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Judge Rules Providence Health Cannot Deny Coverage To Autistic Children

A federal judge in Portland has ruled that Providence Health Plans cannot deny coverage to autistic children for a specific kind of treatment.  The judge said that the insurer’s effort to deny that coverage violated both federal and state laws.

Many parents of autistic children swear by what’s called “Applied Behavior Analysis,” or ABA therapy.  It involves intensive, often one-on-one work. Parents say it helps a child achieve verbal, motor and basic life skills.

But it’s expensive. A 20-hour-a-week regimen can cost $50,000 a year.

Josh Ross was an attorney for parents in this class action lawsuit. He said, “we’re thrilled with the result and I know that our clients are very happy about it.”  He continued, “I mean this will affect a lot of people in Oregon who need this therapy and now will not be able to have denials based on this exclusion from Providence.”

Based on the the size of the class action lawsuit, this decision by U.S. District Judge Michael Simon could affect hundreds of children.

Providence issued a written statement saying it understands the needs of autistic children and that this year, it began offering patients 25 hours of ABA therapy per week.

The company also said it is reviewing the court ruling to determine any next steps.

Providence is not the only company to fight coverage of  ABA therapy.

Paul Terdal has two boys diagnosed with autism. He helped more than a dozen families successfully appeal coverage denials by Kaiser Permanente a few years ago.  Kaiser subsequently agreed to cover ABA therapy.

Terdal said that the Providence ruling is “absolutely fantastic. I mean it is, we’ve been making all of these arguments all along for several years and to have it come out in a solid, well done legal opinion by a U.S. District Court Judge that is basically confirming all you’ve been saying is just amazing.”

Earlier this year, a federal judge in Seattle ruled that Regence Blue Shield violated state law by not covering therapies for autistic children older than six.

Terdal says it takes time for insurance companies to accept treatments. But he said in this instance, the treatment benefits were clear: “I think the insurers have a huge fear of the costs that is frankly really beyond proportion.”

“It’s not as expensive as they think it is when you look over the general population. And they know it works, they know it’s effective, they know they should do it, they’re just thinking of everything they can to get out from under it because they’re worried about costs.”

The Providence ruling could have repercussions for the Oregon Public Employees’ Benefit Board. The board is also being sued in a class action lawsuit for refusing to cover ABA therapy.

But here’s the twist. Providence is acting as PEBB’s administrator and it issued a statement in that case a while ago saying:  “Under Providence’s Plan, services ‘related to developmental disabilities, developmental delays or learning disabilities’ are specifically excluded from coverage.”

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