The following FAQ about Shayan's Settlement is up on the Uniform Medical Plan (UMP) website.
On August 8, 2012, the Health Care Authority (HCA) mailed a notice to UMP subscribers who have a covered member with a diagnosis of autism spectrum disorder. This notice explained the proposed settlement agreement between the HCA and the parties who brought the suit.
The first part of the settlement covers Applied Behavior Analysis (ABA) Therapy provided during the "interim period": June 11 to December 31, 2012. To get coverage of ABA Therapy during the interim period, you must request authorization as described below.
After the proposed settlement is approved by the court, UMP will mail letters to members who received the notice explaining how to request authorization of ABA Therapy during the interim period. Currently, a court date is set for September 12, 2012. Once a decision is made, UMP will send letters to affected members within two business days.
What is ABA Therapy?
ABA Therapy is a behavioral therapy technique used to treat severe symptoms associated with an autism spectrum disorder and intended to produce significant improvement in behavior and functional skills. ABA Therapy is sometimes performed in an intensive outpatient setting for younger patients because it is believed that intensive early intervention produces the most significant and long-lasting outcomes.
How will benefits for ABA Therapy be paid during the interim period?
During the interim period, ABA Therapy will be paid at 100% up to a maximum of $1,750 per month with no visit maximum. The plan will cover any provider type for services during the interim period, as UMP is still establishing network providers.
ABA Therapy must be authorized by the plan.
How can I request authorization of ABA Therapy during the interim period?
When the settlement is approved, UMP will send letters to affected members describing the authorization requirements; these will also be posted online. UMP will respond to authorization requests within 14 calendar days, as long as sufficient documentation is provided.
What happens if my authorization request is denied?
If your authorization request is denied, you will receive information about how to appeal. Note that the appeals process for ABA Therapy services during the interim period is different than the usual UMP appeals process.
Will ABA Therapy prior to June 11 be covered?
The proposed settlement covers only the interim period. Coverage of ABA Therapy provided before June 11, 2012, will be addressed in a later phase of the lawsuit.
What about ABA Therapy in 2013?
ABA Therapy will be covered as any other benefit in 2013 and will be included in the UMP 2013 Certificates of Coverage. You will need to request preauthorization for 2013 services, even if you have already been approved for 2012.
Questions?
For coverage questions and issues: Call UMP Customer Service at 1-888-849-3681
For questions about the lawsuit, you may contact the legal representatives of the Class at: Eleanor Hamburger or Richard SpoonemorePhone: 206-223-0303Mail: 999 Third Ave, Suite 3650, Seattle, WA 98104Email: ehamburger@sylaw.com or rspoonemore@sylaw.com