SETTLEMENT REACHED WITH TUFTS ASSOCIATED HEALTH PLANS OVER RESTRICTING ACCESS TO TREATMENT FOR AUTISM SPECTRUM DISORDER

SETTLEMENT REACHED WITH TUFTS ASSOCIATED HEALTH PLANS OVER RESTRICTING ACCESS TO TREATMENT FOR AUTISM SPECTRUM DISORDER

Agrees to Reimburse Members and Providers, Revise Policies to Ensure Access to Autism Services

            BOSTON – In her continued efforts to ensure access to behavioral health services, Attorney General Maura Healey today announced a settlement with Tufts Associated Health Plans, Inc. (Tufts) to resolve allegations that it inhibited member access to coverage of Autism Spectrum Disorder treatments.

            “We can’t treat patients with behavioral health issues, including autism, differently from those with physical conditions,” said AG Healey. “Together, we need to break down the barriers that for too long have made the treatment of behavioral health secondary in our health care system. We appreciate that Tufts will take these actions to help ensure access to behavioral health treatment.”

The AG’s Office alleges that Tufts violated the state’s autism insurance, mental health parity and consumer protection laws when it inhibited member access to treatment for Autism Spectrum Disorder, specifically Applied Behavioral Analysis (ABA) therapy. Tufts allegedly violated these laws by implementing policies that required parental presence at every ABA appointment to obtain coverage and prohibiting coverage for ABA therapy provided in daycare or preschool settings.

Under the terms of the Assurance of Discontinuance, filed on Tuesday in Suffolk Superior Court, Tufts will reimburse members who paid out-of-pocket for ABA therapy as a result of its policies and reimburse providers who refunded payments from Tufts as a result of these policies.

Tufts will also refrain from implementing future policies that require parents to be present at ABA therapy sessions and will revise its policies to reflect that ABA therapy is covered in daycare and preschool settings.

In addition, Tufts will pay $90,000 to the Commonwealth, including $5,000 in civil penalties, $20,000 in attorneys’ fees and costs, and $65,000 to be distributed to programs to improve care and treatment related to autism.

Since taking office, AG Healey has made ensuring access to behavioral health services a priority.

In June, the AG’s Office issued a report that indicated that current approaches to managing behavioral health care complicate efforts to better coordinate patient care over time and across settings. According to the report, health care benefits are categorized as either “behavioral health” or “medical,” a distinction that complicates efforts to better coordinate overall patient needs.

The AG’s Office also recently settled with two health insurance companies, the Insurance Company of the State of Pennsylvania and American Fidelity Assurance Company, to resolve allegations that they violated state consumer protection laws by excluding coverage of certain health services required by Massachusetts law, including behavioral health.

This matter was handled by Assistant Attorney General Shannon Choy-Seymour and Deputy Division Chief Eric Gold of the Health Care Division.