Court Ruling in autism case hailed as a breakthrough for insurance coverage

Editors note: During the 2009 Oklahoma Legislative Session, Rep Kris Steele, drafted legislation dubbed as the Republican Autism Plan to create an ABA research project at OUHSC. Autism advocates informed him that ABA has over 25+ years of clinical research and we do not need to spend hundreds of thousands of tax payer dollars to reinvent the wheel. This is nothing more than a stall. - Wayne

By Bryan Denson | OregonLive

For two years, Lisa McHenry fought a legal battle to force her insurer to pay for her son’s specialized autism therapy. But PacificSource Health Plans of Springfield refused and prevailed at every turn in court.

Then came a ruling this week by U.S. Magistrate Judge Janice M. Stewart in Portland, who ordered PacificSource to reimburse McHenry for the last eight months of her boy’s therapy.

“It’s the first decision in the country where a court has decided that ABA therapy (Applied Behavioral Analysis) is medically necessary for children with autism,” said Megan Glor, one of McHenry’s attorneys. “Insurance providers have been very reluctant to cover ABA therapy because it’s very expensive.”

The case offers a glimpse at opposing forces — insurers that won’t pay for the therapy and a nationwide parents movement pushing them to cover the disorder as a medical condition.

McHenry, who lives in Happy Valley, sued PacificSource in May 2008 to force the company to pay for her son Joe Joe’s therapy.

The case appeared to be resolved earlier this year, when Stewart ruled in favor of the insurer. The magistrate found that the boy’s therapist, Emily Hoyt, wasn’t an eligible provider under McHenry’s policy.

But in February, the state Department of Human Services certified Hoyt an eligible provider of therapy to Joe Joe, now 6.

On Tuesday, the judge ruled that PacificSource owed McHenry and her husband, Jon, their out-of-pocket expenses since then.

“Jon and I are absolutely over the moon. This is huge for Oregon,” Lisa McHenry said Wednesday. “This is huge for our family.”

Stewart ordered parties to the lawsuit to come up with a statement of past-due benefits.

Glor said she thinks PacificSource will be required to cover more than just the last eight months, but an additional $50,000 that the McHenrys paid for their son’s therapy from January 2007 to last February. A lawyer for PacificSource said the court has already ruled that the company doesn’t owe retroactive benefits.

“At the end of the day, the court said they don’t get any retroactive benefits,” said Richard Hansen. “She’s entitled to whatever costs she’s incurred since February, when the therapist became — under the court’s decision — an eligible provider.”

Source: http://www.oregonlive.com/happy-valley/index.ssf/2010/09/court_ruling_in_autism_case_hailed_as_breakthrough_for_insurance_coverage_of_special_therapy.html

Details of BCBS Plan

Some of the details of Blue Cross Blue Shield of Oklahoma's plan were released via TV interviews on Tuesday, Dec 30, 2008. In the interviews with Fox 25's Britten Follett and OETA's Jason Doyle, Dr. Joe Nicholson stated that OT, PT, and Speech will be covered along with diagnosis of autism. There will be an annual cap of $ 25,000.00 for those services.

However, there will be no coverage for ABA or behavioral therapy due to BCBS's long standing and incorrect belief that ABA is experimental and does not have clinical research to prove it's effectiveness.

This type of statement has been a go to for the insurance company to deny children with autism the medical necessary and clinically proven therapies. BCBS did not take into account what the US Dept of Education, US Dept of Defense, the Surgeon General, American Academy of Pediatricians, and many other national and federal organizations and agencies have adopted as the most effective behavioral therapy, ABA or Applied Behavorial Analysis.

In what was thought to be an exciting development and breakthrough for members of BCBS of Oklahoma, it quickly fizzled out. However, we see this is a first step, perhaps small, but at least a first step towards providing the medically necessary and clinically proven treatments and therapies for our children and adults with autism in Oklahoma.

Wayne Rohde