Jul. 07, 2008
Families of Autistic Children, Insurers Battle Over Coverage
By Evan George
Daily Journal Staff Writer

      LOS ANGELES - A labyrinth with no end is how one father described the dizzying process parents must maneuver to secure medical treatments for a child with autism.
      Many say the struggle for medical care is as complex and maddening as the disorder itself, because even families with robust health coverage must fight, petition or sue their insurers to get the costly therapy that doctors say is crucial to help children with autism.
      A new class action and a handful of autism-related legislation winding through Sacramento highlight that struggle.
      In April, the father of a 2-year-old diagnosed with autism sued Kaiser Permanente, the country's largest HMO, for allegedly denying treatment and instead pushing its autistic patients onto state-funded clinics called Regional Centers, which treat mental disabilities.
      Thanks to a 1999 law, health plans must cover a slew of mental illnesses and disorders, including autism, the same way they cover physical ailments.
      The class action against Kaiser, the first of its kind in the state, claims the company is not meeting that legal obligation.
      Representatives for Kaiser said they provide all autism therapies that are medically necessary. They say the disputes center on defining, in each case, which treatments are "medically necessary" and which are simply "educational."
      Parents of autistic children throughout California said the problem is not confined to one company, or even just private health plans.
      "Everywhere we turn, whether it's the Regional Centers, the school district or our insurance providers, none of them want to pay for the services because it is so expensive," said Joie Rightmier, president of the nonprofit Los Angeles Families for Effective Autism Treatment.
      Autism, which is considered a spectrum of severe and life-long developmental disorders, is typically treated with intense and early treatments, which include speech, behavior and occupational therapies.
      Statewide, Regional Centers served 36,952 children with autism in 2007, up from 32,809 in 2006, according to state records. It is the fastest-growing child development disorder in the country and continues to snowball and overwhelm the public system.
      Families of disabled children have long relied on state-funded clinics for services. But that was expected to shift at least slightly after California passed the 1999 law that forces private insurers and HMOs to pony up care for certain mental illnesses.
      The Mental Health Parity Act requires that health plans cover costly disorders like autism and prohibits staunch fee increases or limits on services.
      Managers at several Los Angeles-area Regional Centers said health plans had not picked up the slack.
      "With these rising rates of autism I would imagine insurers are looking at the bottom line," said Thomas Widger, clinical director for the California Autism Foundation.
      Widger said that speech therapy for autism runs about $100 an hour, and far more for intensive behavior interventions.
      "What is the fiscal impact of that on an insurance company? I think they're probably trying to put the brakes on," Widger said.
      A state legislative Blue Ribbon Commission on Autism last year found that all major health plans had inconsistent policies for treating autism and were not meeting their legal responsibility to cover medically necessary services for autistic children.
      Those findings have led to a handful of state bills related to autism, including SB1563, intended to clarify what treatments health plans must provide.
      A spokeswoman for the California Association of Health Plans, which opposes that bill, said that HMOs and insurers play a role with schools and the state to serve autistic children.
      "Obviously health plans have the responsibility to provide medically necessary coverage," said Nicole Kasabian Evans for the California Association of Health Plans.
      The question, the health plans contend, is what autism therapies are medically necessary and what can be considered educational.
      When a patient requests a service that is denied they can appeal to the state for a second opinion. That appeals process has reviewed 119 cases since 2001 in which an autistic patient sought speech therapy or other treatments. Seventy of those cases were resolved in favor of the health plan, and in 49 cases, the decision was overturned in favor of the patient, according to the Department of Managed Health Care, which regulates HMOs.
      Still, families of many patients said they are refused treatments they believe they are entitled to.
      Kaiser Permanente has drawn particularly fervent scorn from enrollees and patient advocates.
      When Feda Almaliti of Fremont could not convince Kaiser physicians that the HMO, not a state-funded Regional Center, should treat her son, she took her anger online: She started an Internet listserve that boats 140 members, all parents fighting with Kaiser.
      "I'd always felt like Kaiser was great with kids, until my son was diagnosed with autism and everything completely did a 180," Almaliti said.
      "I would print out the Mental Health Parity law and take it to the doctors and say, 'You can't do this, it's against the law,' but they kept referring to their internal policy that they don't treat autism."
      Almaliti said she was willing to join the class action against Kaiser.
      In that case, Guillermo Arce is suing for allegedly denying autism treatments for his 2-year-old son. He also claims that Kaiser systematically shuffles the burden of covering enrollees diagnosed with autism onto the state-funded regional centers.
      Allegations include breach of contract, bad faith and violations of the Business and Professions Code. Arce v. Kaiser, BC388689 (L.A. Super. Ct., filed April 8, 2008).
      Scott C. Glovsky, the Pasadena attorney who is representing Arce, said he had been contacted by dozens of other potential plaintiffs since filing.
      "Kaiser is making record profits by failing to comply with Mental Health Parity law and dumping autistic kids on the taxpayers," said Glovsky, who last week filed a similar lawsuit against Blue Cross.
      Arce had medical coverage with Kaiser for his son, Andrew, when he was born in 2005. Doctors diagnosed Andrew with autism around the time of his second birthday, according to the complaint. Arce contends that the treatments he sought, including behavior therapy, were medically necessary and should be covered.
      A Kaiser spokeswoman said she could not comment on the specific lawsuit.
      But John Brookey, an assistant medical director for Kaiser, said the accusation that the HMO shifted responsibility to state clinics was not accurate. Brookey said that Kaiser doctors "worked collaboratively" with regional centers.
      He said Kaiser doctors' largest role was in screening and diagnosing autism in their patients and that many therapy services were more appropriate coming from Regional Centers or in a school setting, because they were not medically necessary.
      Almaliti, who said she pays more than $800 for coverage, said that referring her to free state clinics made her policy worthless.
      "Having insurance is a privilege, but I'm paying for that privelege and I'm not getting anything for it," Almaliti said.
      Almaliti said the only treatment Kaiser had offered related to her son's autism was a prescription doctors offered her for her frustration. "They'll prescribe all the anti-depressants they have for us parents," she said.
      evan_george@dailyjournal.com
      **********

 
Daily Journal Newswire Articles
www.dailyjournal.com
© 2008 The Daily Journal Corporation. All rights reserved.