Amy Dawson wins key decision in lawsuit to help low-income children who have autism obtain coverage for therapy.
Amy Dawson, attorney with Sapientia Law Group and founder of the Autism Advocacy and Law Center in Minneapolis (www.autismlawcenter.com), received a favorable decision from the Minnesota District Court, Second District, on Tuesday. Dawson represents a 2‑year-old autistic child named T.O. who was denied coverage for an intensive type of autism therapy called Applied Behavior Analysis (ABA) or Intensive Early Intervention Behavior Therapy (IEIBT). The lawsuit aims to ensure that low-income children who have autism receive coverage for medically necessary treatment for autism. Dawson offered proof that low-income children who have autism are systematically denied coverage for evidence-based, medically necessary autism therapy by HealthPartners — even while other children enrolled in Medical Assistance routinely receive coverage for the same type of therapy. Ramsey County Judge Robert Awsumb remanded the case to an administrative law judge for clarification on several key issues. Dawson feels confident that these further proceedings will lead to winning coverage for her client’s autism therapy and she also hopes that it will end the disparate treatment of low-income children with autism.
HealthPartners, acting as the administrator of T.O.‘s MA health benefits, denied coverage for T.O.‘s therapy on the grounds that IEIBT is not included in the MA benefit set. The court’s order embraced the proof offered by Dawson that this assertion is belied by the fact that when DHS administers the MA benefit set, IEIBT is routinely covered as a type of “skills training.” Dawson brought suit against HealthPartners and the Minnesota Department of Human Services (DHS) challenging the denial of coverage for IEIBT treatments for 2‑year-old T.O. She argued that the state provided MA coverage for ABA/IEIBT treatment for children insured under MA’s “fee-for-service” plans, for which eligibility is based on the child’s disability, but allowed HealthPartners to deny coverage to families enrolled in MA’s pre-paid managed-care programs (MA-PMAP), in which low-income families are enrolled. The practice of not paying for IEIBT treatments under the MA-PMAP effectively deprives low-income children of access to treatments.
Dawson’s suit has prompted Minnesota’s Department of Human Services and the Legislature to take a closer look at the disparity in application of the MA benefit set between low-income children enrolled in MA-PMAP and children who are enrolled in MA on the eligibility basis of “disabled.” She is hoping that this test case will lead to a change in policy that will ensure that all families, regardless of income, are informed of all MA coverage options, as well as the option of ABA/IEIBT treatment for children with autism spectrum disorder, and be given a fair chance to navigate the system to take advantage of the treatment.
Part 1 – “Autism’s $100,000 question,” Star Tribune, April 3, 2011, story by Maura Lerner:
Part 2 – “Autism’s $100,000 question — Kids with autism face double standard,” Star Tribune, April 4, 2011, story by Maura Lerner:
The April 3rd issue of Star Tribune includes an article highlighting the success Amy Dawson’s son Mac has seen with ABA treatment: “Intensity, then progress,” Star Tribune, April 3, 2011, story by Maura Lerner: