Appeals Court Says HMO Regulator Cannot Discriminate Against Autistic Children

In a complex opinion issued yesterday, the California Court of Appeal ended the Department of Managed Health Care’s (DMHC) discriminatory practice of allowing HMOs to deny treatment for autistic children of state employees and low-income families enrolled in the Healthy Families program on the basis that such treatment can only be administered through state-licensed providers.

The case was brought by the non-profit Consumer Watchdog and Strumwasser & Woocher LLP. The treatment at issue, known as Applied Behavioral Analysis (ABA), has been found to be the most effective treatment for autistic children. After the lawsuit was filed, the California Legislature agreed with Consumer Watchdog by passing a law in 2011 clarifying that HMOs and health insurers must provide coverage for ABA for children enrolled in private health insurance plans and that such treatment could be provided through providers who are certified by a national board, but not state-licensed. However, the Legislature did not include public employees and Healthy Families enrollees.

The remaining issue to be decided by the Court of Appeal was whether the DMHC could allow HMOs to deny ABA for children enrolled in public health plans if an ABA provider does not hold a state license.  As Consumer Watchdog and Strumwasser & Woocher LLP pointed out in the lawsuit, no state licensing currently exists for ABA therapists. For more information, visit http://www.strumwooch.com

Last Updated 12/02/2020

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