The Slippery Territory of Autism

A treatment for autism called applied behavioral analysis is basically helping those with autism develop new behavior with a system of rewards and consequences.

It’s generally known as one of the most successful forms of therapy available for autistic children. So if it has some success, why isn’t it always covered by private insurance?

That was the central question at a hearing of the Senate Select Committee on Autism and Related Disorders.

“Applied behavioral analysis has been rejected basically because it is an educational service, rather than a medical service,” said Andrew George of the Department of Managed Health Care.

That explanation flummoxed the committee’s chair, Darrell Steinberg (D-Sacramento). “I’ve heard from families, from parents who aren’t covered for ABA. You’ve had, what, several thousand cases, and you’ve addressed 33 of those cases directly. What are thousands of people supposed to be doing? Why not clarify the law here?”

Clarifying the law, though, is not up to the Department of Managed Health Care, George said. Applying existing law is all the department is doing, he said.

“That’s the issue we’re grappling with,” Tim LeBas said, also from the Department of Managed Health Care. “We have to go back to the Knox-Keene Act to determine it.”

The Knox-Keene Health Care Service Plan Act, passed by voters in 1975, defines the type of services that need to be covered by private insurers. Recent standard-of-care protocols might not be in the Knox-Keene Act, and that disturbed Sen. Elaine Alquist (D-Santa Clara).  

“This is the year 2010, so we should not be doing things the way we did in the ’80s,” Alquist said. “We all know about the autism tsunami. I am troubled to hear parents are meeting barriers to health coverage for their children. We are talking about a specific therapy that works, and we feel it should be covered.”  

But the trouble with grilling the Department of Managed Health Care about the issue is that those officials say that “should” is not really part of what the department is allowed to address.

“We do not look at the symptoms of an enrollee, we do ask they submit a treatment plan from the provider,” Holly Pearson of the Department of Managed Health Care said. “We can’t go much further than that because we don’t have the expertise. What we’re looking at is coverage. We’re not determining medical necessity, just whether this is covered. It’s a coverage issue.”

Amending the Knox-Keene Act to include ABA therapy for autistic children is the purview of the state legislature. So it’s likely that there will be many more hearings on this subject in the future.

 

 

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