Advocates Gain Traction in Insurance Coverage for Autism

Group Health Cooperative has become the first insurer in Washington to pay for such treatment, while legislation is being drafted in Oregon

July 24, 2012 -- Advocates have strengthened their hand in seeking additional insurance coverage for applied behavioral analysis (ABA) treatment. Throughout the West Coast, they’ve achieved victories in the court system and, in Oregon, are focusing their attention on legislative changes.

A settlement agreement awaiting court approval between Group Health Cooperative and the Seattle-based law firm Sirianni Youtz Spoonemore will establish ABA coverage for more than 664,000 residents of Washington and northern Idaho whose members are insured under plans 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, CEO and president of Group Health. “We’re pleased to be taking this step toward resolving issues associated with coverage certain therapies for patients with autism.”

Rick Spoonemore, a partner in the Seattle law firm, added, “We commend Group Health for stepping forward to be the first insurer to provide this benefit. We believe this agreement sets the standard for coverage of ABA therapy by which all other insurers will be judged.”

Sirianni Youtz Spoonemore has five other class-action lawsuits pending against Washington insurers on behalf of developmentally disabled individuals who are challenging the exclusion of neurodevelopmental and behavioral therapies. Defendants include Premera Blue Cross and Regence Blue Shield.

A partial settlement has been reached in Washington involving a class of public employee members with autism who filed legal action against the Washington State Health Care Authority. They’re seeking coverage for ABA therapy recommended by an autism expert that deals with a person’s behavior impacting their development, communication or adjustment. Coverage would also include therapy in natural settings,
such as a child’s home or community by assistants working under the supervision of licensed providers.

“This is a watershed moment for Washington families with autism,” said Arzu Forough, CEO of Washington Autism Alliance & Advocacy. “With HCA’s leadership, we’re entering a new era of full coverage for persons with autism.”

A similar case is set for trial on October 15 in California by plaintiffs suing Kaiser Permanente to pay for intensive autism treatments.

Dual paths are being pursued in Oregon, according to Paul Terdal, an advocate and father of two autistic children, who said that 12 families have succeeded in gaining treatment through litigation or administrative appeals.

After legislation to cover autism treatment stalled in committee last February, a work group has been meeting to discuss the framework for future legislation, including legislators, insurance industry representatives and advocates spearheaded by Sen. Alan Bates (D-Ashland), a physician and a member of the Senate Health Care, Human Services and Rural Health Policy Committee.

“We expect to hear from Senator Bates shortly about our next steps for legislation in Oregon, and to file a bill by September,” Terdal said. “It’s not clear yet whether it will be discussed in legislative days in September. All (of the) insurance companies in Oregon have been actively participating in the process and providing feedback, so there is less of an urgent need for public input.”

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