Healthy Choices

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State to health insurers: Stop denying speech therapy

11/18/2013 3:16 PM

11/19/2013 10:43 AM

After dozens of consumer complaints, the California Department of Managed Health Care on Monday ordered three prominent health insurance companies to stop denying speech therapy to patients.

Health Net, Blue Shield and Anthem Blue Cross were all slapped with cease-and-desist orders by DMHC attorneys for what they said was unlawful denial of medically necessary therapies. Health Net, with the highest number of complaints at 41, was hit with a $300,000 fine.

All three health insurers had language in their policies that allegedly violated state law mandating access to speech therapy.

Health Net’s policy, for instance, states: “We do not consider speech therapy medically appropriate for any of the following: .... Delayed or suppressed speech development due to an idiopathic (non-diagnosable) disease or injury which occurred before the child developed any level of functional speech, that is, before 18 months of age.” (The bold and underlined words were included in Health Net’s document.)

One consequence of the insurers’ policies was that children with autism could not get speech therapy. Parent activist groups have been among the most outspoken critics of the denial of speech therapy services, but autistic families made up only 10 percent of this group of complaints.

Health Net executives released a statement responding to the allegations. “We just received the order today, and we are reviewing it,” the statement said. “Once we have finished our review, we will consider all our options.”

Blue Shield, with 14 complaints registered against it, and Anthem Blue Cross, with 24 complaints, responded similarly, saying they too had just received the orders and were reviewing them. Blue Shield added, “We will work with the Department to resolve any issues.” Anthem Blue Cross commented, “We will work to ensure we are in compliance with the requirements for speech therapy.”

Attorneys filing the legal actions, which included separate accusations for each of the companies, said the insurers “unlawfully categorically denied coverage for speech therapy on the ground that the enrollee did not have a sufficient physical condition to trigger coverage, and did not consider whether the requested therapy was medically necessary to treat the enrollee’s condition.”

Most of the complaints filed with the Department of Managed Health Care had gone through the insurer’s private grievance process and had been denied.

The department said that children with developmental disabilities, expressive language disorders, speech delays and cerebral palsy were among those denied coverage.

California law says that medically necessary speech therapy is a basic health care right. In Health Net’s case, the denials delayed care for enrollees by more than 80 days.

The insurers may contest the cease-and-desist orders and file legal defenses against the accusations. In that case, said DMHC spokeswoman Marta Green, hearings will be held by the state Office of Administrative Law.

If the insurers contest and lose, they will have to reimburse enrollees for the cost of speech therapy.

About This Blog

Sacramento Bee reporters Cynthia Craft and Sammy Caiola write about community health issues in the Sacramento region. Their work is in conjunction with the California Endowment, a non-profit health foundation created in 1996.

Cynthia H. Craft is The Sacramento Bee's senior writer on health. She graduated from Ohio State University and previously worked at the Los Angeles Times and California Journal. She was a fellow in 2012 at the National Library for Medicine in Washington, D.C. at the National Institute for Health. Reach her at ccraft@sacbee.com or 916-321-1270. Twitter: @cynthiahcraft.

Sammy Caiola joined The Sacramento Bee as a health reporter in 2014. She is a recent graduate of Northwestern University's Medill School of Journalism, where she was a Top 10 finisher in the William Randolph Hearst College Journalism Awards. Reach her at scaiola@sacbee.com or 916-321-1636. Twitter: @SammyCaiola.

 

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