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Blue Shield to stop denying coverage of autism therapy

In separate agreements with California's two insurance regulating agencies, Blue Shield of California has agreed to stop denying coverage for an autism therapy called applied behavior analysis. The insurer previously deemed ABA experimental and said it wasn't a healthcare service or medically necessary.

The California Department of Insurance issued an order against Blue Shield, saying the insurer failed to comply with the state Mental Health Parity Act, which requires private insurance plans to provide equal coverage for mental health conditions. "Decades of research show [ABA] to be a successful and well-established treatment for autism and not an experimental or investigational treatment," said Adam Cole, the department's general counsel, in a statement.

Meanwhile, the Department of Managed Health Care (DMHC) reached a settlement with Blue Shield to begin covering ABA. In some cases, Blue Shield will provide retroactive reimbursement for certain out-of-pocket expenses, according to ABC7. Under the agreement, Blue Shield can't deny coverage for behavioral treatments, although it can still consider the medical necessity of those treatments. The insurer also agreed to avoid interruptions in care, expand access to healthcare providers, and reimburse some individuals for treatments that it previously refused to cover, the San Francisco Chronicle reports.

DMHC is also close to reaching a similar agreement with Anthem Blue Cross and Kaiser Permanente, notes the Chronicle.

To learn more:
- read the Blue Shield-DMHC agreement (.pdf)
- read the California Department of Insurance statement
- see the San Francisco Chronicle story
- view the ABC7 piece

Related Articles:
Blue Shield ACO keeps premiums low, could be model for others
Blue Shield of California must explain rate hikes
Is Blue Shield's refund good business or spin campaign?

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