Bill calls on HMOs to cover therapy for autistic students

Health care providers in California would be required to cover a widely used behavior therapy for autistic students under legislation scheduled for an initial hearing today in Sacramento.

As many as 100,000 school age children with autism are believed to be receiving some form of the behavioral health treatment either through school districts or state-supported clinics - which can cost as much as $70,000 a year per patient. The therapy has been generally categorized as educational - not medical - by health care providers and thus many insurance companies have declined to pay for the service.

But SB 770 by Senate leader Darrell Steinberg, D-Sacramento, would mandate coverage for the therapy, clearly identifying it as medically necessary when needed. This specifically includes applied behavioral analysis,' which is a favored treatment by many experts that work with autistic children.

Parents of autistic children shouldn't have to spend their days and sleepless nights battling with insurance companies because of a lack of clarity regarding this highly effective therapy," said Steinberg in a statement. "Applied behavioral analysis has long been considered medically necessary and has proven remarkably effective for a majority of families."

The bill comes on the heels of a July settlement between the California Department of Managed Health Care and two of the state's biggest health care providers - Anthem Blue Cross and Blue Shield of California.

The department, which among other things regulates Health Maintenance Organizations, has held that applied behavioral analysis is a covered health care service under California law and that insurance plans are required to provide the treatment when medically needed.

Complaints about the coverage issue prompted state regulators to begin their investigation in 2007, which resulted in the finding that both firms either delayed or failed to arrange for the services to be provided to some of their enrolled families.

Although neither firm admitted wrongdoing, they have agreed to begin paying for an initial six months of services for HMO patients provided that the treatment has been deemed "medically necessary."

One of the big problems with the settlement, Steinberg and others have pointed out, is that it requires that the providers of the therapy be licensed or supervised by a licensed provider of the treatment. But California does not issue a license for applied behavioral analysis therapy - thus there is some concern how much service will actually be provided under the settlement.

Steinberg noted that the uncertainty of who is authorized to perform the treatment adds urgency to the need for clarifying legislation. "We need a more expansive network which includes those who are expertly trained and on the cutting edge of ABA therapy so parents don't have to jump through bureaucratic hoops to get children the services they need," he said.

To address that issue, SB 770 identifies a wide array of health care professionals as qualified to provide the treatment from licensed physicians and psychologists to family therapists and clinical social workers as well as those certified by a national testing board engaged in behavior therapy.

The intent is to ensure that professionals who are currently providing the care and are being paid by school districts or regional clinics - will be designated to continue to provide the treatment.

What remains unclear is exactly how the new insurance benefit would mesh with the existing system.

Schools and regional clinics currently provide and pay for a large majority of the behavior treatment to K-12 students - but exactly how the insurance companies would be brought into the process without disrupting existing relationships and individual treatment has not yet been put into regulatory guidelines - as one staffer said, SB 770 provides a framework to start the process. more