California insurers are wrong to deny autism treatment coverage because providers are not state licensed, a judge says.
In a case before Los Angeles County Superior Court, Kaiser Permanente said they would not pay for behavioral therapy for a child with autism because the treatment provider was not licensed by the state. This reasoning is frequently used by insurers in California because applied behavioral analysis (ABA) and other behavioral therapies are usually provided by certified therapists who are not state-licensed.
But in a preliminary ruling the judge found that the coverage denial is in violation of California’s Mental Health Parity Act, which requires that insurers provide the same level of coverage for mental and behavioral health as physical conditions.
The ruling comes as part of a lawsuit brought by a watchdog group against the California Department of Managed Health Care. Advocates want the department to err on the side of consumers in disputes with insurers over treatments for autism. The judge’s ruling allows the case to go forward to trial, reports the Los Angeles Times. To read more click here.
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Shaun, I read the article and it looks to me as though both Kaiser and the California Department of Managed Health Care were both called onto the carpet for their illegal and anti-consumer practices. One of the most interesting aspects the article’s author included is that the judge specifically identified the DMHC “memo” as being “the very essence of regulation” apparently backing up the assertion from those filing the suit that DMHC has been promulgating “underground regulations” (without any real oversight, etc.).
As a professional healthcare administrator, I’ve worked in several different geographies under the oversight of different regulators. For the life of me, I can’t figure out why DMHC won’t stand up to Kaiser and its ilk.