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Federal judge rules that insurers can't deny ABA therapy for treatment of autism

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A federal judge in Oregon yesterday ruled that insurance providers cannot deny coverage of Applied Behavior Analysis (ABA) therapy for the treatment of autism. The Governor of Oregon, John Kitzhaber, today agreed with this ruling and will adjust state health plans to reflect the decision.

The ruling in the class action lawsuit came when Judge Michael H. Simon deemed that Providence Health Plan violated state and federal laws when it denied coverage of ABA therapy for children diagnosed with autism and other developmental disabilities, but granted coverage for children without a diagnosis. This is a violation of federal and state health parity laws as well as mandates which decree that insurers must cover treatments, such as ABA therapy, for children diagnosed on the autism spectrum, but simultaneously deny them.

ABA therapy can be very expensive, costing upwards of $50,000 annually. It typically entails interventionists working in a family's home, and sometimes a child's school, to address behavioral deficits for between 20 and 40 hours per week. In the state of California, regional centers fund ABA therapy by service providers, as well as insurance companies. In 2011, California issued a warning to insurance companies after nine denials of ABA treatment had been overturned on appeal.

The disparity between insurance mandates and what insurance companies actually cover occurs because the medical community accepts ABA as a medically necessary treatment of autism, whereas certain insurers view it as an educational service provided by schools. Furthermore, since autism is classified as a "developmental disability" rather than a mental health disorder, some insurers exclude ABA coverage for those with autism. Excluding a certain population from medically necessary treatments is, again, a violation of mental health parity laws.

The federal ruling will hopefully set a precedent for insurance companies across the United States. It also comes in light of President Obama last week signing the Autism CARES Act into law which was set to expire on September 30. The reauthorization approves $260 million annually through 2019 for research, prevalence tracking, training for medical professionals and service providers, early identification, adult services and other related autism efforts.