Ruling's Effect on Autism Coverage

by David Gorn

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The Second District Court of Appeal in Los Angeles last week ruled that the Department of Managed Health Care cannot use licensure as a basis for denial of a type of autism treatment to state employees.

The ruling means better access for patients to applied behavior analysis (ABA) therapy, according to Jamie Court, president of Consumer Watchdog, the consumer advocacy group that brought the lawsuit.

"This case was a landmark ... and a big victory for public employees, who will be able to get ABA therapy," Court said.

Court said the state previously had a policy of allowing denial of ABA therapy because of a lack of licensing -- though health plans, he said, weren't actually denying it. And at one point, he added, the state worked on the assumption that ABA therapy was educational, not medicinal.

The bigger issue, Court said, involves the central principle of whether or not ABA therapy is a medically necessary treatment, and that part of the ruling came across clearly, he said.

"This was a resounding affirmation that ABA therapy is the right medicine for the job," Court said.

The next big issue is to challenge the lack of access to ABA therapy services among Medi-Cal beneficiaries -- particularly those who previously were in the Healthy Families program, Court said. Medi-Cal is California's Medicaid program, and Healthy Families is the state's Children's Health Insurance Program.

Many children lost access to ABA during this year's transition to Medi-Cal managed care, Court said, though some of those kids could be eligible for help in the regional centers.

"This lawsuit could never reach that far, but the next question is, since Healthy Families [families] had access to ABA therapy, should that entitlement go with them?" Court said.

"The real takeaway is that Medi-Cal recipients have been left out [of ABA therapy coverage]," he said. That's the last remaining question that needs to be answered, and that would be resolved with another lawsuit or new legislation."


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