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Washington employees accuse aerospace giant of Mental Health Parity violations
(APRIL 20, 2014) --Aerospace giant Boeinghas been hit with a complaint in federal court by its Washington state employees who claim the company's denial of insurance coverage of applied behavior analysis (ABA) for their children withautism violates thefederal Mental Health Parity Act. Filed by two families whose sons have autism, "C.S." and "D.Z.",the suit seeks certification as a class action on behalf of Boeing's 81,000 Washington-based employees.
Listed #30 on the Fortune 500 list as the nation's largest aerospace and defense firm, Boeing reported earning $3.9 billion in profits last year on $81.7 billion in revenues. Headquartered in Chicago, half of Boeing's employees are based in Washington. The suit was filed in U.S. Dstrict Court in Seattle.
The case has added significance because Boeing self-insures its employee health plan and therefore isregulated under federal ERISA lawwhich is immune from state autism insurance reform laws, such asthe law in its headquarters state of Illinois. The suit was filed bySeattle attorneys Ele Hamburger and Richard Spoonemore who have been winning a series of similar federal class action suits in Washington over ABA denials. The complaint alleges Boeing's denial of ABA benefits violates the 2008 Wellstone Domenici Mental HealthParity and Addiction Equity Act as well as its fiduciary responsibilities under ERISA.
Boeingdoes not expressly exclude ABA coverage in its health plan, but ratherhas its claims administrators exclude all coverage of ABA therapy through internal policies and restricted provider networks, the complaint alleges.
Boeing's non-mental health claims administrator, Blue Cross Blue Shield of Illinois (BCBSIL), excludedABA therapy coverage.When a Boeingemployeeoverturned thedenial,according to the complaint,Boeingdirected BCBSIL to classify ABA therapy as a mental health service to be administered by Value Options, which administers Boeing's mentalhealthclaims.
Boeing directed Value Options to limit its provider network in Washington state to exclude licensed ABA agencies, the plaintiffs assert.
"The effect of Boeing/Value Option's failure to include in its network any licensed ABA agencies in Washington state is the same as a blanket exclusion," according to the complaint."It is impossible for plaintiffs and the proposed class to obtain coverage for the ABA therapy services they need because Boeing will not contract with any providers who can deliver it."
The Mental Health ParityActdoesnotrequire Boeing to cover mental health services; rather it requires employers if they do choose to provide mental health coverage -- as the Boeing plan does-- to cover the benefits“at parity” with medical benefits.ERISA requires Boeing to abide by the Mental Health Parity Act and other regulation in administering its plan.
"By applying a blanket, hidden exclusion of ABA therapy to treat (autism), in violation of the Parity Act and its regulations, Boeing is systemically and uniformly failing to properly administer its Plan," according to the complaint. "It is alsobreaching its fiduciary duties to plaintiffs and class members, who have not received the benefits to which they are entitled."
The suit seeks a court order stopping Boeing from denying ABA coverage in its health plan and requiring reimbursement for past claims
This lawsuit seeks remedies for Boeing's breach of fiduciary duty under ERISA and its failure to properly administer the terms of Plan, as modified by the Parity Act and its implementing regulations. It further seeks to recover the benefits that have been wrongfully denied to plaintiffs and the class they seek to represent. It also seeks a court order declaring Boeing's exclusion of coverage for ABA therapy to treat ASD through a restricted network of providers void and unenforceable. The lawsuit further seeks an injunction to prevent any future or ongoing efforts by Boeing to use and enforce any blanket exclusions of ABA therapy to treat ASD.
The class consists of all individuals who have been, are, or will be Washington state participants or beneficiaries under The Boeing Master Welfare Plan that have been, are or will be in effect or renewed
Denials followed by delays prompts new regulatory enforcement
(April 17, 2014) -- The California Department of Insurance has won the go-ahead to enforce toughnewrequirements to stop private insurers from denying and delayingcoverage forbehavioral health treatments, such as applied behavior analysis (ABA), for autism.
The department based the new regulations on its interpretation of the state's 1999 Mental Health Parity Actand won approval Wednesday from the Office of Administrative Lawto begin enforcement. California is one of 35 states to require certain commercial insurers to cover behavioral health and other treatments for autism by law, yet still encounters widespread non-compliance by the industry.
"Approval of the mental health parity regulation will help end improper insurer delays and denials of medically necessary treatments for autistic individuals," said Insurance Commissioner Dave Jones. "This regulation provides clear guidance to the industry, stakeholders and consumers on the requirements of the Mental Health Parity Act from 1999."
The department proposed the newregulations when it found insurers were able to delay or deny medically necessary treatment for individuals with autism as required under California's 2011 auitism insurance reform law. The regulations further define the circumstances in which insurers must cover behavioral health treatment by specifically applying the requirements under the Mental Health Parity Act.
Since 2009, the Insurance Departmenthas referred23 cases related to denials of behavioral health and other autism treatment to external clinicians for Independent medical review. Of those, 19were overturned.
