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Stanford Medicine

Autism, Health Policy

Who pays for autism therapy?

The battle to get health insurers to cover a particular therapy for children with autism – Applied Behavior Analysis, or ABA – is heating up, and an article posted today on AISHealth gives a quick update on four Blue Shield/Blue Cross plans that are resisting pressure to pay for such services:

At least four Blues plans are in legal or regulatory hot water over their refusal to cover the cost of applied behavior analytics (ABA) – a common form of treatment for children with autism spectrum disorder – in their standard policies. The controversy could reach a climax in 2014 when the health reform law will require health plans to cover behavioral therapies on par with other medical treatments in all policies.

At issue is what ABA actually is and who’s eligible to provide it. On the one hand, mental health professionals, including the National Institute of Mental Health, government programs including Medicaid, the U.S. Surgeon General, the American Academy of Pediatrics, the American Psychological Association, the American Society of Pediatrics and more than half of all states consider ABA to be, as the California Department of Insurance (CDI) puts it, “a common and proven approach toward improving the lives of children with autism” and a “proven transformative therapy.”

ABA therapy is based on behavioral conditioning techniques, CDI points out, “and reinforcement of positive behaviors to shape behaviors and teach new skills.” It adds, “Decades of research show it to be a successful and well-established treatment for autism and not an experimental or investigational treatment.”

But many health plans, including Blues plans, question that. Some call the therapy experimental, and others say it’s an educational service, not medical treatment. And many plans say they just can’t cover services provided by non-licensed professionals. For example, Empire Blue Cross and Blue Shield, which is owned by WellPoint, Inc., “takes into account the terms of the member’s policy,” says spokesperson Sally Kweskin. “Many policies only provide benefits for services rendered by licensed clinicians, and many benefit contracts exclude coverage for services that are educational in nature.”

Mind you, the Blues aren’t the only insurers under pressure. A news release issued yesterday from a law firm in Philadelphia announced that its suit against CIGNA Insurance for denying coverage for ABA therapy for autism had been granted class action status in federal court.

The stakes in these cases are pretty high as the cost for covering all requests for ABA would be a substantial sum. There is, of course, no cure for autism, and until there is, many families will be demanding these services.

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