- Review of Existing Oregon Laws Mandating Autism Coverage
- Draft Autism Health Insurance Legislation for 2013
- Public Meeting – Friday, October 26th, 7:00 PM
It’s been a long time since I’ve written; we’ve done a lot over the last few months, including work with Sen. Bates and the autism legislation workgroup to develop new autism health insurance legislation for 2013, and enforcing our existing laws by requiring insurers to cover autism treatment.
This message will describe the framework for the legislation we’re working on for 2013. I encourage everyone interested in learning more about this, or in helping us pass new legislation and enforce the laws that we already have to come to a public meeting at the First United Methodist Church at SW 18th and Jefferson in Portland on Friday, October 26th, at 7:00 PM – the details are below.
Tomorrow, I will send a separate message about a national initiative to raise awareness of autism-related issues during this election.
Review of Existing Oregon Laws Mandating Autism Coverage:
Before describing the potential legislation we are working on for 2013, it is important to remember that we already have two laws in Oregon mandating coverage of treatment for autism:
- ORS 743A.168, Oregon’s Mental Health Parity law, enacted in 2005, requires group health insurance policies to “provide coverage for expenses arising from treatment for … mental or nervous conditions at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement of expenses arising from treatment for other medical conditions….” Autism is legally considered to be a “mental or nervous condition” for the purposes of this law.
- ORS 743A.190, Children with Pervasive Developmental Disabilities, enacted in2007, requires all health benefit plans (including individual plans) to “cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.”
In addition, the Federal Mental Health Parity and Addiction Equity Act (MHPAEA) also provides very strong requirements for group plans (but not individual plans)
My own children are currently receiving comprehensive coverage of Applied Behavior Analysis therapy from Kaiser on an Individual Plan solely through the strength of ORS 743A.190 – their individual plan is exempt from both ORS 743A.168 and the Federal MHPAEA. They are entitled to this coverage because their full-featured individual plan includes excellent mental health benefits, and ORS 743A.190 requires their insurer to make these benefits available for treatment of autism.
In the McHenry v PacificSource case, the U.S. District Court ordered PacificSource to pay for ABA therapy. The judge cited ORS 743A.168 as requiring PacificSource to cover autism under Oregon law, and referred to that statute more than a dozen times in explaining the details of her decision.
Simply put, Oregon already has comprehensive autism health insurance mandates. Unfortunately, as with Oregon’s mandates for other conditions, the autism mandates don’t provide a specific laundry list of treatments that must be covered. The insurance industry has used that as an excuse to exclude coverage of Applied Behavior Analysis and other leading treatments, and the Insurance Division has not been as assertive in its’ enforcement as its’ colleagues in other states, like California.
Draft Autism Health Insurance Legislation for 2013:
Note: this description is mine alone; it represents my honest best attempt to describe our agreement, but does not reflect a consensus statement approved or published by all parties to the negotiations.
In 2011 and 2012, we attempted to replace Oregon’s existing autism insurance mandates with a comprehensive mandate based on those passed in 32 other states, which specifically inventory the various treatments that must be covered, such as rehabilitative care, psychological care, medical care, and behavioral health treatment (such as Applied Behavior Analysis, or ABA).
For 2013, our Legislative Sponsor (Sen. Bates) has directed us to focus the bill exclusively on coverage of Applied Behavior Analysis, one of the leading forms of treatment. Oregon’s existing laws mandating autism coverage (ORS 743A.168 and 743A.190) will remain in force, and will continue to require coverage of “all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan” (ORS 743A.190) and “coverage for expenses arising from treatment for [autism] at the same level as … other medical conditions” (ORS 743A.168).
The proposed law for 2013 would require all state regulated plans (including individual and group plans, PEBB, OEBB, Healthy Kids, and the Oregon Health Plan) to provide coverage of Applied Behavior Analysis (ABA) as a treatment for autism, with the following framework:
– For coverage of Applied Behavior Analysis therapy, an insurer may require that an autism diagnosis has been confirmed by a certified autism diagnosis center, provided that the confirmed diagnosis can be completed within 4 to 6 weeks of the initial request for ABA therapy.
