A consumer group filed a lawsuit Tuesday against the state agency that oversees HMOs, accusing it of violating state law by siding with insurance companies in denying treatment for children with autism.
Consumer Watchdog, a Santa Monica nonprofit group, along with a Los Angeles physician who is the mother of two autistic children claimed the Department of Managed Health Care allows insurers to deny an essential treatment for autism, in violation of state law that provides that insurers must cover all medically necessary treatments.
The suit accuses the department of changing its policies, forcing parents to appeal insurance denials through an internal grievance process rather than letting an independent panel of doctors make treatment decisions.
"We want the department to follow the law. Doctors – not insurance companies and government lawyers – decide what care kids should get," said Jerry Flanagan, Consumer Watchdog’s director of health policy.
The Department of Managed Health Care defended its policies for ensuring treatment to people with autism, also known as Autism Spectrum Disorder. The disorder affects as many as 1 in 150 children born in the United States.
"We have explicitly told health plans that they may not exclude any particular therapies or treatments for Autism Spectrum Disorder that have been determined to be health care services, and are administering the consumer complaint process according to law," said Lynne Randolph, spokeswoman for the department.
At issue is a therapy called applied behavioral analysis, which is widely accepted as beneficial to children with autism. The treatment is also expensive, costing $36,000 to $75,000 a year.
Insurers have denied coverage, arguing it is an educational rather than a medical service. Parents who appealed with the state Department of Managed Health Care won 15 out of 16 times through the agency’s independent medical review process last year.
The lawsuit contends that the department in March started funneling appeals over treatment denials through its own grievance review system, where department staff make the determination.
