Neurodevelopmental and Behavioral therapies’ exclusions in the Self-Funded plans

WAAA-LOGOIf your child or children are:

  • insured through a large employer that is self-insured (i.e. coverage through private (for-profit or nonprofit) employer including cities or counties), and
  • they have been denied medically necessary neurodevelopmental therapies (i.e. Speech Therapy, Occupational Therapy) or behavioral therapy (i.e. Applied Behavior Analysis)

WAAA would like to hear from you at your earliest convenience, please call 425.894.7231 with the following information:

  • your employer’s name
  • the type of treatment that is prescribed, but denied or unreasonably capped
  • name of the insurance company that manages your benefits

Please forward this note to any parent whose children may be in a similar situation.

Thank you for your consideration.

 

Mira Posner
Attorney
Washington Autism Alliance & Advocacy
16225 NE 87th St. Ste. A-9
Redmond, WA 98052
Phone: 425-894-7231
Fax: 206-299-3661

Court Certifies National Class Action for all CIGNA Insureds

PHILADELPHIA, Aug. 22, 2012 –/PRNewswire/ — A federal court in Philadelphia yesterday granted class action status to a lawsuit brought by the parents of an autistic child against CIGNA Corporation and related CIGNA entities for their policy of denying insurance coverage for an autism treatment known as Applied Behavior Analysis (ABA) therapy.  In their lawsuit, the plaintiff, Kristopher Churchill and Luis Rolando, allege that the CIGNA companies have a nationwide policy of classifying ABA as experimental, and therefore they do not provide insurance coverage for this therapy.  The plaintiffs claim that the classification of ABA as experimental and the denial of insurance coverage for ABA violates federal laws governing insurance plans. The court’s order today means that the case will proceed as a nationwide class action on behalf of all families having children with autism who were denied coverage by CIGNA for ABA therapy.

According to the lawsuit, ABA is a well recognized and scientifically valid form of autism treatment for children.  Numerous authorities and organizations have supported using ABA to treat autism.  For example, the use of ABA for treating autism has been endorsed by the U.S. Surgeon Generaland the National Institute of Mental Health. The American Academy of Pediatrics has said that the effectiveness of ABA “has been well documented through 5 decades of research.”  Currently, 31 states mandate insurance coverage for ABA-type autism treatments.

In the Court’s Order entered yesterday, Judge Juan R. Sanchez held that the following subclass shall be certified pursuant to FRCP 23(b)(3):

All individuals who, on or after November 24, 2006, (1) were enrolled in a plan administered by a CIGNA Defendant, or insured under health insurance coverage offered by CIGNA Defendant in connection with a plan, and (2) are currently enrolled in a CIGNA-affiliated plan, and (3) who, on or after November 24, 2006, made a claim or make a claim for Applied Behavior Analysis and/or Early Intensive behavioral Treatment for Autism Spectrum Disorder which was denied on the grounds that such treatment is deemed by a CIGNA Defendant to be investigative or experimental.

Churchill and Rolando are represented by Gerard Mantese, Brian Saxe, and John J. Conway of Michigan.  Mantese and Conway are counsel in several cases seeking insurance coverage for ABA therapy.  In 2010,  Mantese and Conway obtained final approval of a class action against Blue Cross Blue Shield of Michigan requiring payment of $1 million in claims for ABA.  They are also currently counsel for several military beneficiaries seeking coverage of ABA from the military’s Tricare insurer.  On July 26, 2012, a federal court in Washington D.C. granted summary judgment ordering that ABA Therapy be provided to military beneficiaries in that case.

Contact information for Churchill’s attorneys follows:

Gerard Mantese, Esq. Brian Saxe, Esq. Mantese Honigman Rossman and Williamson, P.C. 1361 E. Big Beaver Road Troy, Michigan 48083 248-457-9200 Office 248-515-6419 Cell

John J. Conway, Esq. John J. Conway, P.C. 26622 Woodward Avenue, Suite 225 Royal Oak, MI 48067 313-961-6525   Office 313-574-2148   Cell

SOURCE Mantese Honigman Rossman and Williamson

“Essential Health Benefits” Bulletin – Good news for autism! Will Washington state go green?

Late last week U.S. Department of Health and Human Services (HHS) indicated they will be permitting states to maintain coverage for autism behavior therapies, such as Applied Behavior Analysis (ABA), as part of their essential health benefits package when provisions of the new federal health care law take effect in 2014.
“HHS has committed to giving states flexibility in determining benefits,” said Lorri Unumb, Esq., vice president for state government affairs. “Entering 2012, 29 states representing 70 percent of the U.S. population have already made that decision and it is to require coverage of autism benefits. Today’s guidance gives states the freedom to maintain the coverage they have designed for their citizens without having to defray costs for ‘excess’ benefits.”

Under the Patient Protection and Affordable Care Act of 2010, the HHS was directed to determine an essential_health_benefits_bulletin package that would be offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges created under the law that begin operation in 2014. HHS, in its decision on Friday, gave the states the flexibility to choose from four types of health plans in establishing a benchmark for what services should be covered.

“Autism Speaks is optimistic this will enable states to continue to provide comprehensive autism therapies, such as ABA, as part of their essential health benefits package,” Unumb said. In the 29 states which have enacted autism insurance reform, Unumb said, most of the four plans would cover behavioral health treatments, such as ABA.

Here in Washington state however the disparity continues despite herculean efforts by advocates, multiple lawsuits testing one of the most comprehensive Mental Health Parity Laws in the nation.  As we ring in the new year, thousands of families are cautiously optimistic that Washington State Health Care Purchasing Agencies will catch up to the rest of the nation to provide our children, adolescents and adults with ASD’s basic health care benefits for treatment of autism.

Going for Green in 2012!!!

Peacefully,

Arzu Forough