Autistic children still denied benefits

July 5, 2014

Thank you for the [June 16] coverage of autism. While IBJ looked carefully at this from the industry standpoint, there is a very real side that impacts the family.

Imagine your child had a chronic condition requiring on-going treatment, like diabetes, epilepsy or cystic fibrosis, and every six months you had to fight for weeks in order to continue medical treatment, even though your child’s entire clinical team and physicians agree that treatment is medically necessary. This is what parents of children with autism face, if they even have access to autism coverage.

State law, known as the Indiana Autism Mandate, requires that insurers cover medically necessary services for autism treatment, including applied behavioral therapy. This has been reinforced by the Indiana Department of Insurance through Bulletin 136.

Indiana law also defines autism as a chronic neurological condition. Because autism is a chronic neurological condition, the mandate does not allow insurers to impose an age limit on treatments.

Two years ago, Anthem Blue Cross Blue Shield sent a letter to families to inform them that they were changing the way they review services for school-aged children.

However, there has been no change in the mandate or Bulletin 136; that is, Anthem is still required to cover medically necessary services for covered persons with autism, regardless of age.

Public schools are not required by special education law to provide medically necessary therapy. They are only required to provide services deemed necessary for a child with a disability to access a free, appropriate, public education in the least restrictive environment.

Instead of performing individualized, case-specific medical review before denying services, it seems that Anthem has engaged in automatically denying certain levels of service based solely upon the age of the child, forcing the family to pursue appeals. This process repeats every six months for each child.

Advocates for families have met with Anthem on a number of occasions in an attempt to address this situation at a systems level.

We look forward to working with Anthem and the DOI to address the systemic denial of medically necessary services to children over age 7, and to improve Anthem’s medical necessity review process to reflect current medical standards for autism treatment.

John Dickerson, executive director, The Arc of Indiana
Michele Trivedi, Arc Insurance project manager

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