Tufts reaches settlement with AG office

By Phyllis Hanlon
April 1st, 2016

The passage of mental health parity was intended to mandate equality in the care of behavioral issues with that given to physical conditions. In spite of the requirements, some insurers have been found to limit access to certain mental health services.

The Massachusetts attorney general’s office recently resolved allegations that Tufts Associated Health Plans restricted member access to Applied Behavioral Analysis therapy, a standard treatment for individuals diagnosed with autism spectrum disorder.

The AG’s office alleged that Tufts set a policy that required parents to be present during every ABA session in order for the service to be covered. Additionally, the insurer did not allow for coverage when ABA therapy took place in daycare or preschool settings.

According to Sonya Hagopian, vice president, Corporate Communications and Public Relations for Tufts Health Plan, the policies in question date back to when the autism insurance reform bill (ARICA) passed in 2010.

This bill required private health insurers in Massachusetts to provide coverage for the diagnosis and treatment of ASD. “At the time the law was passed, there was very little guidance upon which to develop new policies,” she said. “We did our best to interpret the law, recognizing the responsibility we have to manage the benefit in a way that provides access to necessary services, while carefully balancing costs.”

In a settlement with the AG’s office, Tufts has agreed to make changes to two of its policies regarding coverage for ABA therapy.

Hagopian said, “As of Jan. 1, 2016, for all fully-insured policies issued in Massachusetts, Tufts Health Plan updates its policies to remove the exclusion for services provided in a daycare/preschool setting.”

Tufts policy on parental presence during ABA therapy had been removed in 2014, according to Hagopian, prior to discussions with the AG’s office. But at the request of the AG’s office, Tufts included this policy change in the settlement agreement.

Hagopian pointed out that Tufts conducted an internal review to measure the impact of these policies on members and found it to be minimal. “No members were denied service based on the daycare/preschool exclusion and the few members denied coverage for ABA therapy, based on parental presence later received authorization for the services,” she said.

The AG’s office reports that the $90,000 total settlement includes $5,000 for civil penalties, $20,000 for legal fees and $65,000 that Tufts requested be used for autism treatment and outreach. The AG’s office will ultimately decide which organization will implement an outreach program.

“It is always our intent to implement policies that support health and do not limit access to care. We recognize it is possible that members may have not contacted us to seek authorization for these services because they believed coverage was not available,” Hagopian said.

“Because of this, we will reimburse any such members for out-of-pocket costs incurred in such cases, assuming the services were eligible under the member’s plan. A similar process will be available for providers who believe they were denied payment or voluntarily refunded payments related to ABA therapy services where a parent was not present.”

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