April 24th, 2015 by Michele Trivedi
The Arc of Indiana, along with other autism advocacy organizations and autism treatment providers, has made various efforts to work directly with representatives from Anthem to address serious concerns that parents, physicians and ABA providers have about the way the company handles medical necessity determinations for autism treatment, specifically for Applied Behavior Analysis therapy (commonly called “ABA”).
We worked diligently for the past three years, having several face–to- face meetings with Anthem Medical Directors and staff, ABA providers, affected families, the Indiana Department of Insurance, and experts in the field of Applied Behavior Analysis therapy for autism treatment.
Unfortunately, as hard as we worked to get issues addressed at the systemic level, our counter-parts at Anthem were willing to address issues on a case-by-case, one authorization period at a time basis only. We were very concerned that this would lead to litigation. We had hoped to address the issues within the appropriate insurance regulation channels and bring relief to families who are suffering and children who are going without medically necessary treatment because of their age and misinformation about what public schools are required to provide for children with autism.
The Indiana Autism Mandate, the first in the nation, requires coverage for all medically necessary treatment for autism. It has no language that allows insurers to determine coverage based upon services that the insurer perceives the public school, or any other agency, “should” provide. Public schools must provide access to an appropriate education; they do not treat medical conditions.
The Indiana Mandate was passed to address discrimination against persons with autism within the health insurance industry, and to address that the cost of intervention for persons with autism was being thrust upon the parents and tax-payer funded systems (public schools and Medicaid) with no medical care responsibility being borne by the private insurance system. All must share in the investment in bringing this population to its full functioning potential. It is in all of our best interests.
Anthem maintains that children over age 7 should get their care from the public school. No, they should get their education from the public school. They should get their medical care and clinical treatment from the health care system, like everyone else. Can you imagine if Anthem said “we will not pay for insulin for diabetic children during school hours?” “We will only pay for chemotherapy if it is conducted outside of school hours?” “We won’t pay for your child’s hospitalization because it was intense and lengthy and they need time to play and should be in school?” By denying school aged children the intensity of services that they need medically, this is exactly what Anthem, and at least one other insurer, is saying to children with autism.
It is a shame that, in the course of three years, reasonable people could not have addressed this serious concern without litigation. We at The Arc remain ready and willing to address issues experienced by the disability community directly with the companies and state agencies involved, but we must be met at the table with an equal desire to find a true solution. In the meantime, the calls from devastated families who do not know where to turn continue to come to our office. If you have questions or need assistance, contact us at 317-977-2375 or 800-382-9100; or email Michele Trivedi, The Arc Insurance Project Manager.
Listen: A View into Insurance and ABA Therapy