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Insurance Update

Specialized Behavior therapies (including Applied Behavior Analysis) and neurodevelopmental therapies are “mental health services” designed to treat autism, a DSM (Diagnostic and Statistical Manual of Mental Disorders) category.  Under Mental Health Parity, blanket insurance policy exclusion for services, therapies and supplies (as well as unreasonable caps) related to the treatment of autism spectrum disorders violates Mental Health Parity laws.

Summary of MHP cases 102213 Please contact ehamburger@sylaw.comor call 206-223-0303 for status of these cases.  

If your children’s therapies are unreasonably capped or they have no benefits for treatments of autism, WAAA can help.  Contact 425.894.7231 or  Info@washingtonautismadvocacy.org.  Please indicate whether your child is covered through private insurance or medicaid.  Washington Autism Alliance & Advocacy is committed to ensure timely access to medical benefits designed to treat autism for all children in Washington.”

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Washington’s Network Adequacy Statute and Rules require health plans to ensure that enrollees are entitled to sufficient, timely and appropriate health care services and choice among health care providers (this includes behavior therapies). In articular, the statute requires that “[e]ach carrier must provide for appropriate and timely referral of enrollees to a choice of specialists within the plan if specialty care is warranted(such as Applied Behavior Analysis).

If the type of medical specialist needed for a specific condition is not represented on the specialty panel, enrollees must have access to nonparticipating specialty health care providers.Health carriers are required to maintain adequate networks of providers in order to ensure that health plan enrollees can obtain treatment in their local communities without undue delay, traveling onerous distances or incurring additional out-of-pocket expenses:

An example of “reasonable proximity” is provided in the regulations through the Office of Insurance Commissioner:

“For example, a carrier should not require travel of thirty miles or more when a provider who meets carrier standards is available for inclusion in the network and practices within five miles of enrollees.”

The court is asked not to permit health carriers (Washington State Health Care Authority-HCA) to work around the Court’s Order by imposing a new condition of participating in a research study, for coverage of ABA therapy for autism.

Washington’s Mental Health Parity Act and its Network Adequacy statutes and regulations prohibit HCA’s conditions.

Stephanie Marquis, spokeswoman for the insurance commissioner, has said: “We’re working on a regulation that addresses the issues the courts have ruled on so far that will ensure consumers get the coverage they’re entitled to and insurers understand what they’re required to cover. “The draft language should be ready by the end of the year, she said.

In the meanwhile if any individual with ASD’s has been denied coverage for neuro-developmental therapy (speech, physical therapy, occupational therapy, sensory-motor, neuropsychological evaluation etc.),  behavioral therapy (including Applied Behavioral Analysis therapy) or mental health therapy based upon exclusions or limitations in their Washington state insurance policies, please contact WAAA,  425-894-7231 or info@WashingtonAutismAdvocacy.org.

4 Responses to Insurance Update

  1. Vivien Koo says:

    Our son is 8 years old who was diagnosed with ASD since he was three. My husband’s company insurance is Premera Blue Cross and we have never been able to access ABA coverage for my son. Last year, we had to pay out-of-pocket for Anthony to access ABA therapy so that he can function adequately at his school.
    Since we cannot afford his ABA therapy anymore this year. (We are a household of 6, with 4 kids, one in college) Our financial burden is heavy. We decided to homeschool Anthony hoping that he can have a learning environment. We feel that without the ABA intervention, he would not be able to cope with the academic and social demands of a mainstream classroom environment.
    Can we get any help in negotiating with the company or Blue Cross? Under the new WA Healthcare Exchange, would we be able to get another insurance carrier that can provide ABA coverage for our son?

  2. James Olson says:

    We have never been able to get coverage for our son Alexander around ABA. Often we’d hear you have to have a qualified specialist, but our carrier wouldn’t have one listed in the state. Or it would be out of Network and out of Network wasn’t covered. Only there was no one within network doing ABA. Sometimes we’d get coverage for physical therapy but with a $1500 limit. I’m looking at getting new insurance through the affordable care act. Is there any information on which carriers or plans provide coverage for ABA or physical therapy? I can’t tell by reading the plan descriptions.

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