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Subcommittee asks insurers, advocates to surface denials after hearing on coverage for Down syndrome services
Summary
A New Hampshire Commerce and Consumer Affairs subcommittee heard that the Insurance Department has not logged clear, systemic denials for behavioral therapy billed to treat children with Down syndrome; the department offered to review claims coding and requested concrete denied cases to investigate.
The House Commerce and Consumer Affairs subcommittee examined Bill 353 focused on coverage for behavioral therapies used by children with Down syndrome and asked the New Hampshire Insurance Department to probe whether denials are a coding problem rather than a coverage gap. Michelle Heaton, director of life and health at the Insurance Department, told the committee the department "receive[s] complaints all the time about a variety of different issues" but has not identified a clear pattern of denials specific to this issue and urged anyone who has been denied commercial coverage to file a complaint so staff can investigate and work with carriers and providers.
Heaton explained that coding can obscure whether a child with Down syndrome is receiving applied-behavioral-treatment services: claims may be coded under autism or other diagnoses, so a child could be receiving treatment that is reimbursed without showing up in a search for "Down syndrome" denials. She said the department could look at claims data to identify denial reasons but cautioned the population is small and data limitations make some analyses difficult. The department offered to revisit prior work on the topic, issue guidance to carriers and providers where helpful, and follow up with the committee by email with statutory references.
Committee members pressed for clarity about existing mandates, and Heaton said early-intervention benefits are in statute and apply from birth through age 3; she added that essential health benefit requirements can require coverage beyond age 3 "to the extent that they're medically necessary." Committee members asked the department to send the relevant RSA language to staff for inclusion in the committee report.
Advocates said they would identify people who say they were denied coverage and give those examples to the department for case-level review. The committee asked staff to include a brief statement in the committee report noting that (1) early-intervention statutes exist, (2) the department is available to review specific denied cases and issue guidance where carriers or provider coding is unclear, and (3) advocates should submit concrete complaint records so the department can investigate. The committee requested a follow-up from the department before its October 17 deadline to help inform whether future statutory changes are needed.
