Insurer’s Secret Plan to Cut Autism Treatment for Children #

A major health insurance company has developed an internal strategy to limit access to autism treatment for children, despite acknowledging it as the “gold standard” therapy. The company aims to reduce costs by preventing new providers from joining its network, terminating existing ones, and authorizing fewer treatment hours than requested.

The plan targets children covered by Medicaid plans managed by the insurer in multiple states. Internal documents outline “key opportunities” to cut expenses as autism diagnoses and treatment costs have risen sharply in recent years.

Tactics include:

• Preventing new providers from joining the network
• Terminating existing providers, including “cost outliers”
• Scrutinizing medical necessity with “rigorous” clinical reviews
• Authorizing fewer treatment hours than requested

In some states, this could impact over 40% of the company’s autism therapy providers and up to 19% of patients receiving treatment.

The strategy focuses on applied behavior analysis (ABA) therapy, which helps children with autism develop basic skills. Experts say greater awareness and improved screening have contributed to autism rates increasing from 1 in 150 to 1 in 36 children over the past two decades.

Impact on Families #

One mother, Sharelle Menard, has seen her 10-year-old son Benji make significant progress through ABA therapy. However, the insurer recently denied the full hours his clinical team says he needs, stating he had been in therapy too long without enough improvement.

This decision baffled experts, who say it misunderstands the long-term nature of autism treatment. When Benji’s therapy hours were previously reduced, he regressed behaviorally and had to be withdrawn from school.

His therapy center is now providing the denied hours without reimbursement while appealing the decision. The center’s founder said: “We don’t think it would be safe for him to do what the insurance is saying.”

Broader Implications #

Mental health advocates and autism experts expressed outrage at the company’s cost-cutting strategy, calling it “unconscionable and immoral” to restrict access when there is urgent need for services.

Some said the approach may violate mental health parity laws requiring equal coverage of mental and physical health care. There are also concerns it could violate Medicaid regulations on maintaining adequate provider networks.

While acknowledging the high costs of autism treatment, experts warned that limiting access could ultimately lead to greater expenses as children age without proper intervention. They emphasized that appropriate treatment should be based on individual patient needs as determined by their clinical teams.

As insurers tighten restrictions, families may face difficult choices between paying out of pocket or losing access to vital therapies for their children with autism. Meanwhile, provider waitlists continue to grow as the need for autism services shows no signs of diminishing.