There is a fight brewing in Indiana regarding continued insurance coverage for applied behavioral analysis for the treatment of autism, and the end result may cause an important ripple, affecting how autism treatment is covered in other states.
Parents of an autistic son brought forth a class action suit on April 9th against Indianapolis-based Anthem Blue Cross and Blue Shield after the insurance company cut services for their son. Anthem maintains that autism treatment is not the responsibility of insurance but of the school system during school hours. In a denial letter to Wes Pierce’s parents, Anthem maintained that “educational, recreational and vocational services are not covered benefits of the health plan.” (Wall, 2015). In May of 2012, Anthem sent a letter to families of autistic children stating that therapy for their school-aged children would not be covered during the time that their children are in public school due to the federal Individuals with Disabilities Education Act which requires public schools to provide services to autistic children via their individualized education plans, also known as IEPs. Anthem’s rationale for this turn-around: “Anthem cannot duplicate coverage for services that are available through the public school system.” (Wall, 2015)
Anthem’s decision has angered many Indiana families who care for autistic children. In May of this year a rally occurred on Monument Circle in front of Anthem’s corporate headquarters and more than 1,200 people have joined a private Facebook page entitled IndianaFightForABA.
The High Cost of Autism
The Center for Disease Control and Prevention estimates that autism affects 1 in 88 children in the United States; up to 730,000 people between the ages of 0 and 21 have an autism spectrum disorder (NCSL, 2015). Applied Behavioral Analysis is considered the gold standard of treatment for more severe forms of autism; however it is also a very intensive form of therapy, utilizing behavioral conditioning that involves repetitive, task-and-reward based activities to promote social skills. An autistic child can receive anywhere between 20 to 40 hours of treatment a week and severe forms of autism often necessitate treatment inside the home. Thus, some families can spend anywhere between $50,000 and $120,000 per year on autism-related therapies. Public schools receive about $8,400 per year to pay for services that are needed for each special-needs child enrolled in their schools. Many families have expressed frustration with the treatment efforts offered by their public school system due to the limitation of resources but claim visible improvements in their autistic children after receiving ABA therapy. According to Wes Pierce’s mother, her son “gained weight and experienced unexplained pain in his back and buttocks area while attending school. I later learned from another parent that W.P. was being left strapped into his wheelchair for most of the school day. I believe that this was because the school lacked the resources to directly manage W.P. in a productive manner.” (Wall, 2015)
The $50,000 to $120,000 price tag for ABA therapy is unmanageable for many families. With funding of $8,400 per year per child, public school systems also lack the financial resources to cover such an expense, and now it appears that Anthem feels the financial weight of autism therapy as well. Anthem says it paid claims for ABA therapy for a thousand children last year.
The Class Action Suit
Chester and Kathi Pierce filed their class action suit against Anthem Blue Cross Blue Shield on April 9th, 2015. In a class action suit, one person or family brings the case to court as representatives and file a claim not only on behalf of themselves but also for ‘class members’ who have been similarly affected. A class action suit charges that a company has engaged in unlawful conduct which impacts an entire group or class. In this case the entire group or class is “all individuals (1) who have been, are, or will be covered by an Anthem health plan through their employer on or after April 9th, 2012; (2) who have or will have a child that is age seven or older; (3) whose child has been, is, or will be diagnosed with a pervasive developmental disorder; and (4) whose child has required, requires, or will require ABA therapy as part of a treatment plan approved by a treating physician.” (Morris, 2015) Members must satisfy all four elements to be considered part of the law suit. The Indiana suit involves only Anthem Blue Cross Blue Shield Insurance and does not address other insurance company policies on the treatment of autism.
According to the suit, Anthem’s violations include:
Limiting the number of hours of ABA therapy covered for non-medical reasons based on the purported availability of similar services in public schools to children age seven or older.
Offering ABA therapy providers “take-it-or-leave-it” deals to temporarily and marginally increase the number of hours of therapy authorized in exchange for participants or beneficiaries giving up their right to appeal coverage denials.
Reviewing and determining medical necessity of ABA therapy with the help of individuals who are not specialists in the treatment of pervasive developmental disorders. (Morris, 2015)
Unfortunately class action suits are not swift forms of litigation and can often take many years to resolve. The Pierce family’s case may not get heard until December 2016 in the Southern District of Indiana. And yet with the growing number of autism cases being diagnosed each year, it is likely that autism providers, families with autistic children and insurance companies around the country will be following this case with close interest.
Chapman, Sandra (2014) Mother of Boy with Autism Fights Anthem Insurance Decision retrieved from http://www.wthr.com/story/23911945/2013/11/07/mother-of-boy
Wall, J.K (2015) Parents of Autistic Children Gird for Showdown with Anthem retrieved from http://www.ibj.com/articles/print/52894-parents-of-autistic-kids-gird-for-showdown
Ali, Syed (2015) FAQ on Anthem Class Action Suit Concerning Autistic Children retrieved from http://indianainjuryaccidentlawyers.com/blog/faq-on-anthem-class
Morris, Sally (2015) FAQ Regarding the Anthem/ABA Class Action Lawsuit retrieved from http://www.arcind.org/news/faq-regarding-the-anthemaba-class-action
NCSL(2015) Insurance Coverage for Autism retrieved from http://ncsl/org/research/health/autism-and-insurance-coverage