- The Oregon Health Authority will establish a program for certification of autism diagnosis centers
– Insurers will be required cover Applied Behavior Analysis (ABA) as a treatment for autism, without a contractual age, dollar, or visit limit
- Children ages 0 to 8 who have a certified medical diagnosis of autism and are seeking up to 25 hours of ABA therapy per week must be covered without preauthorization
- Older patients (over age 8), and those who need more than 25 hours of ABA therapy per week, will still be covered but may be subject to preauthorization. An insurer could deny such coverage on the basis of an individualized determination of medical necessity, subject to appeal to External Review, but could not impose a contractual age or visit limit on ABA therapy beyond which ABA would not be covered regardless of medical necessity
– The law will create a Behavior Analyst Licensing Board under the Oregon Health Licensing Agency. This permanent board will establish specific credentialing requirements for Licensed Behavior Analysts (BCBA), Licensed Assistant Behavior Analysts (BCaBA), and Behavior Analysis Technicians.
- The board will establish a grandfathering period, in which currently practicing behavior analysts can continue to practice while working towards completion of BCBA certification.
- The law will continue to allow reimbursement for ABA services provided by other licensed health care professionals, so long as the services performed are in the licensed health care professional’s scope of practice and are commensurate with the licensed health care professional’s formal university training and supervised experience.
- Behavior Analysis Technicians (Line Therapists) will be certified or registered by the board, but not licensed. The law will not include specific requirements for these technicians; the board will set these requirements through administrative rule. The intent is to require a criminal background check, and that the Behavior Analysis Technicians would work under the direction of a Licensed Behavior Analyst or other licensed provider who would be responsible for ensuring the Behavior Analysis Technician’s qualifications and training, just as Physician’s Assistants work under the license of their supervising Physician
- As with Oregon’s other licensing boards, the Behavior Analyst Licensing Board will be responsible for maintaining and enforcing standards of professional conduct for its’ licensees
– Oregon’s schools will be required to continue providing special education services for autism, and will be prohibited reducing, eliminating, or shifting required services to private insurers
Applied Behavior Analysis (ABA) is a broad field that encompasses a range of techniques and approaches, from UCLA/Lovass to Early Start Denver Model and many others. The law will allow reimbursement for ABA services provided by non-BCBA licensed health care professionals, so long as the services performed are in the licensed health care professional’s scope of practice and training. Some Oregon speech language pathologists are currently practicing forms of ABA, for instance, and should be able to take advantage of this feature to expand their practices to provide more intensive services than are currently possible.
Oregon insurers now provide coverage for rehabilitative care, such as speech, occupational, and physical therapy for autism, but with strict visit limits, such as 20 visits per therapy per year, regardless of medical need. This complies with ORS 743A.190, but may not comply with the Federal MHPAEA. Our bills in 2011 and 2012 would have removed these contractual visit limits on rehabilitative care, allowing patients to access any medically necessary amount of these services. Since we have been directed to limit the 2013 bill to ABA only, this feature has been cut out – we will continue to rely solely on the coverage mandated by ORS 743A.190 and Federal law.
Public Meeting – Friday, October 26th, 7:00 PM:
On Friday, October 26th, at 7:00 PM, we have scheduled an open, public meeting to discuss Autism Health Insurance Reform, review the legislation that will be considered in the 2013 session, and plan next steps.
Date: Friday, October 26th
Time: 7:00 PM to 8:30 PM
- Room 202
- First United Methodist Church
- 1838 S.W. Jefferson Street
- Portland, Oregon 97201
- Review legislation for 2013 session
- Plan grassroots campaign to support legislation
- Enforcement update – how to get coverage now
Free, on-site childcare will be available. If possible, please let me know if you will be coming with your children so I can give a headcount to the childcare workers.
A map of the church building can be found here: http://fumcpdx.org/pdf/FUMC_map_2007_color.pdf