A California appeals court held September 10 that under a recently-enacted state statute covered health plans must provide coverage for Applied Behavioral Analysis (ABA)—a therapy used to treat the symptoms of autism in young children—even when the treatment is not administered by a licensed physician. Plaintiff Consumer Watchdog challenged the California Department of Managed Health Care’s (DMHC’s) policy that no coverage will be required for mental health services administered by a provider not licensed or certified under California law. The appeals court noted that ABA is often performed, or supervised, by an individual certified by the private Behavior Analyst Certification Board (BACB).
According to the appeals court, under the statute, which was enacted during the pendency of the case, BACB-certification “has implicitly been recognized as an exception to the licensing laws and, therefore, DMHC can no longer uphold a plan’s denial of coverage for ABA on the basis that a BACB-certified provider is not licensed.” However, the court said, to the limited extent the issue of DMHC decisions prior to the effective date of the new statute is before the court, the court found that “DMHC had, prior to July 1, 2012, no clear, ministerial duty to order plans to provide coverage for therapy provided or supervised by BACB-certified providers.”
Consumer Watchdog v. Department of Managed Health Care, No. B232338 (Cal. Ct. App. Sept. 10, 2013).