Thursday, July 14, 2011


Department of Managed Health Care secures agreement to expand coverage for autism treatments

(Sacramento) – The California Department of Managed Health Care (DMHC) has announced that it has reached an agreement with Blue Shield of California, one of the State’s largest health plans, that the plan will provide coverage for Applied Behavioral Analysis (ABA), a form of treatment for autism. The agreement will provide immediate coverage upfront to potentially thousands of additional children annually.

“The DMHC has worked tirelessly over the last few years to provide coverage for the appropriate and effective treatment to children suffering from the potentially devastating effects of autism spectrum disorders,” said Edward G. Heidig, Interim Director of the DMHC. “Rather than just dealing a onetime blow to health plans through an enforcement action, this is another positive step towards mending the broken system for California families dealing with this issue.”

As autism rates soar, health plans have resisted covering some types of treatment such as ABA, arguing that many of such therapies are educational rather than health care services. In 2010, the Centers for Disease Control estimated that 1 in 110 children have an autism spectrum disorder.

Also in 2010, the DMHC prevailed in the Los Angeles Superior Court, in which Consumer Watchdog challenged the DMHC’s enforcement of the law, which requires that health care services, including ABA, must be provided by a licensed health care professional. This decision affirmed the DMHC’s right to order health plans to provide treatment in certain cases.

However, health plans have reported a shortage of providers with the proper licensure or certification to provide many autism therapies. In addition, other court challenges to the law continue and legislation to clarify the law is still under consideration, which could further expand or restrict coverage for autism treatment.

In order to extend more services to more families without further delay, the DMHC gained this settlement to also allow persons to provide ABA and other therapies whom are under the supervision of a licensed provider. This position is consistent with current law, because if a plan voluntarily chooses to provide services not considered health care under the law, licensure is not a requirement.

Consumers have complained to the DMHC that health plans do not cover many treatments for autism, such as ABA. Over the past few years, the DMHC has worked extensively to ensure that children with autism spectrum disorders receive the care they need and are entitled to under the law and their health care contracts. Since early 2009, 93 percent of the 148 disputes brought to the DMHC by consumers, whose health plans have denied some form of autism treatment, have been resolved in favor of the consumer. The DMHC agreements will provide coverage upfront without the consumer needing to bring a complaint to the DMHC first.

Compliance with the agreements will be monitored by staff who will serve as a liaison with both the plans and consumers who may have questions or problems getting treatment.

The California Department of Managed Health Care is the only stand-alone HMO watchdog agency in the nation, touching the lives of more than 21 million enrollees. The DMHC has assisted more than 1 million Californians resolve their health plan problems through its Help Center, educates consumers on health care rights and responsibilities, and works closely with health plans to ensure a solvent and stable managed health care system. 

Settlment Agreement