Judge Rules on State’s Authority Over Autism Coverage Disputes
Los Angeles Superior Court Judge Robert O'Brien recently ruled that the California Department of Managed Health Care did not follow the proper steps for implementing a new government regulation when it changed its policy for reviewing coverage disputes related to autism therapy, the Los Angeles Daily Journal reports.
However, O'Brien's ruling protects DMHC's authority to oversee such coverage disputes (Gallegos, Los Angeles Daily Journal, 1/5).
California's mental health parity law requires insurers to cover mental conditions to the same degree that they cover physical ailments.
However, many insurers avoid covering an autism therapy called applied behavior analysis because they claim it is an educational treatment rather than a medical service. ABA can cost up to $70,000 annually per child.
DMHCÂ initially forwarded any coverage disputes over ABA to independent medical review panels. However, in March 2009 the department issued a memo indicating that it would channel coverage appeals to DMHC's attorneys rather than to the independent medical panels.
The change in procedure prompted the advocacy group Consumer Watchdog to file a lawsuit against the state (California Healthline, 11/16/09).
Plaintiffs asked the court for an injunction to force DMHC to reinstate the process of referring complaints to an outside medical panel.
However, O'Brien ruled that the request was "not within the scope of this petition." Although O'Brien declined to issue an injunction, he said DMHC's policy change constituted an "underground regulation."
Brietta Clark, a health law professor from Loyola Law School, said the ruling means that California "cannot change its policy based on behind-the-scenes negotiations but has to go through the open, public process that allows advocates, patients and providers to weigh in."
Cindy Ehnes, DMHC director, said the main message of the ruling is that the department is "following the correct course to ensure that patients continue to get the services to which they are entitled under their health coverage."
Consumer Watchdog attorneys said they were disappointed with the court's decision, but added that they hope Gov. Jerry Brown (D) will open the issue to public comment and reinstate the independent medical review panels (Los Angeles Daily Journal, 1/5).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.