Blue Shield Agrees To Provide Coverage for Autism Therapy

Blue Shield of California has signed an agreement saying it will pay for a certain type of autism therapy that it previously had refused to cover, the San Francisco Chronicle reports.

The treatment -- called applied behavior analysis or behavioral intervention therapy -- typically consists of intensive sessions with a therapist who uses conditioning techniques to help influence behavior. Many insurers have denied coverage for the therapy, arguing that it is not a medical service and that health plans are not required to cover it by law.

Agreement With DMHC

Maureen McKennan -- acting deputy director for plan and provider relations at the Department of Managed Health Care -- announced the deal during a hearing at the state Capitol on Wednesday. McKennan said that Blue Shield signed the agreement on Monday and that it took effect immediately.

The deal applies only to Blue Shield members whose health insurance policies are overseen by DMHC.

Under the terms of the agreement, Blue Shield said it will not deny coverage for behavioral autism treatments, although it will consider the medical necessity of such treatments. In addition, the insurer agreed to:

• Avoid interruptions in care;
• Expand access to health care providers; and
• Reimburse some individuals for treatments that Blue Shield previously refused to cover.

McKennan said that state regulators are close to reaching a similar agreement with Anthem Blue Cross and that they also are in discussions with Kaiser Permanente.

Senate President Pro Tempore Darrell Steinberg (D-Sacramento) has introduced a bill (SB 166) that would require all California health plans to cover the behavioral autism therapy (Buchanan, San Francisco Chronicle, 7/14).

DOI Action Against Blue Shield

In related news, California's Department of Insurance on Wednesday issued a cease-and-desist order calling for Blue Shield to stop denying coverage for the behavioral autism therapy (Payers & Providers, 7/14).

The order contends that Blue Shield's denials violate the 1999 California Mental Health Parity Act, which requires insurers to provide the same level of coverage for certain mental health conditions as they do for physical conditions.

DOI said it issued the order after the parents of two children with autism requested the department's assistance in responding to Blue Shield's denial of coverage for the behavioral therapy (Central Valley Business Times, 7/13).

According to a DOI spokesperson, the order does not take effect immediately. An administrative law judge will need to review the order and Blue Shield potentially could appeal the judge's ruling (Payers & Providers, 7/14).

Blue Shield Response

In a statement, Blue Shield said that it will begin covering behavioral autism treatment in all cases "until the underlying legal issues are resolved in court."

The insurer added that it already has complied with DOI's request to cover the therapy for the two children whose families had requested DOI's assistance (Payers & Providers, 7/14).