In another 40 cases that have been closed, the individual delays in obtaining treatment averaged nearly half a year; delays currently average over 10 months, or almost a year, for those cases which are still open. The cumulativedelays on open and closed casestotal 12,864 days, or 35.2 years.
"These lengthy delays all involve treatment that experts agree is most effective when provided in early childhood," the department argued in its regulatory proposal. "The benefits anticipated from the proposed regulation include significantly lessening or eliminating these delays and denials of treatment and substantially improving treatment efficacy and outcomes."
Gov. Brownback enacts law making Kansas 10th state to expand coverage
OVERLAND PARK, KS(April 16, 2014) -- Governor Sam Brownback today signed legislation expanding autism insurance coverage beyond the state employee health benefit program, culminating a six-year campaign to enact more meaningful reform in Kansas. Enactment of the law also made Kansas the 10th state to amend its original autism insurance law to make it stronger.
“Autism Speaks applauds Governor Brownback's support of the autism community," said Mike Wasmer, a Kansas resident who serves as Autism Speaks' director of state government affairs. "This bill is an important step toward providingaccess to medically necessary treatment for allindividuals with autism in Kansas.”
Sponsored by Rep. John Rubin (R-Shawnee), the new law,HB.2744, will require state-regulated large group and "grandfathered" small group individual health plans to cover medically necessary treatments, including applied behavior analysis (ABA), for autism for children up to age 12.
The bill as initially proposed by the House Insurance Committee would have limited ABA coverage to 10 hours per week, but was raised after vigorous opposition from the state's autism community. As enacted, the new law allows for 25 hours per week of ABA for four years from the time of diagnosis and then reduces to 10 hours per week.
The new law is spearate from the state's 2010 autism insurance reform law which applies only to state employees. The 2010 legislation when introduced would have covered the private market, but was amended into a pilot program limited to state employees to gauge the impact on health care costs. When the 2010 law was enacted, Wasmer, then president of the Kansas Coalition for Autism Legislation (KCAL), said, "This is not the end, but rather the start of getting autism treatment to all in need in the state of Kansas."
After being judged a success, the program was made permanent for state employees, but Kansas lawmakers continued to resist efforts to expand the coverage to the private market. In 2012, efforts to force a bill out of a committee fell one vote shy of success.
After Rubin introduced a bill this year that would have provided broader coverage, the insurance lobby filed a second version with much more restrictive terms and would have cut back existing benefits for state workers. After heated opposition from the state's autism community, HB.2744 was introduced as a compromise measure.
Wasmer said the new law marks a step forward, but that efforts will continue to provide the best coverage for the most children. The existing state employee autism benefit will continue unaffected by the new law.
House, Senate members briefed on needed changes in ABA coverage for military kids
WASHINGTON, DC (April 9, 2014) -- Military families raising children with autism and Down syndrome today called on Congress to overhaul insurance coverage provided under TRICARE for applied behavior analysis (ABA) during Capitol Hill briefingsorganized by Autism Speaks.Reps. John Larson (D-CT) and Tom Rooney (R-FL), who have championed TRICARE reform bills in the past, said they remain committed to improving ABA coverage for military kids and will soon introduce new legislation.
Kimberly Kapacziewski [left], whose son Cody, has been diagnosed with autism, came to Washington from Fort Benning, Georgia, where her husband, Joe, serves as a sergeant first class with the Army Rangers. Kapacziewski lost the bottom part of a leg to a hand grenadewhile serving his fifith tour in Iraq in2005, but later returned six times to active duty with the Rangers as an amputee.
Patricia Heath [right], whose daughter Marissa has been diagnosed with Down syndrome, is stationed at Eglin Air Force Base in Pensacola, Florida with her husband, Brandon, an Army master sergeant.
They were joined by Dr. Paul Wang, Autism Speaks' head of medical research, and Karen Driscoll, Autism Speaks' associate directorforfederalgovernment affairs and military relations. The wife of a retired Marine, her son has autism.
Kapacziewski said she and her husband had to travel to an Army base in Texas simply to find a pediatric specialist who could diagnose their som with autism. Medical professionals said Cody needed a minimum of 25 hours a week of ABA therapy, but TRICARE caps benefits at 12 hours.
"Her husbandhas already sacrificed a leg for his country, does he have to sacrifice a child too?" Larson said.
Heath said her daughter received three years of ABA therapy and was making tremendous progress when TRICARE cut off all benefits in 2012 by limiting coverage to children with autism, excluding those with Down syndrome, Fragile X, Angelman syndrome and other developmental disabilities. Her daughter soon regressed and once briefly wandered from home.
Driscoll said advocates or TRICARE reform are calling for ABA coverage to be made permanent for all children with disabilities, expanded access to treatment by allowing more trained providers to deliver reimbursable services, and continued vigilance over the Department of Defense to insure military dependents receive care that is consistent with best practices.
Wang cited the continued growth in the prevalence of autism which now affects an estimated 1 in 68 children. The benefits ofABAin treating autism and other developmental disabilities has been amply documented, he said, noting a recent endorsement before Congress by the American Academy of Pediatrics.