News articles have recently been published throughout the state reporting that Indiana’s largest health insurer, Anthem Blue Cross and Blue Shield, is taking a harder line on paying for therapy for school-age children with autism.
While the articles reported on this issue from the “industry” standpoint there is a very real side that impacts the family.
Imagine your child had a chronic condition that requires 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 ABA therapy. This has been reinforced by the Indiana Department of Insurance through IDOI Bulletin 136.
Indiana state law also defines autism as a chronic neurological condition. Because autism is a chronic neurological condition, the Indiana Autism 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 Indiana Autism Mandate Law 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 that are deemed necessary for a child with a disability to access a free, appropriate, public education (FAPE) in the least restrictive environment.
Instead of performing individualized, case specific medical review BEFORE denying services, it seems that Anthem has engaged in the process of 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 in order to prevent children who meet medical necessity from having care needlessly delayed by the appeals process.
We look forward to working with Anthem and the IDOI 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.
Hoosier families who have a loved one with autism want nothing more than to give their children every opportunity to succeed. We need to look to ways to help give them that opportunity, not put more obstacles in their path.
Michele Trivedi serves The Arc of Indiana as The Arc Insurance Project Manager