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Autism Treatment Denials Spark Lawsuits

Margaret Dick Tocknell, for HealthLeaders Media, July 18, 2011

This article was updated at 9:18 ET to correct an editing error.

Efforts to gain health insurance coverage for an autism treatment called applied behavior analysis have taken several steps forward in Michigan and California.

Health plans traditionally balk at authorizing the treatment. Blue Cross and Blue Shield of Michigan is facing a class action suit for denying an autism treatment called applied behavior analysis, while Blue Shield of California, under pressure from state officials, has reached a settlement to provide coverage for ABA services under certain circumstances.

Autism is a complex neurobiological disorder often characterized by language and communication difficulties, as well impaired social interaction. Despite extensive research, the cause remains unknown and there is no known cure. According to the Centers for Disease Control, 1 in 110 American children are diagnosed with an autism disorder.

Health plans across the country, including Kaiser Permanente, CIGNA, Empire Blue Cross Blue Shield, and Anthem Blue Cross, have been reluctant to cover the costs of ABA treatments, which can involve 20 to 40 hours per week of one-on-one therapy and can cost $30,000 to $50,000 annually. The health plans often contend that is ABA is experimental or that it is an educational service and doesn't meet the definition of medical care. In addition, licensure of ABA therapists can be a sticking point.

Medicaid, however, does cover ABA, and the U.S. Surgeon General and the American Academy of Pediatrics have recognized the success of behavioral treatments for autism.

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