It's time for Medical Insurance Companies in Oregon to cover Autism Treatment

Autism Health Insurance Reform: Vote Scheduled in Senate Health Care Committee 4/18

SB555, the Senate version of the Autism Health Insurance Reform bill, has been scheduled for a vote in the Senate Health Care, Human Services and Rural Health committee on Monday, April 18th, at 3:00 PM.  This meeting will be a “work session” (vote) only – there will be no public testimony.  We believe that the bill will pass, and that it will move on to the Joint Ways and Means committee.

Senate Health Care Committee Hearing – Monday, April 18th, 3:00 PM:

Date:  Monday, April 18th

Time:  3:00 PM

Location:

  • Hearing Room A
  • Oregon State Capitol
  • 900 Court St. NE, Salem, Oregon 97301

Note that no public testimony will be taken – this will be a vote only.  It would still be helpful to have a crowd in the audience to show our support as they cast this crucial vote.  We’re third on the agenda, so it is likely that we’ll be finished very quickly – although agendas are often rearranged.

Amendments and Limitations:

There will be additional amendments before the bill moves forward.  The legislature is coping with a $3.5 billion budget deficit, which must be resolved through budget cuts – unlike the Federal government, the state government is required to balance its’ budget each year.  While our bill will result in substantial savings to the government through reduced need for special education and community services for individuals with autism – since, thanks to treatment, they will be higher functioning – it will also increase insurance premiums for the Public Employees Benefits Board (PEBB) and Oregon Educators Benefits Board (OEBB), and these increases must be managed through the state budget.

The legislature has chosen to control costs on SB555 by imposing two limits on coverage of Applied Behavior Analysis (ABA):  by age, to children who are 11 years of age or younger (i.e., through eve of 12th birthday), and by limiting it to 87 hours of treatment per month (i.e., 20 hours per week).  (There had been a proposal to impose a $50,000 per year cap on ABA services, but it appears to have been dropped – it is widely accepted that the Affordable Care Act bans such monetary caps, so such a limit would not have been enforceable).

These limitations are a disappointment:  while the evidence for treating younger children with ABA is especially strong, there is ample evidence that older children and adults can also benefit from ABA.  Further, intensive ABA is usually recommended at 30 or even 40 hours per week for younger children, and this limitation at 20 hours per week would force families to either pay for the extra time themselves or do without.

We had hoped to have no age limits of any kind on this bill, but in practice only a few other states have ABA benefits without any age limits (Massachusetts, Indiana, Wisconsin); nearly all impose an age limit of some sort.  Most states have age limits between 15 and 21 years of age, but several have limits even lower than this proposed limit:  Maine’s limit is 5, Vermont’s limit is 6, and Texas’ limit is 9.  Although it hasn’t been tested in court yet, there are strong legal arguments that such age limits are a violation of the Federal Mental Health Parity law and the Federal Affordable Care Act – indeed, the draft fiscal impact analysis for SB555 suggested that they may be unenforceable.

It is worth noting, however, that nothing in the bill says that insurance companies don’t have to pay for ABA for individuals above the age of 11 – only that they must pay for ABA for those with autism that are age 11 and under.  This is important, because SB555 also states clearly that it doesn’t limit coverage or reduce benefits guaranteed by Oregon’s Mental Health Parity law:  a recent legal decision in McHenry v. PacificSource used that law to require coverage for ABA.  Since that remains in effect, and is explicitly not overridden by SB555, it should still be possible to use that state law to get coverage of ABA for older children and adults.

What We Are Getting:

Even with these proposed limitations on ABA, the law remains an incredibly strong tool for everyone with autism:

  • Formal recognition of ABA providers (both BCBAs and Line Therapists) as approved providers under Oregon law – so insurance companies will be required to reimburse them for their services
  • There are no age limits on any other form of autism treatment – unlike the current law, which restricts autism treatment to children age 18 or under
  • Required coverage will include speech language pathology, occupational therapy, psychological care, psychiatric care, pharmacy care, augmentative communication devices, and medical accommodations for usual care (like sedation for dentistry)
  • Insurance companies will no longer be allowed to impose visit limits on other forms of treatment, including speech language pathology, occupational therapy, psychological care, psychiatric care, and so forth.  Currently, our Kaiser policy provides 20 hours of speech language pathology lifetime, 20 hours of occupational therapy per year, and all of 6 (count ‘em, 6!) hours of outpatient mental health care per year.  ALL of those limits will be lifted completely – insurers will be required to cover all medically necessary treatment for autism

Endorsements:

Over the last week, I have met with both local and national autism advocacy and professional organizations to discuss the proposed amendments and limitations on coverage for ABA, including:

  • Autism Society of Oregon
  • Portland Asperger’s Network (Board of Directors)
  • Oregon Association for Behavior Analysis
  • Northwest Autism Foundation
  • Autism Speaks
  • Behavior Analyst Certification Board

I have also consulted with leading national experts on autism and ABA.  Their response has been uniform:  accept the deal, with the proposed limits on ABA, and move forward to support passage.  All of these organizations have either submitted new endorsements of SB555, or restated their endorsements to explicitly acknowledge and accept the proposed limitations on ABA.

It is our hope that, if those limits remain in effect when (if) the bill is approved, we can revisit them in the near future once we can demonstrate that ABA is more cost effective that the fiscal impact analysis suggests.  If we were to stand our ground on this issue, the bill would certainly fail – and, worse, we would inflict lasting damage on our relationship with the legislature, making it much more difficult to get support for other efforts in future years.

Thanks,

Paul,

Parent

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