Regence refusing to cover autism treatments

Guest Opinion: The lone private holdout, Regence continues to exclude or limit coverage for key autism therapies. Next month, the state Supreme Court will decide whether to make them.
Will the state Supreme Court force Regence to cover autism treatments?

Will the state Supreme Court force Regence to cover autism treatments? Credit: www.classactionsnews.com

Regence BlueShield is now the lone remaining major health insurer in Washington State that refuses to reimburse parents for treatment prescribed to their autistic children. On June 12, Regence will defend its position before the Washington Supreme Court in O.S.T. v. Regence BlueShield. That's when the Supreme Court will consider whether to affirm a lower court’s ruling that ordered Regence to cover speech, occupational and physical therapy treatments for autism.

Today we all have friends who have been touched by autism. In the past 10 years, diagnoses of childhood autism have skyrocketed. Autism Spectrum Disorder (ASD) is now more common than childhood cancer, juvenile diabetes and pediatric AIDS combined. In 2013, the U.S. Centers for Disease Control and Prevention estimated the prevalence of Autism Spectrum Disorder was one in 50 for children aged 6-17. That represents a 72 percent increase since 2007.

Scientific research shows that early intervention and treatment of children with autism is highly effective. The literature indicates that currently available treatment allows almost half the treated children who receive it to be mainstreamed by first grade.

Early treatment dramatically reduces social costs. A seven-year old study estimated that, in the middle of the last decade, the incremental societal cost for a person with ASD was $3.2 million. But with rapidly improving treatment an autistic child who receives therapy early on is much more likely to lead a productive life, thus easing these burdensome costs.

Given these facts, it seems reasonable that private health insurers would cover treatment of childhood autism. Indeed, a landmark Washington law requires health insurers to pay. Enacted in 2005, the Mental Health Parity Act aimed to end discrimination in health insurance against people with mental health conditions, including neuro-developmental conditions like autism.

Despite the law, Washington insurers continued to exclude or limit coverage of key autism therapies. Diagnoses and improvements in treatment grew, but insurers failed to keep up and a string of recent lawsuits followed. Parents of autistic children sued Group Health Cooperative in 2010, and then Premera Blue Cross and Regence BlueShield in 2011 to try to obtain coverage. And the parents won.

On April 17, 2012, a Washington Superior Court ruled that “the exclusion in [Premera’s] policies for ‘[s]ervices, therapy and supplies related to the treatment of … developmental delay or neurodevelopmental disabilities’ violates Washington public policy and the Mental Health Parity Act.” Group Health lost its suit in June 2012; Regence BlueShield in December of that year.

The courts required the insurers to immediately cover speech, occupational and physical therapies for childhood ASD. But the court orders only apply to some, not all, of the companies’ plans. Regence, for example, administers numerous employer self-funded insurance plans. Those plans aren't subject to the court rulings and Regence is not voluntarily extending autism coverage for them.

Nor did Regence and Premera apply the court rulings to other autism treatments. According to Dr. Stephen Glass, a University of Washington professor of child neurology who testified in the court cases, the standard of care for treating severe ASD is individualized, intensive behavioral therapy, often conducted by trained workers at the child’s home. The most common form of this therapy is called Applied Behavioral Analysis, or ABA. Regence continues to exclude coverage for ABA therapy, despite broad recognition of its efficacy. Premera used internal licensing requirements to deny coverage for treatment by ABA therapists who were certified by a national certifying organization. Among major private insurers, only Group Health, which settled the parents’ lawsuit in 2012, covered ABA therapy.

In 2012, Regence and Premera appealed the court rulings to the Washington Supreme Court, further delaying resolution.  Meanwhile, because many parents cannot afford to pay out-of-pocket for the therapies, affected children are not receiving treatment that could alter the trajectory of their lives.

Just weeks ago, Premera settled with the parents, leaving Regence alone to fight against coverage of autism before the Washington Supreme Court. Based on the Settlement Agreement Premera signed on May 9, it will cover medically necessary speech, occupational and physical therapy services, as well as medically necessary ABA therapy. Premera will also create a $3.5 million fund to reimburse parents who have paid out-of-pocket for past neuro-developmental therapy.


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Comments:

Posted Mon, Jun 2, 7:43 a.m. Inappropriate

Regence deserves to have an autistic child in its home 24/7 ... or would Regence simply let the child become a shipwreck and ruin a lot of lives?

Therapy has made a productive person of a certain 28 year old. His parents are still alive to tell the tale. What an exhausting trip, and this even with the father advocating consistently. Much out of pocket funding and even more full-time parental focus is the cost.

Maybe we have gone back to the days where we isolate a disabled person in a wheel chair for their lifetime, or a room, stay mum, and lock the door?

sgh

Posted Mon, Jun 2, 1:06 p.m. Inappropriate

Premera's probably laughing right now, having quickly stepped back and left Regence standing alone looking stupid.

For years we enjoyed better coverage under Premera for our son's therapies than we do now under Cigna.

tvjames

Posted Fri, Jun 6, 4:52 p.m. Inappropriate

Regence has indeed been forced by the court to cover the treatment.

My daughter's 50, so she's never benefitted from the knowledge that was gained in the last 10-20 years. She's in a wonderful group home operated by L'Arche. However, I'm worried about the costs that we are adding to our stumbling health care system. We've got two burgeoning populations who need care: autistic people and those with Alzheimer's. Obamacare has no cost controls built into it, since Congress wouldn't allow that. For those whose family members need expensive therapy (and god knows, parents need their kids/adult kids to have the help they need since we all burn out at some point), we'll have to lobby Congress to rein costs in somehow. My daughter is taking a number of expensive prescriptions because she (like most autistics) has co-occurring psychiatric conditions, and if she weren't on Medicare/Medicaid, I don't know what we'd do.

sarah90

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