eCapitol News
Author: William W. Savage III
Date: 06/22/2009
(OK) In the wake of a Michigan court's landmark settlement regarding the denial of autism coverage, parents of Oklahoma children denied coverage in the same manner are considering the possibility of filing their own lawsuit locally.
"We've got several people who we're in the middle of studying [the cases of] about filing a suit against Blue Cross Blue Shield [of Oklahoma] and other insurance companies," said Wayne Rohde, the Edmond father who has spent the past two legislative sessions advocating a state mandate for autism coverage for insurance companies. "We've been looking at it for the last two or three weeks. We're in the process now of rounding up parents who have denials [and] clarifying their denial process."
Pursuing litigation became a more realistic option after Blue Cross Blue Shield of Michigan announced Friday the news of a settlement between the company and about 100 families who had joined in a class action suit against the state's largest insurer.
The $1 million settlement also includes a provision that BCBS of Michigan will cover the therapy at the center of the suit - applied behavioral analysis - for employers with group mental health policies, according to reports in the Detroit Free Press.
Coverage of ABA, as the therapy is known, was denied to the Michigan children on the basis that it constituted "experimental" treatment.
"The important part of this lawsuit is that a court through this settlement has determined that ABA services are not experimental, as Blue Cross Blue Shield and other insurance companies like to classify it," Rohde said. "That's what we've been debating for years. They've even gone to the length of calling [ABA] educational, meaning it's not their responsibility and it's the public schools' responsibility."
That was the position taken by BCBS Oklahoma on Monday when asked about the Michigan lawsuit and the company's announcement late in 2008 that it would provide new autism benefits.
Nicole Amend, senior supervisor of public relations for BCBS Oklahoma, said BCBS Michigan is a different company and that BCBS policies in Oklahoma "have a specific exclusion related to autism which is not affected by this court decision."
"I think we have to look at it as far as, at this time, we don't intend to change our policies in response to the Michigan lawsuit," Amend said, adding that BCBS Oklahoma "is actually the only insurance company" in the state currently expanding its autism coverage.
The company announced in December that it would begin covering previously excluded autism-related expenses. Monday, Amend provided details of the new coverage, which she said will begin Jan. 1, 2010.
Amend said children will be covered from birth up to age 6 for the primary diagnosis of autism spectrum disorders, with additional coverage of evaluation, management procedures, speech therapy, physical therapy and occupational therapy. The benefit will have an annual maximum of $25,000 and a lifetime maximum of $75,000, she said.
"Those [maximum] amounts were chosen to allow the most comprehensive benefit with minimum impact to our members' premiums," she said, adding that the new benefits should not have a significant impact on premiums. "They weren't just arbitrary numbers that we threw out there."
But, Amend said the items covered by the new benefit "are not" ABA therapies, which Rohde said represent 80 to 90 percent of treatment costs.
"Those will not be covered under the autism benefit," she said. "Those programs are considered to be behavioral and educational training and not medical treatments. These are more [like] training modification programs, on the theory that behavior is learned through the theory of the interaction of the individual and the environment.
"So, we don't see them as medical treatment," she said. "Health insurance would provide for [situations] such as, you break your foot, you would need medical attention for that."
Rohde called those statements "just foolish."
"It has 20-plus years of science behind it to prove it is a medical treatment," he said. "This [lawsuit] does lay some very important groundwork for what we have always known to be true."
Rohde said the U.S. Department of Education, the American Academy of Pediatricians, multiple surgeon generals and others "have all accepted ABA as the proven therapy."
But, Amend said BCBS Oklahoma disagrees.
"There has been no well-constructed, randomized clinical trial that demonstrate ABA as being a more effective treatment when compared to a control group," she said.
Rohde said he believes the Michigan settlement undercuts that argument.
"I just see a lot more lawsuits popping up if BCBS and other insurance companies continue to deny this type of coverage," he said. "The ball is in their court, so to speak."
Asked whether BCBS of Oklahoma feared or expected local litigation as a result of the Michigan decision, Amend said: "I would say we're definitely watching. As health care is in the news lately, it's a topic we are very aware of."
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