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Updated Sunday, November 18, 2012 at 09:27 PM

Parents sue to demand equal insurance coverage for autism

By Carol M. Ostrom
Seattle Times health reporter

When it comes to health insurance, should autism and other neurodevelopmental disabilities be treated like a sprained back — or like diabetes?

In essence, that's the question at the heart of a pile of class-action lawsuits filed against insurers over the past two years by parents demanding equal treatment for mental-health conditions.

The parents say autism and other conditions affecting the brain should be covered like chronic medical conditions are now — with no limits on the number of visits for treatment.

Group Health Cooperative, one of several insurers targeted by the lawsuits, has announced that as it awaits clarification from a judge, it is suspending coverage limits. That will apply to neurodevelopmental therapies, behavior-modification programs and visits with mental-health practitioners and therapists for issues such as learning, communication and motor skills disorders.

With rehabilitation services, such as speech therapy, Group Health also agreed to stop requiring patients to have "significant, measurable improvement" within a 60-day period in order to continue therapy.

Group Health has also removed caps and limits on Applied Behavioral Analysis (ABA), a type of therapy of particular interest to families of those with autism-spectrum disorders, such as Asperger syndrome, said Group Health spokesman Mike Foley.

Other insurers, including Premera and the state's Uniform Medical Plan for state workers, still spell out limits for various therapies for neurodevelopmental conditions in coverage information. Ele Hamburger and Rick Spoonemore, the lawyers for the parents, say the others should follow Group Health's example.

In the current case, before U.S. District Court Judge Robert Lasnik, Group Health has argued it can limit neurodevelopmental therapy because it applies the same visit limits to physical-rehabilitation therapy. And Hamburger said Group Health has indicated it will pursue that argument in court.

In the meantime, Sean Corry, a longtime advocate for mental-health parity, said Group Health's decision to suspend limits retroactively to June 1 was "remarkably great news."

In briefs in the cases against insurers' restrictions, Hamburger and Spoonemore argue that visit limits are illegal. Under state and federal mental-health parity acts, they said, visits for treatment of mental-health conditions must be handled like any other medically necessary office or hospital visits.

All the lawsuits, Hamburger said, "are about trying to get the insurers to treat disorders that impact the brain in the same way that they treat disorders that affect the rest of the body."

Autism-spectrum disorders (ASD) are now believed to affect one in every 88 children, and estimates of prevalence of other neurodevelopmental conditions vary widely.

Hamburger says full mental-health parity in insurance coverage, without visit limits, age limits or blanket exclusions, could potentially impact tens of thousands of patients statewide.

In June, Lasnik ordered Group Health to end its age limits for neurodevelopmental therapy.

The insurer complied, and began covering children over age 6. But it then began lumping together all autism treatments, Hamburger said, such as separate visits for speech therapy, physical therapy or neurodevelopmental therapy, and treating them as a "rehabilitation service" — which its contracts limited to a 60-visit total per year.

In the June order, Lasnik said Group Health must "cease their application of any treatment limitations that are not generally 'imposed on coverage for medical and surgical services,' " quoting the state's mental-health parity act, which was enacted in 2005 and took full effect in 2010.

Hamburger and Spoonemore compare therapy for autism and other neurodevelopmental conditions to outpatient medical or surgical services. "There is no general limitation on the number of times an insured can visit a doctor, or obtain surgery," they wrote in court papers filed in the Group Health case.

"This is not a close question," the lawyers wrote. "The Parity Act prevents Group Health from imposing visit limits on mental health services, including neurodevelopmental therapies to treat DSM-IV (a manual classifying mental disorders) conditions, since it does not impose visit limits on medical and surgical services generally."

Parents John Morton and Clara Chan of Seattle, who were involved in a different lawsuit against Group Health to get coverage of ABA therapy, say the therapy has made all the difference for their 4-year-old, Declan, who was diagnosed with autism. Their daughter, Kaiya, 22 months, also was diagnosed with an autism spectrum disorder, and began therapy last month.

Before Declan began therapy, he didn't recognize them, make eye contact or respond to his name, Chan said. "He's a different kid," she said. "It's been lifesaving, really."

Corry said implementation of laws requiring parity "has not been smooth sailing, especially when mental-health therapies that should be covered under the broad parity law have had coverage illegally restricted by the (insurance) carriers under their neurodevelopmental therapies coverage."

Last week, Corry, Mental Health Parity Coalition Chairman Randy Revelle and others met with state Insurance Commissioner Mike Kreidler to urge regulatory action.

"Frankly, we have had enough of litigation and we urged the commissioner to make a clear and strong statement in support of full mental-health parity," Corry said.

Stephanie Marquis, spokeswoman for the insurance commissioner, said: "We're working on a regulation that addresses the issues the courts have ruled on so far that will ensure consumers get the coverage they're entitled to and insurers understand what they're required to cover."

The draft language should be ready by the end of the year, she said.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com.

On Twitter @costrom.

Insurance parity

The state Office of the Insurance Commissioner has started the process for a regulation to clarify coverage for consumers and insurers. Draft language should be ready by year's end, and coverage would begin as soon as the final regulation is signed. More information: http://1.usa.gov/105v6Fn

To stay informed, join the OIC Listserv: http://1.usa.gov/ZOQa3V

Problems with restrictions on mental-health coverage? Call the Insurance Commissioner's Consumer Hotline, 800-562-6900.


COLIN DILTZ / THE SEATTLE TIMES
Clara Chan and John Morton of Seattle were involved in a lawsuit against Group Health to get coverage of Applied Behavioral Analysis for their autistic son, Declan, 4. Daughter, Kaiya, 22 months, has autism spectrum disorder and started therapy last month.




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