Insurers balk at autism therapy

Patient advocates called on state regulators Tuesday to force health insurers to cover certain autism treatments.

Consumer Watchdog in Santa Monica sent a letter to Cindy Ehnes, executive director of the state Department of Managed Health Care, and her boss, Gov. Arnold Schwarzenegger, expressing concern about delays in resolving coverage complaints from parents of autistic children.

The parents say insurers are refusing to cover needed behavioral therapy for their children. But, the parents say, when they took their complaints to the department, it sat on them for months.

Consumer Watchdog founder Harvey Rosenfield said in the letter that state laws require the department to take swift action on the parents’ complaints and that delays could exacerbate the children’s condition.


Autism is a disorder that impairs communication and socialization. Its cause is unknown. There is no cure. But experts and public health authorities say that the disputed behavioral therapy is effective, especially when started at an early age, at mitigating symptoms and improving self-sufficiency.

The department had been sending disputes over the treatment to panels of independent physicians. Increasingly over the last year, those panels had been deciding that the treatments were medically necessary, and the insurers were made to pay.

Then, late last year, Kaiser Permanente, the state’s largest nonprofit health insurer, changed its rationale for denying the coverage.

Instead of saying the treatment is not medically necessary, Kaiser now says the therapy is not covered because it is educational and not medical.


The new tactic prompted the department to put several treatment disputes on hold while it considered how to respond.

“The proper handling of Independent Medical Reviews for autism coverage has been a high priority for the DMHC, and the issues in these cases are highly complex, as are most issues concerning autism,” said Department of Managed Health Care spokeswoman Lynne Randolph.

“Children with autism and their families deserve a complete examination by the DMHC of all complexities of these cases, which is what we have been providing,” Randolph said.

The department’s reconsideration of the disputes stoked concern among parents and patient advocates that it might allow insurers to avoid covering the treatments.

Rosenfield threatened to sue the department if it retreated.

“There are no exceptions to the legal requirement that the plans provide coverage for ‘medically necessary’ treatment to autistic patients . . . no matter what the [insurers] cynically attempt to call it,” Rosenfield said in the letter to the department.

The new pressure on regulators raises the stakes in an ongoing controversy over treatment for children with autism.

Parents of autistic children have filed at least two class-action lawsuits against Kaiser in recent months, accusing the insurer of using a series of sham excuses to deny treatment in order to avoid the expense.


Charles Bacchi, interim president of the California Assn. of Health Plans, said that requiring insurers to cover behavioral therapy would drive up everyone’s premiums.

“We believe that health plans provide comprehensive coverage for autism related medical services for parents and children every single day,” he said. “However, educational services, we believe, are more appropriately covered by schools and [government] regional centers.”

Like the association, Kaiser has “asked the department for clarity surrounding the department’s views about sending coverage disputes of non-healthcare services to” independent physician review panels, said Jim Anderson, a spokesman for Kaiser.