- Associated Press - Saturday, May 2, 2015

INDIANAPOLIS (AP) - An Indiana couple whose son has autism is suing Anthem Blue Cross and Blue Shield, alleging that its policy of denying coverage for autism therapy during school hours violates state and federal laws.

Chester and Kathi Pierce of Elkhart sued the Indianapolis-based health insurer last month in U.S. District Court in Indianapolis on behalf of their son, Wes.

The couple is seeking class-action status for their suit, which alleges that Anthem’s 3-year-old policy of denying coverage for autism therapy during school hours violates both an Indiana mandate for autism coverage lawmakers passed in 2001 and the federal mental health parity law.

That federal law requires insurers to cover mental health services to the same extent that they cover services for physical health needs, the Indianapolis Business Journal reported (https://bit.ly/1dpOitJ ).

Their suit contends that Anthem’s policy has forced some families to change insurers or go with less of the therapy they say helps their children. Autism therapy is known formally as applied behavior analysis, or ABA, and can cost $30,000 to $50,000 a year, if delivered 40 hours a week, year-round.

“Anthem’s determinations improperly conflate clinical ABA therapy with the educational services provided by Indiana public schools,” the Pierces’ lawsuit states.

Anthem spokesman Tony Felts declined to discuss the suit. He said in a statement that Anthem is committed to getting autistic children the right treatments but it recognizes “that no two autism cases are alike.”

“Therapy that works for one individual may not be effective for another. In partnership with providers, parents and educational institutions, Anthem is paying for the care that is helping kids with autism spectrum disorders live a better life,” Felts said.

In May 2012, Anthem sent a letter to families with autistic children informing them it would no longer pay for therapy for school-age children during the time they are or could be in a public school. Anthem claims the federal Individuals with Disabilities Education Act requires public schools to provide services to autistic children.

In the case of Wes Pierce, who is 12, Anthem cut his number of therapy hours from 40 to 25 in July 2013. After Anthem cut the number of therapy hours it reimbursed, and cut it again to 20 in July 2014, Wes’ progress reversed and he now uses only five to 10 words, Kathi Pierce stated in her affidavit.

The Pierces say they can’t afford to pay for therapy on their own.

Autism advocates and families have met periodically over the past three years with Anthem’s medical directors, ABA therapists and state insurance officials, said Michele Trevedi, manager of The Arc Insurance Project at The Arc of Indiana, which provides services to Indiana residents with intellectual and developmental disabilities.

But Trevedi said Anthem insisted on treating the issue case-by-case, rather than “at the systemic level.”

“We were very concerned that this would lead to litigation,” she said.


Information from: Indianapolis Business Journal, https://www.ibj.com

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