1. Case Name: D.F. et al. v. Washington State Health Care Authority, et al.
2. Type of Treatment Services Denied: Applied Behavioral Analysis (ABA) therapy for autism
- Plaintiff: Eleanor Hamburger & Richard E Spoonemore, Sirianni Youtz Spoonmore Hamburger
- Defendant: Melissa A. Burke-Cain & Kristen K. Culbert, Office of the Attorney General
4. Format: Order granting, in part, Plaintiffs’ Motion for Partial Summary Judgment and denying Defendants’ Summary Judgment Motion
- ERISA Claim?
- Class Action/or Individual Action: Class Action
- Defendant: Health Plan
- Type of Insurance Plan: Washington Health Care Authority self-funded Uniform Medical Plan
- Type of Coverage Denial: Medically Necessary ABA therapy
6. Legal Pointer: Health care plans may not have a blanket exclusion for mental health services when there is not an equivalent exclusion for medical/surgical services.
7. Legal Issues and Causes of Action: Plaintiffs sought partial summary judgment in the form of an injunction requiring Washington Healthcare Authority (HCA) to cover Applied Behavioral Analysis (ABA) for children with autism for whom the service was medically necessary. Plaintiffs contended that ABA therapy can enable children with autism to attend school, even in mainstream classrooms, or avoid institutionalization.
Ruling: The Court concluded that Plaintiffs were entitled to a declaration that specific exclusions contained in health benefit plans administered by the Defendants that exclude coverage of ABA therapy, even when medically necessary and performed by licensed health providers, did not comply with Washington’s Mental Health Parity Act. The Court further declared that under the Mental Health Parity Act Defendants were required to cover medically necessary ABA therapy, as determined on an individualized basis, when provided by licensed providers.
The Court reserved ruling on whether Defendants were required to cover ABA therapy when provide by certified or registered – as opposed to licensed – health providers.
The Court denied Plaintiffs’ request for injunctive relief and denied Defendants’ motion for summary judgment.
8. Narrative Case Description: D.F. and his family first enrolled in the Aetna Public Employees Plan in January 2009. SF and his brother, DF, received ABA therapy through a program prescribed and monitored by Dr. Stephen Glass. The program was implemented by Allison Apple, Ph.D., a licensed mental health provider. The boys’ parents were initially told that this therapy would be covered by Aetna under a “transition of care” benefit, but later Aetna declined coverage for a consulting appointment with Dr. Glass and all other therapy related to ABA on the grounds that ABA was not covered under the plan. Plaintiffs’ parents appealed the denial. HCA denied the appeal on the grounds that the treatment was not “medically necessary.”
Plaintiffs’ parents then requested an independent review. The review found that ABA therapy was the standard medical care for children with autism and concluded that ABA therapy was medically necessary. After this review, Aetna paid for SF’s ABA therapy, which was provided by a master’s level therapist who was certified as a mental health counselor. Subsequently, however, Aetna amended its certificate of coverage to specifically exclude ABA therapy, even if it was medically necessary.
HCA argued that it did not cover ABA therapy because it was provided by unlicensed practitioners. HCA further contended that it only provided coverage for care performed by licensed health care providers. Plaintiffs’ parents argued that HCA denied coverage even though care was performed by licensed mental health providers. Plaintiffs’ parents further argued that ABA therapy was excluded from coverage by HCA regardless of who provided it and regardless of whether it was medically necessary. Plaintiffs’ parents stated that there was no similar blanket exclusion for any category of medical care.
Both parties relied on language in the party law to support their arguments. Plaintiff cited RCW 41.05.600(1), which denied “mental health services” as “medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders…” and then listed certain categories of treatment that were expressly not included in the definition of “mental health services.” Plaintiffs argued that this provision meant that all other mental services were to be covered, without limitation and that that was the legislature’s way of remedying past discrimination against mental health care.
HCA pointed to RCW 41.05.600(2)(c), which provided in part that “treatment limitations or any other financial requirements on coverage for mental health services are only allowed of the same limitations or requirements are imposed on coverage for medical and surgical services.” HCA argued that this provision allowed it to restrict coverage to licensed mental health providers, since only medical and surgical services performed by licensed providers were covered. HCA also noted that RCW 41.05.600(4) provided that a health plan may require that “mental health services be medically necessary…if a comparable requirement was applicable to medical and surgical services.”
The Court was not persuaded that the statute’s definition of mental health services evidenced a legislative intent that all services that purport to remedy mental health problems must be covered by HCA, regardless of medical necessity. The Court was also not persuaded that the legislature intended to require HCA to cover services no matter the qualifications of the provider.
The Court concluded that HCA was not in compliance with the Mental Health Parity Act insofar as it imposed a blanket exclusion of ABA therapy, even when provided by licensed therapists. The Court further stated that HCA was required by the Act to cover medically necessary ABA therapy that was provided by licensed therapists.
9. Additional Comments: Although both parties attempted to persuade the court of their respective positions on the medical necessity of ABA therapy, or lack thereof, the Court concluded that it was apparent that ABA therapy may provide benefit to some individuals.
HCA also contended that Plaintiffs failed to exhaust their administrative and/or contractual remedies; however, the Court held that S.F. exhausted his contractual remedies under the Certificate of Coverage and there was no need for other class members to go through a similar exercise.
10. Website: To view the Stipulation Regarding Interim Coverage, click the following link: http://www.washingtonautismadvocacy.org/updates/wp-content/uploads/DF-v-WSHCA.pdf
11. Practical Implications and Lessons Learned: This was the first ruling on Washington State’s Mental Health Parity Act since it was enacted in 2005.
12. All Legal Theories Presented in Case: Violation of Washington’s Mental Health Parity Act
13. Successful Legal Theories in Case: All