[Note: Shared for #AutisticHistory archive purposes. This is NOT An Autistic Ally.]
Schwarzenegger Administration Sued For Allowing Health Insurance Companies To Deny Autism Care
Santa Monica, CA — The mother of an autistic child joined Consumer Watchdog and its attorneys today to announce a lawsuit against the California Department of Managed Health Care (“DMHC”), the Schwarzenegger Administration agency responsible for regulating many of California’s health insurers. The suit alleges that the DMHC has wrongfully allowed insurance companies to refuse to pay for autism treatments, resulting in the denial of critically needed, medically necessary treatment for autistic children.
The suit, filed by Consumer Watchdog and Strumwasser & Woocher LLP, alleges that the DMHC, and its Director Cindy Ehnes, recently changed the state agency’s policy to permit insurers to deny coverage for Applied Behavioral Analysis (“ABA”), an essential treatment for autism, in plain violation of the California Mental Health Parity Act. That law requires health insurers to cover and pay for all medically necessary treatments for autism, including ABA. If successful, the suit would require the DMHC to bar insurers from refusing to cover medical necessary ABA treatments. The suit also seeks to compel the DMHC to turn over records that would expose the full extent of the DMHC’s violations of the California Mental Health Parity Act and the Knox-Keene Act.
Download the complaint filed at the Los Angeles Superior Court here.
Download the lawsuit exhibits here.
“Californians, including those stricken by autism, and their parents and caregivers, expect regulators to enforce the law, not to side with insurance companies seeking to boost their profits by denying patients the care they need,” said Harvey Rosenfield, founder of the non-profit advocacy group Consumer Watchdog and author of the landmark insurance reform initiative Proposition 103. “Governor Schwarzenegger, a longtime and vocal supporter of the Special Olympics and developmentally disabled children, will now have to explain in court why his administration is allowing health insurers to evade state mental health laws and shift health care costs to already beleaguered taxpayers.”
Governor Schwarzenegger, who appointed the current Director of the DMHC, has received $711,200 in campaign contributions from Blue Cross, Kaiser and Blue Shield – three health insurers regulated by the DMHC that commonly deny coverage for autism treatments.
The DMHC’s actions upholding heath insurance denials for medically necessary autism treatment puts children at risk by forcing parents to seek treatment through over-stretched taxpayer-funded programs, or to forgo treatment altogether.
“HMOs and health insurers are denying autistic children the most effective medical treatment that is available, with severe consequences for them, their families, and the state’s taxpayers,” said Fredric D. Woocher, lead counsel in the suit.
“Insurance companies are blatantly violating California law. Yet the Department of Managed Health Care is not only standing by and doing nothing to prevent these violations; it is actually supporting the insurers as they abandon autistic children and their families.”
Insurer’s New Tactic in the Battle to Avoid Paying for Autism
ABA is a form of behavioral therapy that has been scientifically proven to improve brain function in autistic children. For years, insurance companies refused to pay for ABA on the grounds that it was “experimental” and that there was insufficient medical evidence to show that it was an effective treatment for autism. But the evidence supporting the efficacy of ABA is now overwhelming. The Centers for Disease Control and Prevention, the National Institute of Mental Health, and the United States Surgeon General all agree that behavioral interventions, such as ABA, are a critical component of any comprehensive autism treatment program.
According to the lawsuit, until March of this year, health care consumers were able to appeal an insurer’s denial of ABA through the DMHC’s Independent Medical Review (“IMR”) system, in which a treatment denial is reviewed by a team of doctors that is unaffiliated with the insurance company that denied the treatment and independent of the DMHC.
The suit alleges that as the IMR doctors increasingly overturned insurer treatment denials, compelling the insurers to pay for ABA, insurers privately urged the DMHC to change its procedures and process the treatment denials through the DMHC’s own internal grievance review system. Unlike the IMR system, in which independent doctors evaluate whether a treatment should be provided on the basis of whether it is medically necessary and effective, the grievance system is conducted by DMHC staff, who are not doctors and who simply defer to the insurers’ determination of whether the claim is even covered by their health care policies.
“Health insurers want to re-write the law to benefit their bottom line and the regulators are holding the pen,” said Pam Pressley, Consumer Watchdog’s Litigation Director. “California’s mental health laws are clear: doctors get to decide whether care is needed, not insurance company bureaucrats or government lawyers.”
Consumer Watchdog has learned that the health insurance industry mounted a lobbying campaign to convince the Schwarzenegger Administration that ABA is an “educational” program not covered by health insurance policies. On March 9, 2009, the DMHC issued a memo indicating that the agency would review ABA and other autism treatment denials through the DMHC’s internal grievance system as urged by insurers.
