Blue Shield of California Life and Health Insurance Co. has entered into a settlement with the California Department of Insurance in an enforcement action the department filed after Blue Shield allegedly said it wouldn't cover behavioral therapy for autism as a medical benefit.
An autism therapy approach known as Applied Behavior Analysis is required to be covered by insurers under California's Mental Health Parity Act, according to the CDI.
During a recent hearing before the Senate Select Committee on Autism, CDI representatives testified that independent medical reviews have shown ABA to be a "necessary therapy."
In July, the department slapped Blue Shield with an enforcement action after determining the company failed to comply with the state's mental health law when it denied coverage for an autism therapy approach. But Blue Shield of California's chief operating officer Paul Markovich said at the time the company would cover the autism therapy approach and that it was "perplexed" by the enforcement action (Best's News Service, July 14, 2011).
"This agreement confirms Blue Shield of California's existing ABA policy dating back to July 11, 2011," Blue Shield said in a statement, referring to an agreement with the California Department of Managed Health Care that committed Blue Shield to pay for ABA services if they are supervised by a licensed provider.
"Since that time, we have treated all CDI members the same as DMHC members by covering the services," Blue Shield said.
As a result of the CDI settlement, Blue Shield agreed to stop denying ABA therapy as a noncovered service, challenging the medical necessity of ABA therapy or forcing parents into an independent medical review to secure treatment. Blue Shield also agreed to establish a dedicated customer service unit to respond to inquiries from families seeking approval of medically necessary ABA therapy and to pay for services at the higher in-network benefit levels.
"We want to acknowledge the importance of Blue Shield's agreement to end their dispute with the Department of Insurance over coverage of ABA therapy as a life-saving medical benefit for autistic children," California Insurance Commissioner Dave Jones said in a statement. "This favorable settlement agreement eliminates the frustration and insecurity so many families have faced when seeking autism treatment for their children."
Blue Shield of California Life and Health Insurance Co. currently has a Best's Financial Strength Rating of A (Excellent).
(By Jeff Jeffrey, Washington Correspondent: jeff.jeffrey@ambest.com) (c) 2012 A.M. Best Company, Inc.
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