A showdown is brewing over autism therapy in
"Our autism community has said, 'OK, we're done. We've had enough,' " said
It has also pinched the finances of therapy providers around the state, which previously enjoyed generous insurance coverage that stems from the mandate for autism coverage passed by the
"Anthem cannot duplicate coverage for services that are available through the public school system," Anthem stated in the letter to parents.
The insurer has physicians with specialties in psychiatry - but not necessarily autism - review therapists' treatment plans for each patient. Anthem never issues a complete denial of coverage. But for school-age children, it often reduces the number of treatment hours for which it will pay from the amount requested by therapists.
Autism parents and their therapists say that, since 2012, Anthem has typically paid for 20 to 25 hours per week of therapy for school-age children.
In the case of
The Pierces say they can't afford-to pay for therapy on their own. Autism therapy, which is known formally as applied behavior analysis, or ABA, can cost
Public schools receive about
The Pierces previously had tried services in the public schools.
"While attending school, W.P. made no progress in potty training,"
"W.P. also gained weight and experienced unexplained pain in his back and buttocks area while attending school," Pierce added. "I later learned from another parent that W.P. was being left strapped into his wheelchair for most of the school day. I believe that this was because the school lacked the resources to directly manage W.P. in a productive manner."
In early 2011, the Pierces removed their son from public school and started commuting to Fishers so Wes could receive ABA therapy from the
But after Anthem cut the number of therapy hours it reimbursed, and cut it again to 20 in
"This member's treatment plan and behaviors do not appear to need full-time ABA therapy," wrote Dr.
Kennedy encouraged the Pierces to pursue an individual learning plan with their local public school for services that would help Wes with employment and independent living.
Ten days before that denial,
Heading to court
It didn't have to come to this, noted
She said autism advocates and families have had meetings the past three years with Anthem's medical directors, ABA therapist and officials from the
"We were very concerned that this would lead to litigation," she said.
The lawsuit is being led by
The lawsuit alleges that Anthem's policy violates both
"Anthem's determinations improperly conflate clinical ABA therapy with the educational services provided by
Several parents of autistic children view the Pierces' lawsuit as the best way - short of new legislation - to properly enforce the state's autism insurance mandate.
"This lawsuit is very important to autism families," wrote