Insurers have been skirting their obligation under recently enacted state law to provide costly behavioral therapies for autism, according to the Department of Insurance, which is proposing emergency regulations aimed at enforcing the law.
In July, California joined more than two dozen other states in requiring private insurers to cover such treatments when medically necessary.
But state officials said they have received dozens of formal complaints that insurers have been delaying and denying coverage by imposing limits on how much therapy a child can receive and who can provide it, and in some cases by requiring extensive cognitive testing before treatment can begin.
The emergency regulations stipulate that those are not valid justifications for denying treatment. Officials said they planned to file the proposed rules Thursday with the state Office of Administrative Law, which will decide in March whether to put them into effect.
"Behavioral therapy is a medical treatment and has to be covered," Insurance Commissioner Dave Jones said in an interview.
Richard Wiebe, a spokesman for the Assn. of California Life and Health Insurance Companies, said insurers are reviewing the proposed regulations and preparing comments for official review. "The science continues to evolve," he said. "The regulations should … let that evolution take place."
An explosion in autism diagnoses over the last two decades has driven the demand for intensive behavioral therapies and launched a multimillion-dollar industry. Most prominent among the treatments is Applied Behavior Analysis, or ABA, in which a therapist spends up to 40 hours a week with a child, using praise and firm guidance to teach the child basic life skills. Treatment for one child often costs $50,000 a year or more.
In California, much of the financial burden has fallen to schools and the state. The new law was aimed in part at shifting a chunk of the costs from taxpayers to private insurers.
ABA is supported by decades of research showing it can improve language, behavior and intelligence test scores. But researchers are still trying to figure out how much treatment is required and why some children respond while others make little progress.
Many parents are motivated by controversial claims that with enough therapy a child can "recover" from autism, a wide-ranging social and communication disorder that has long been seen by scientists as an incurable condition.
Kristin Jacobson, an advocate for autism coverage, said in the last several months she has handled several cases in which Anthem Blue Cross has tried to deny treatment because a child had a low IQ.
Less impaired children tend to have better outcomes in treatment, but even those with low intelligence can benefit, research shows. Furthermore, cognitive testing in people with autism is unreliable because social and communication deficits can interfere with test-taking.
"For a nonverbal child with autism who hasn't begun treatment, it's irrelevant," Jacobson said.
Darrel Ng, a spokesman for Anthem Blue Cross, said he could not comment on the company's policy because of pending litigation.