Indianapolis-based Health Insurance Company Denies Coverage for Autism Therapy

Chester and Kathi Pierce of Elkhart, an Indiana couple claimed that the Indianapolis-based health insurer Anthem Blue Cross and Blue Shield have denied coverage for autism therapy during school hours, violating state and federal laws. // The couple seek attention to the case that Anthem’s 3-year-old policy cut down the number of therapy hours from 40 to 25 in July 2013. After Anthem cut the number of therapy hours it reimbursed, and cut it again to 20 in July 2014 for Wes Pierce, 12-year-old boy with autism and other children under the insurance.

Indianapolis Business Journal reported that federal law requires insurers to cover mental health services to the same extent that they cover services for physical health needs. Autism therapy formally known as applied behavior analysis (ABA) can cost $30,000 to $50,000 a year, if delivered 40 hours a week, year-round.

“Anthem’s determinations improperly conflate clinical ABA therapy with the educational services provided by Indiana public schools,” the Pierces’ lawsuit states.

“Therapy that works for one individual may not be effective for another. In partnership with providers, parents and educational institutions, Anthem is paying for the care that is helping kids with autism spectrum disorders live a better life,” said Tony Felts, Anthem spokesman.

Anthem sent a letter to families with autistic children in May 2012, informing them it would no longer pay for therapy for school-age children during the time they are or could be in a public school. This decision may affect the treatment and show a decline in the progression of the children as in the case of Wes.

Michele Trevedi, manager of The Arc Insurance Project at The Arc of Indiana, which provides services to Indiana residents with intellectual and developmental disabilities said that Anthem insisted on treating the issue case-by-case, rather than “at the systemic level.”

Source-Medindia