SAN FRANCISCO (CBS 5) – Parents of Bay Area autistic children are fighting with insurance companies over coverage of a commonly used behavioral therapy called Applied Behavioral Analysis (ABA) and claim state regulators aren’t doing enough to force insurers to pay.
San Francisco resident Sally Brammell said when she submitted coverage claims to her insurer, Anthem Blue Cross, she has gotten a runaround. “It can be very protracted, and very limited,” she said of Anthem’s responses.
Consumer advocates say part of the problem is that two different state agencies regulate insurers. The California Department of Health Managed Care oversees health maintenance organizations, like Brammell’s insurer. The Department of Insurance regulates the rest of the insurance industry.
Each agency has different standards when it comes to covering behavioral treaments for autism like ABA, according to the group Consumer Watchdog. “The Department of Managed Care has come up with an excuse that insurance companies don’t have to pay for ABA because the individuals who are providing the care are not licensed. Well, there is no license,” said Consumer Watchdog spokesman Jerry Flanagan.
Lynn Randolph of the Department of Managed Health Care told ConsumerWatch it “can be a bit of a catch-22” for parents. But she said the different standards are up to lawmakers to fix. “The legislature has not recognized licensure, and it’s up to the legislature to decide if there is going to be a license,” Randolph said. She added the Department of Managed Care sides with parents of autistic children 90% of the time.
But it’s those 10% of denied claims that’s frustrating parents. “Parents shouldn’t have to work this hard to get the insurance coverage that they pay for,” said mother Feda Mahliti of Fremont.
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