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

Autism Health Insurance Reform: SB365 Signed by Governor!

Contents:

  • Update on SB365 – Governor signs SB365!
  • Update on SB414 – Governor signs SB414!
  • HERC begins review of ABA for coverage in Oregon Health Plan
  • Kaiser class action settlement in California

Update on SB365 – Governor signs SB365!

Governor Kitzhaber signed SB365, Oregon’s Autism Health Insurance Reform bill this morning.  SB365 does several things:

  • Establishes the Behavior Analysis Regulatory Board to license and register ABA providers, including Board Certified Behavior Analysts; other licensed providers with experience and training in ABA (such as psychologists and speech language pathologists); and paraprofessionals or line therapists.
  • Grandfathers currently practicing ABA providers to continue practicing and receiving insurance reimbursement, until January 1, 2016
  • Establishes requirements for state-regulated health plans to approve and manage autism treatment, including ABA and any other medical or mental health services identified in an individualized treatment plan. The law applies to kids who begin treatment before age 9, covering up to 25 hours of ABA per week, and continuing for as long as medically necessary regardless of age.  Existing Oregon laws requiring coverage of autism treatment continue to apply to older patients and those seeking more than 25 hours of ABA per week.
    • Coverage requirements apply to PEBB (Public Employees Benefits Board) and OEBB (Oregon Educators Benefits Board) on January 1, 2015; and to all other state-regulated health benefit plans beginning January 1, 2016
    • Requires the Health Evidence Review Commission to begin reviewing ABA for coverage under the Oregon Health Plan.  The Oregon Health Plan must implement any new ABA services that HERC recommends by October 1, 2014, if new medical coding isn’t required, and by April 1, 2015, if new coding is necessary.  This review has already begun (see below).

It is important to remember that Oregon law has mandated coverage of autism “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” since 2007.  We believe that this already legally mandates coverage of medically necessary care such as ABA, and a class action lawsuit has been filed in U.S. District Court against Providence Health Systems to enforce this.  We are optimistic that a successful ruling in this case will motivate the Insurance Division to enforce the law with respect to other insurers as well, which means that comprehensive insurance coverage for autism should be available on essentially all plans well before SB365’s nominal implementation date of 2016.

More specific information about how to best use SB365 and other Oregon laws to obtain insurance coverage will be distributed in the next few weeks.

Here are some articles about SB365:

You may want to contact Governor Kitzhaber to say “thanks” – Autism Speaks has set up a form for this at:  http://advocacy.autismspeaks.org/c.frKNI3PCImE/b.8766321/k.EC1F/OREGON_Thank_Gov_Kitzhaber_and_Your_Lawmakers_for_Better_Autism_Insurance/siteapps/advocacy/ActionItem.aspx

Update on SB414 – Governor signs SB414!

Governor Kitzhaber also signed SB414 in early July.  SB414 greatly strengthens the authority of the Insurance Division to enforce Oregon and federal laws regarding insurance coverage, by allowing it to seek restitution on behalf of a consumer for actual damages resulting from an insurer’s violation of the Oregon insurance code or applicable Federal law, or breach of contract.  Prior to enactment of SB414, the Insurance Commissioner could impose fines or civil penalties but was powerless to force an insurer to actually pay a claim or other compensation to a consumer.

We look forward to working with the Insurance Division on implementation of these new powers.

Here are some articles about SB414:

HERC begins review of ABA for coverage in Oregon Health Plan

As noted above, SB365 requires the Health Evidence Review Commission (HERC) to review Applied Behavior Analysis (ABA) as a treatment for autism, for coverage under the Oregon Health Plan.

This review began last week, with a vote to assign the review to the Evidence-based Guidelines Subcommittee.  That committee will meet on September 12, 2013, to begin the review of ABA.  This process is expected to take about 1 year.  The Oregon Health Plan must implement any new ABA services that HERC recommends by October 1, 2014, if new medical coding isn’t required, and by April 1, 2015, if new coding is necessary.

We will provide another update about the HERC process in the next few weeks, with updates on how you can help.

You can view HERC’s web page on this topic here:  http://www.oregon.gov/OHA/OHPR/Pages/herc/index.aspx#Behavioral_Analysis_for_Autism

Kaiser class action settlement in California

Kaiser has agreed to a settlement in a Class Action lawsuit in California to reimburse consumers for applied behavior analysis (ABA) and speech therapy for their children with autism between 2004 and 2012.  The lawsuit alleged that Kaiser improperly denied coverage for ABA and speech therapy for children with autism under the terms of its contracts and the California Mental Health Parity Act.  Kaiser has set aside nearly $10 million, and will be required to donate any unclaimed funds to non-profit organizations.

This suit applies only to California residents, but the legal principles are very similar to the class action lawsuit in Oregon against Providence, which is also seeking retroactive reimbursement to the date at which Oregon’s Mental Health Parity Act took effect in 2007.

More information is available at:  http://www.autismspeaks.org/advocacy/advocacy-news/kaiser-reimburse-ca-families-93-million-aba-speech

And here:  http://www.gilardi.com/KaiserASDLitigation/

 

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Sincerely,

 

Paul Terdal

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