Blue Shield, CDI Reach Settlement on Coverage of Autism Therapy

TOPIC ALERT:

On Tuesday, California Insurance Commissioner Dave Jones (D) announced a settlement with Blue Shield of California in which the insurer agreed to immediately cover specialized therapy for people with autism, the Los Angeles Times reports (Lifsher, Los Angeles Times, 2/1).

The settlement stems from a dispute over the insurer's compliance with California's Mental Health Parity Law, which mandates coverage of medically necessary behavioral therapy (AP/San Jose Mercury News, 1/31).

Background

The treatment -- called applied behavior analysis or behavioral intervention therapy -- typically consists of intensive sessions with a therapist who uses conditioning techniques to help influence behavior.

Many insurers have denied coverage for the therapy, arguing that it is not a medical service and that health plans are not required to cover it by law.

The Department of Insurance in July 2011 issued a cease-and-desist order calling for Blue Shield to stop denying coverage for the therapy.

The same month, Blue Shield signed an agreement with the Department of Managed Health Care to immediately offer coverage for the therapy to members whose health insurance policies are overseen by DMHC (California Healthline, 7/14/11).

Settlement Details

According to the settlement, Blue Shield will cease efforts to:

  • Deny the therapy as a non-covered service;
  • Challenge whether the therapy is a medical necessity; or
  • Require parents to receive approval from a medical reviewer before allowing treatment (Los Angeles Times, 2/1).

Steve Shivinsky -- a Blue Shield spokesperson -- said the settlement with CDI confirms the policy the insurer implemented last summer (AP/San Jose Mercury News, 1/31).

In a statement, Jones said, "This favorable settlement agreement eliminates the frustration and insecurity so many families have faced when seeking autism treatment for their children" (Los Angeles Times, 2/1).


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