Consumer Watchdog has evidence that the DMHC has in fact upheld the insurers’ denials of ABA on coverage grounds in violation of the Mental Health Parity Act. That law requires insurers to pay for any “medically necessary” and effective autism treatment — a decision that must be made by independent doctors, not by insurance company bureaucrats or government lawyers.
Kristie Sepulveda Burchit, mother of Aidan who suffers from autism, joined the group to announce the lawsuit. Kristie’s insurer, Blue Cross, first refused to provide ABA in 2008 on the ground that it was not medically effective as a treatment for autism. Kristie requested an IMR and the independent physicians who reviewed her appeal overturned the Blue Cross denial. Then, in 2009, shortly after the DMHC issued its March 9 memo, Blue Cross again refused to pay for Burchit’s continued ABA autism treatment, this time on the basis that it supposedly was “not covered” by Kristie’s health insurance policy because ABA is an “educational service.” Burchit has now appealed the denial to the DMHC through the grievance system and is awaiting a decision from the regulator. Consumer Watchdog said that if it wins the lawsuit, the DMHC would have to order Blue Cross to provide ABA treatment for Aidan.
The suit also alleges that the DMHC and its Director Cindy Ehnes:
– Illegally instituted a policy of denying ABA treatment on the ground that providers were inadequately licensed, despite the fact that the law clearly requires health insurers to cover all medically necessary treatments for autism, including ABA, whenever such services are either provided or supervised by a licensed or certified professional.
– Illegally withheld public documents properly requested under the California Public Records Act, which would expose how the DMHC conducts its “grievance system” and would reveal the full extent of the DMHC’s violations of the mental health parity law.
Nearly 1 out of every 150 children born in the United States is diagnosed with autism. As of December 2007, the California Department of Developmental Services provided care to nearly 37,000 Californians with autism.
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Consumer Watchdog, formerly the Foundation for Taxpayer and Consumer Rights, is a non-partisan and non-profit public interest organization with offices in Washington D.C. and Santa Monica. Pamela Pressley is its Director of Litigation. For more information, go to: www.ConsumerWatchdog.org.
Strumwasser & Woocher LLP is known for its successful litigation and resolution of major public policy matters. The firm’s trial and appellate civil litigation practice focuses on government and electoral law, consumer law, environmental protection, land use, and administrative law. For more information, go to: www.StrumWooch.com.
More With Autism Insurance Reform
Autistic people have fought the inclusion of ABA in therapy for us since before Autism Speaks, and other non-Autistic-led autism organizations, started lobbying legislation to get it covered by insurances and Medicaid.
ABA is a myth originally sold to parents that it would keep their Autistic child out of an institution. Today, parents are told that with early intervention therapy their child will either be less Autistic or no longer Autistic by elementary school, and can be mainstreamed in typical education classes. ABA is very expensive to pay out of pocket. Essentially, Autism Speaks has justified the big price tag up front will offset the overall burden on resources for an Autistic’s lifetime. The recommendation for this therapy is 40 hours a week for children and toddlers.
The original study that showed the success rate of ABA to be at 50% has never been replicated. In fact, the study of ABA by United States Department of Defense was denounced as a failure. Not just once, but multiple times. Simply stated: ABA doesn’t work. In study after repeated study: ABA (conversion therapy) doesn’t work.
What more recent studies do show: Autistics who experienced ABA therapy are at high risk to develop PTSD and other lifelong trauma-related conditions. Historically, the autism organizations promoting ABA as a cure or solution have silenced Autistic advocates’ opposition. ABA is also known as gay conversion therapy.
The ‘cure’ for Autistics not born yet is the prevention of birth.
The ‘cure’ is a choice to terminate a pregnancy based on ‘autism risk.’ The cure is abortion. This is the same ‘cure’ society has for Down Syndrome.
This is eugenics 2021. Instead of killing Autistics and disabled children in gas chambers or ‘mercy killings’ like in Aktion T4, it’ll happen at the doctor’s office, quietly, one Autistic baby at a time. Different approaches yes, but still eugenics and the extinction of an entire minority group of people.
Fact: You can’t cure Autistics from being Autistic.
Fact: You can’t recover an Autistic from being Autistic.
Fact: You can groom an Autistic to mask and hide their traits. Somewhat. … however, this comes at the expense of the Autistic child, promotes Autistic Burnout (this should not be confused with typical burnout, Autistic Burnout can kill Autistics), and places the Autistic child at high risk for PTSD and other lifelong trauma-related conditions.
[Note: Autism is NOT a disease, but a neurodevelopmental difference and disability.]
Fact: Vaccines Do Not Cause Autism.