- Update on SB365 – Changes to Medicaid Coverage; Hearing Expected Next Week
- ACTION: Ask your State Senator to support HB3160 – Unlawful Trade Practices Act Reform
Update on SB365 – Changes to Medicaid Coverage; Hearing Expected Next Week
Progress on Budget Analysis:
We have continued to work hard on SB365, the Autism Health Insurance Reform bill, with daily meetings in the capitol to help assess the impact to the state’s budget. We understand that the Legislative Fiscal Office is now finalizing its’ budget estimate, and that the Ways and Means committee will likely hold a hearing within the next few days. We expect SB365 to be well received.
Since the U.S. District Court in Portland has already ruled that existing laws already require coverage of Applied Behavior Analysis similar to that in SB365, we believe that the actual cost of the bill is very small – it is just restating a mandate that already exists. The Insurance Industry, on the other hand – while supporting S365 – asserts that this is a new and expensive requirement. One insurer put the cost at more than $5 per member per month – apparently based on the assumption that everyone on the autism spectrum would be diagnosed at birth, and would immediately begin a 9-year intensive, 25 hour / week ABA therapy program (regardless of the nature or severity of their symptoms). This is clearly ridiculous – individuals on average aren’t diagnosed until age 4 or later, and actual treatment needs vary widely; some individuals need intensive treatment, and others don’t. Actual experience in the many other states that have implemented new autism mandates similar to SB365 is typically just 31 cents per member per month.
We are expecting the official cost estimate to end up somewhere between these figures; once it is published – likely on Monday – the Ways and Means committee can schedule a hearing, and we can determine our response.
Changes to Medicaid Coverage:
One of the most important aspects of the bill for us has been the prospect of extending autism coverage to the Oregon Health Plan (Oregon’s Medicaid plan) and Healthy Kids. More than a year ago, in the first meeting of our legislative workgroup (which included representatives from the Insurance Industry, the autism community, and several government agencies) – we all agreed that any mandates imposed on the insurance industry would be imposed equally on all state managed health plans, including the Oregon Health Plan (OHP) and Healthy Kids. Our workgroup included both a representative of the Oregon Health Authority (OHA), and a member of the Health Evidence Review Commission (HERC) which determines which treatments are covered by these programs.
SB365A – which was unanimously approved by the Senate Health Care committee – does exactly what we agreed to: it requires OHP (and Healthy Kids) to provide the same autism coverage that private insurers must provide.
The Oregon Health Authority has objected – despite its’ participation in the workgroup that reached this agreement – and the Governor has threatened to veto SB365A unless we remove the OHP coverage requirement. OHP determines its’ coverage through a unique process involving a prioritized list of services written by the Health Evidence Review Commission; SB365A – in mandating OHP coverage of autism – would have made autism a unique exception to this process.
The Oregon Health Authority and the Health Evidence Review Commission will administratively reconsider coverage of ABA and other treatments for autism in OHP and Healthy Kids. This could be a good thing – SB365A won’t take effect until 2015; these agencies may be able to provide similar coverage by 2014 instead. On the other hand, the autism community has had very bad experiences with them in the past. In 2008, the Health Resources Commission (predecessor to HERC) wrote a report to the legislature on evidence for treatment of autism which concluded that there was insufficient evidence to support any form of treatment for autism whatsoever – and ever since, OHP has provided essentially no coverage for any autism treatment. This despite findings by the U.S. Surgeon General, National Institute for Mental Health, U.S. Interagency Autism Coordinating Committee, and essentially every professional medical or mental health association, that autism is treatable and that ABA and other treatments are well established, proven techniques. Federal courts in at least four states have specifically ordered Medicaid coverage of ABA as a treatment for autism, finding that failure to provide such coverage was “arbitrary and capricious” and contrary to Federal law.
An amendment has been drafted to remove the OHP mandate, per the Governor’s request, and we expect it to be adopted by the legislature in order to avoid his threatened veto. We also expect OHA and HERC to begin the process of reconsidering autism coverage on OHP and Healthy Kids, and will do our best to ensure that – this time — the process is fair, appropriate, and consistent with nationally accepted standards of care.
Next Steps for SB365A:
We expect the fiscal impact statement to be completed early next week, and once it is, we’ll contact you again to ask for your help in contacting your legislators to support SB365A in the Ways and Means hearing.
ACTION: Ask your State Senator to support HB3160 – Unlawful Trade Practices Act Reform
At the end of May, I sent an Action Alert asking everyone to contact Sen. Monnes Anderson to encourage her to fulfill her campaign promise to support HB3160 – the Unlawful Trade Practices Act reform bill.
I’m very happy to say that our voices were heard, and she DID. The Senate General Government committee voted 3 to 2 (with Sen. Monnes Anderson’s support) to recommend passage of HB3160.
HB3160 is a critical bill – our biggest problem isn’t really the lack of laws mandating insurance coverage for treatment of autism – Oregon law already does require insurance companies to cover treatment of autism; our biggest problem is the extreme difficulty in enforcing those laws. If an insurance company in Oregon doesn’t wish to comply with the law, there is very little a consumer can do about it – there’s no private right of action to sue an insurance company for violations of the insurance code, and the Insurance Division is extremely reluctant to ask an insurance company to do anything it doesn’t want to do.
The Insurance Industry has even been exempted from Oregon’s Unlawful Trade Practices Act – the anti-fraud statute that applies to every other form of business – so if an Insurance Company commits fraud, the Attorney General is prohibited from prosecuting it.
HB3160 would end the Insurance Industry’s exemption from the Unlawful Trade Practices Act, allowing both the Attorney General and individual consumers to sue Insurance Companies for fraud and other illegal claim settlement practices. It has already passed the House, and is now ready for a final vote in the Senate.
Unfortunately, HB3160 doesn’t quite have enough votes to pass yet – we believe 15 Senators are ready to support it, but we need 1 more.
So — I encourage everyone to contact your own State Senator to ask them to support HB3160. Please do this – even if you’ve already written them before.
I have included a sample e-mail message at bottom – but please personalize the message as much as possible, to show the impact that this issue has on you.
Thanks for your help!
Sample E-mail Message in support of HB3160 – Unlawful Trade Practices Act Reform:
[Please feel free to modify this, or insert details about your own story]
Your own State Senator. You can find his or her e-mail at: http://www.leg.state.or.us/findlegsltr/
Please support HB3160 – Unlawful Trade Practices Act reform
Dear Senator (insert your Senator’s name here):
I’m writing to ask you to support HB3160, which removes the Insurance Industry’s exemption from the Unfair Trade Practices Act (UTPA).
Currently, there’s very little a consumer can do to hold the insurance industry accountable for violations of the law. There is no private right of action for consumers to enforce the insurance code, and even the Attorney General is barred from enforcing the law.
Insurers in our state routinely deny valid claims, delay payment and restrict benefits in a manner that reduces consumer access to healthcare – and consumers have essentially no recourse.
There is no legitimate reason for the Insurance Industry – or anyone – to be above the law. Honest insurers should welcome the level playing field that HB3160 would provide, and the confidence that their competitors won’t be allowed to get away with illegal behavior.
Passing HB3160 will help restore the balance, and ensure that consumers can fairly access the insurance coverage that they have paid for when they need it.
Thank you for your support.
[add your name and physical mailing address]