 Health insurance; mandated coverage for autism spectrum disorder.
• SB 464 Health insurance; mandated coverage for autism spectrum disorder.
• HB 303 Health insurance; mandated coverage for autism spectrum

The state legislature voted nearly 2:1 to reject similar legislation in 2009 (HB 1588 Autism spectrum disorder; mandated health insurance coverage).

According to Mary Ann Roser of the Austin (TX, US) Statesman, a clinic that provided chelation therapy for Autism is apparently under investigation by federal authorities. Ms. Roser did not report the nature or cause of the investigation of the CARE Clinics.

CARE Clinics, an autism clinic on Bee Cave Road that was being investigated by insurance companies over insurance claims, was raided by the FBI and IRS agents today.

The clinic has been closed, perhaps permanently.

Agents are removing dozens of boxes of documents, but they declined to say what they are looking for. They directed inquiries to Special IRS Agent Mike Lemoine, who did not immediately return a call.

In an article in May of 2009, Ms. Roser reported that the clinic was having financial trouble.

The owner of an Austin-area clinic that treats children with autism — using techniques that are controversial in mainstream medicine — says investigations by three major insurers have left it with a pile of unpaid claims and a crisis: She’s had to lay off most of her staff and drastically reduce the clinic’s hours.

In addition, Kazuko Grace Curtin said the Texas Medical Board is investigating her medical director. She and the doctor — Jesus Caquias — say the investigation is a way of harassing them because they offer nontraditional care for autism patients.

Link to Ms. Roser’s post entitled “Autism clinic raided by federal authorities” and to the earlier article, “Insurance companies question autism clinic’s charges” Check the discussion following the blog post (the first link).

On behalf of the families of two children with Autism, a consumer advocacy groups claims that regulators in California (US) are allowing insurers to deny access to needed therapy. Consumer Watchdog seeks to require the Department of Managed Health Care to mandate that insurers pay for treatment based on applied behavior analysis for children with Autism.

KABC LA coverage

On the heels of the recent agreement in Michigan (US), I have to wonder whether advocates for children with Autism are seeing the beginning of a wave of changes in insurance support for early and intensive behavioral treatment of Autism.

Consumer Watchdog, which was previously known as “Foundation for Taxpayer and Consumer Rights,” has a pretty broad agenda. In addition to insurance issues, it addresses patients’ rights, political corruption, corporate excesses, and other topics. Consumer Watchdog’s site has links to multiple items regarding Autism.

Also see coverage by Lisa Girion of the Los Angeles Times: “Autism patients’ treatment is denied illegally, group says“; Ms. Girion covered this topic previously (see 10 Mar 2009). For other earlier posts on EBD Blog about insurance coverage for children with Autism, see 25 Jun 2009 and 20 Sep 2008.

Although insurance carriers in California must pay for some services, in a memorandum to insurers Monday 9 March 2009 insurance regulators in California indicated that insurance coverage does not have to extend to applied behavior analytic (ABA) treatment for children with Autism. According to Lisa Girion, the memorandum from the Department of Managed Health Care requires insurers to pay for speech, occupational, and physical therapy, but not for educational services aimed at improving daily living skills.

The letter is focused on “ensuring that individuals with Autism Spectrum Disorders (ASD) receive the care they are entitled to under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and accompanying regulations.” It requires that insurers maintain a network of services for evaluation and referral of individuals with ASD that conforms to, Knox-Keene Act. This part addresses screening, diagnosis, qualified providers, and so forth. Under the head “Part B: Treatment for Persons with ASD,” the letter reads

Health plans must do the following:

Cover all basic health care services required under the Knox-Keene Act, including speech, physical, and occupational therapies for persons with ASD, when those health care services are medically necessary.

>>…snip….< <

2. Provide mental health services only through providers who are licensed or certified in accordance with applicable California law.

3. May not categorically exclude any particular health care treatment or therapy for Autism Spectrum Disorder.

So, ABA cannot be expressly denied. As Ms. Girion reported, it must be that the focus of the treatment (e.g., self-care, head banging) that are not considered legitimate targets for mental health. One has to wonder whether speech therapy predicated on behavior analytic principles—and most of the effective speech therapies for children with Autism are based on ABA principles—will become a target.

I have little trouble considering healthy living a mental health issue. Of course, I’m biased, but that might be the path to take. As Ms. Girion notes and the memorandum reads, the Department of Managed Care still requires a process for review of appeals by independent medical providers.

Links to Ms. Girion’s story, “Autism patients in California are dealt insurance setback,” and to the CA Department of Managed Care memorandum.

According to correspondent Julio C. Abreu (Senior Director for Government Affairs at Mental Health America), negotiators for the US House and Senate are near or have reached a compromise that reconciles H.R. 1424 (“No Discrimination in Health Insurance Act of 2008″) and S. 558 (“Mental Health Parity Act of 2007″). These two bills are different versions of similar legislation that will require private health insurance plans to cover mental health (and other) services, just as they cover other conditions. This is, excuse me, HUGE for families of children and youths with emotional and behavioral disorders. I hope that the mental health community, including Mental Health America, the National Alliance on Mental Illness, and the Alliance for Children and Families, springs into action and endorses resolution of this long-festering problem.
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