Calif. Orders Insurers To Cover Speech, Occupational Therapy

On Monday, the California Department of Managed Health Care sent "cease and desist" orders to three prominent insurers that denied coverage for speech and occupational therapy services without determining whether such care was medically necessary, the Sacramento Business Journal reports.

Background

Previously, DMHC sent similar notices to two other insurers that denied members coverage for speech and occupational therapy (Robertson, Sacramento Business Journal, 11/18).

In 2012, DMHC reached a settlement with Kaiser Permanente Foundation Health Plan after receiving complaints from more than 100 policyholders who were denied coverage for the therapies.

In August, UnitedHealthcare announced that it had reached an agreement with DMHC to stop denying coverage of speech therapy services to its members (California Healthline, 8/28).

Details of Cease and Desist Orders

This week, DMHC sent cease and desist orders to:

Anthem Blue Cross, which received 14 complaints;

Blue Shield of California, which received 24 complaints; and

Health Net, which received 41 complaints.

The majority of the complaints previously had been processed through the insurers' grievance procedures and were denied, according to the Sacramento Bee's "Healthy Choices."

DMHC said that all three insurers' policies for speech therapy coverage violated state law.

In addition, Health Net was fined $300,000 for repeatedly listing requests for speech and occupational therapy services as coverage issues, rather than medical necessities. The delays resulted in some policyholders having to wait more than 80 days to receive care (Craft, "Healthy Choices," Sacramento Bee, 11/18).

Next Steps

All three insurers said they are reviewing the orders and considering how to move forward (Sacramento Business Journal, 11/18).

DMHC spokesperson Marta Green said the insurers could choose to appeal the orders, in which case hearings would be held by the state Office of Administrative Law. If their cases were rejected, the insurers would have to reimburse policyholders for the cost of speech therapy, Green said ("Healthy Choices," Sacramento Bee, 11/18).

Patient Advocate's Response

Beth Capell, a policy consultant at Health Access, said, "These types of therapy are very important for kids in terms of their development," adding that the group is "pleased the state is moving forward to require that children get access to care" (Terhune, Los Angeles Times, 11/18).

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