Group Health Cooperative to Offer Special Autism Benefit in Washington State

FOR IMMEDIATE RELEASE:
July 12, 2012

CONTACT:
Mike Foley, 206-448-4148 

Afterhours, 206-448-4056

CONTACT CLASS COUNSEL:

Eleanor Hamburger, 206-223-0303

Rick Spoonemore, 206-223-0303

Sirianni Youtz Spoonemore

Group Health Cooperative to Offer Special Autism Benefit in Washington State

Court settlement would extend autism coverage to include applied behavioral analysis (ABA) therapy

SEATTLE  – Group Health Cooperative and Sirianni Youtz Spoonemore, counsel for a class of Group Health enrollees with autism, have filed a proposed settlement agreement in D.M. v. Group Health Cooperative, No. 10-2-28618-7 SEA (King County Superior Court, Judge Beth Andrus), which, if approved by the court, will establish coverage for applied behavior analysis (ABA) therapy to treat autism and autism spectrum disorders.  The proposed settlement agreement applies to Group Health members diagnosed with autism or an autism spectrum disorder who are insured under a Group Health plan not governed by the Employee Retirement Income Security Act (“ERISA”).  Non-ERISA plans include church, tribal, and state and local government plans.

 

“The court process is moving us toward a determination of appropriate coverage following the passage of the mental health parity laws at the state level,” said Scott Armstrong, Group Health president and CEO.  “We are pleased to be taking this step toward resolving issues associated with coverage certain therapies for patients with autism.”

 

Group Health was one of the first health plans in the nation to offer mental health benefits to its members in the 1960s. Group Health publicly supported the passage of Washington’s Mental Health Parity Act in 2005.

 

Group Health will provide coverage for ABA therapy for certain plan members to treat autism and autism spectrum disorders.  The ABA coverage will be provided pursuant to specific coverage criteria and will include providing therapy in settings such as a child’s home, by therapy assistants working under the supervision of licensed providers.  Class members may contact Group Health customer service to find out more.

“We are very pleased to work with Group Health to make ABA therapy available to children with autism, like our son,” said John Morton, D.M.’s father.  “We have seen remarkable improvement in our son since he started ABA therapy,” said Clara Chan, D.M.’s mother.  “This agreement paves the way for many children with autism to have access to this essential therapy.”

“We commend Group Health for stepping forward to be the first insurer to provide this benefit,” said Rick Spoonemore of Sirianni Youtz Spoonemore.  “We believe this agreement sets the standard for coverage of ABA therapy by which all other insurers will be judged.”

 

The class action against Group Health is one of six pending class action lawsuits against Washington insurers brought by Sirianni Youtz Spoonemore on behalf of developmentally disabled insureds challenging  exclusions of neurodevelopmental and behavioral therapies. 

Group Health Cooperative 

Group Health is one of the nation’s leading nonprofit health systems, recognized for its consumer-governed cooperative origins and innovative solutions for improving care. Established in 1947, Group Health Cooperative, together with its subsidiaries Health Options, Inc. and KPS Health Plans, provides health coverage to more than 664,000 residents of Washington state and North Idaho.

 

More than 420,000 members receive care from Group Health Physicians medical group at Group Health Medical Centers locations across the Puget Sound region and Spokane. Group Health advances health in the community through its medical education, charitable foundation, and nationally recognized research institute.

 

Sirianni Youtz Spoonemore

Sirianni Youtz Spoonemore is a Seattle law firm specializing in individual and class action ERISA, health, pension, and disability litigation as well as general commercial litigation.

 

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8 thoughts on “Group Health Cooperative to Offer Special Autism Benefit in Washington State

  1. Is this reserved for licensed ABA only?
    What is the status on Speech-Language services, many of which use the ABA principles.

  2. My son is 17 yrs old and when he was diagnosed, Seattle Children’s Hospital sent us home with nothing. We tried to help our son as best as we could with the little information we gathered ourselves. Many services such as speech and occupational therapies that he received through Group Health stopped when he turned 10 and DSHS stopped a few years later. Any therapy he has received ever since has been paid in part by us and by DDD. Now that Group Health is willing to pay for some services, are there any programs that may help my son that would be covered? Like I said, he is 17 already and in most programs you start very young. I would really appreciate the help!

  3. Erika, a comprehensive neuropsychological evaluation would provide a road map of what treatments are medically necessary. If you are a class member in Class members in D.M. v. Group Health Cooperative or Z.D. v. Group Health Cooperative can call Sirianni Youtz Spoonemore at 206-223-0303 and ask for Ele Hamburger or Rick Spoonemore. If GHC doesn’t have a neuropsych in your area with appropriate experience with your son’s needs, you may be able to ask for a single case agreement for another provider. Dr. Ann Uherek is excellent at providing comprehensive neuropsych. evaluations and accepts private insurance.

  4. We are in the process of choosing a health plan for our family, and one of our choices is Group Health. How do I know that the GH plan that I am looking at, will have the ABA benefits? I am not sure what non-ERISA plans are…in the description it makes it sound as though it would mainly be government plans that are available. Our option is under the Machinists Health and Welfare Trust Plan (I’m not sure if that helps).
    On another note, we were with Group Health when our son received a diagnosis of autism at the age of 2.5. In the report, the psychologist specifically stated that ABA was NOT recommended. Is this something that I should forward to one of the class action attorneys? We always just paid out of pockets for ABA services, such as social skills groups.

  5. Christy, you can find out from the HR department if their benefits are ERISA (self-insured, self-funded) plan or if it’s a state regulated plan. When a psychologist states ABA is NOT recommended, that means they don’t find it to be medically necessary. If another healthcare professional (neurologist, or psychologist) believes that to be inaccurate, then they will have to make a medical necessity determination. You can read more about Medical Necessity, which is required for insurance coverage of any treatment or service, @ http://www.washingtonautismadvocacy.org/family/insurance-2/medical-necessity/

  6. what is the financial impact on families who for many years had to out source for help from d.s.h.s. will damages phase cover the the medical bills that have been building up? at the end of the day someone will have to pay-up.and was services helpfull to the fullest or just another hand out from medicaid. would the private insurer give better treatment to maintain treatments to really make impacts and gains with nuerodevelopments, can families really be compencated for exclusions that exist due to family members in need?? thanks to the expert leagle team who got the job done, cant thank you enough for the well needed help for our loved ones. i hope your check is big for your efforts..

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