Jan 3, 2014 11:40 PM by Maddie Garrett

State Tries to Bridge Gap in Insurance Coverage for Autism Therapy

A change is coming down for the Colorado Division of Insurance, after News 5 investigated a gap in insurance coverage for children with autism. New rules with the Affordable Care Act eliminated lifetime caps for treatment, so the Division of Insurance adopted new policies that parents said dramatically reduced the amount of autism therapy covered by insurance companies.

But now those changes are being reversed in a way, the Division made an emergency regulation that states insurance companies must go back to covering the same amount of autism treatment they did in health plans issued prior to May 2013. It's meant to bring back up the amount of therapy children were used to getting.

"If they lose service hours, they're losing all of those skills and all that potential," said Dawn Zinc, Assistant Therapeutic Director at Play Date Behavioral Interventions.

The therapy involved is called Applied Behavioral Analysis, or ABA therapy. Under previous Colorado law there was up to a $34,000 cap on treatment, which Zinc said transfers to 6 to 18 hours of ABA therapy a week.

After the Division of Insurance changed the cap, children are only getting that much per month. Zinc said that much of a reduction would mean regression for children with autism.

"What we weren't prepared for was insurance companies that already had a set amount in authorization for hours, switching to the minimum," said Zinc.

But after parents and autism organizations objected, the Division made a change.

"Well it was due to the feedback at one of the hearings," said DORA Communications Manager Vincent Plymell. "they felt that is was worthwhile to make this emergency regulation, this change."

For now, a temporary rule is in place, telling insurance companies to go back to the plans from a year ago, making sure children don't lose therapy while the division comes up with a permanent solution. Plymell explained the minimum of 550 sessions at 25 minutes each is still in place, but insurance companies are supposed to provide more therapy than that if that's what children were receiving before the new rules took effect.

"I think it's responsible and what needs to be done, because insurance would cut it if they could," Zinc responded.

Zinc said most insurance companies have gone back to the old plans and are covering more therapy, except for one, Kaiser Permanente.

"Parents are... trying to get this insurance company to return their calls and it's just not happening and our thought is that's the way they want it to be. But we're not going to accept it, we're going to keep fighting to keep these kids in therapy," said Zinc.

Fort Collins mom Cari Brown told News 5 that Kaiser has yet to approve any more therapy for her son Craig, and are still limiting him to the 550 sessions a year, which will run out in a few months. She said Kaiser told her they are still interpreting the emergency regulations.

"Obviously we can apply for more therapy once we run out, but there has been no promise that more would be approved. Additionally, no timeline for their "interpretation process" has been given," Brown wrote in an email.

News 5 called Kaiser Permanente Friday afternoon, and asked for comment on their interpretation and response to the Division of Insurance's emergency regulation. However, representatives with Kaiser said they were not able to make a comment on Friday and would work on a response for next week.

Dawn said until the ABA therapy is covered, more families are applying for scholarships to get the treatment they need. She said they have a six month to a year wait list for scholarships, and that is only growing.

"That just means we may not be able to bring on new kiddos, new clients on a scholarship as long as we have to fund the clients we already have with a scholarship because they lost most of their funding," explained Zinc.

The emergency regulation is in place for the next 120 days. During that time, the Division of Insurance said it will hold additional public hearings and conduct more studies on how much therapy should be covered.

Plymell said the Division would look into any insurance companies not complying with the new rules. He also suggested any parents having issues with their insurance should report it to the Division of Insurance.

For more information on the Division of Insurance's emergency regulation, click here.



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