A ruling says Medicaid program should pay his bills.
A 4-year-old boy from Maple Grove has won his legal battle to force the state of Minnesota to cover his family's expenses for an intensive form of autism treatment known as Applied Behavior Analysis (ABA).
But the ruling stops short of requiring the state to routinely cover the treatment, which can cost up to $100,000 a year.
The case has drawn scrutiny from Washington, D.C., to St. Paul because of questions about whether taxpayers should be paying for the treatment.
The child, identified only as T.O., and his mother sued the state for refusing to pay for his treatment during a six-month period when his family was in a state-funded managed care plan run by HealthPartners. Under the ruling, HealthPartners must pay for the treatment, which in his case totaled about $25,000, according to Amy Dawson, the family's lawyer.
"I think it's an important victory," said Dawson, founder of the Autism Advocacy and Law Center in Minneapolis.
She said she filed the lawsuit to draw attention to what she called a double standard in the state Medicaid program, a health plan for the poor and disabled.
State officials have said that ABA is not a covered treatment under the rules of Medicaid. In April, however, the Star Tribune disclosed that Minnesota taxpayers have paid millions of dollars for ABA therapy for hundreds of children, many from affluent families. Yet the same coverage is routinely denied to children like T.O. in Medicaid managed-care plans for the poor.
ABA programs offer up to 40 hours a week of one-on-one therapy for autistic children, far more than other forms of treatment.
In her lawsuit, Dawson noted that the state began paying for the boy's ABA treatments after he switched into the disability branch of the program. She argued that the state should have been paying for his therapy all along.
In a ruling dated last week, Judge Louis Thayer agreed.
"The services are identical," wrote Thayer, a judge with the Department of Human Services (DHS), which runs Medicaid in Minnesota.
But, he added: "I lack the authority to address the broader issue of whether [intensive therapy] will always be covered."
The boy's mother, who asked to remain anonymous to protect her son's privacy, said she was pleased with the ruling. "It's been too long," she said. "My son's done with the ABA program, and he's doing fabulous now." She said her son, who she thought would never speak, is now functioning above his age level and will begin preschool next month.
HealthPartners officials say they're studying the ruling. "We still think we were administering our contract correctly," said Wendy Burt, a HealthPartners spokeswoman.
According to federal officials, Minnesota is not authorized to offer ABA or other intensive autism therapies under Medicaid. DHS officials will say only that the state has discussed the situation with federal authorities and that it plans to look into the matter further.
Anne Barry, a DHS deputy commissioner, issued a written statement saying the agency will take a fresh look at its autism services.
"This case compels us to review and audit all autism services to ensure they are provided in compliance with our state plan agreement with the federal government and with state statute."
Maura Lerner • 612-673-7384