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

Autism Health Insurance Reform: Update on implementation


  • Update on progress with implementation of Autism Health Insurance Reform in Oregon
  • Washington Insurance Commissioners Hearing on Mental Health Parity – October 22nd, 2013
  • Autumn Fest for Autism – October 19th, 2013

Update on progress with implementation of Autism Health Insurance Reform in Oregon

Even though the legislative session is over, and our bills have passed, the last few months have been busier than ever, as we have worked to ensure that they are implemented effectively.  Here’s a quick summary of what we’ve been working, and where we may need everyone’s help in the coming months:

Autism coverage in the Oregon Health Plan (Medicaid): 

The Oregon Health Plan (OHP) provides very little coverage of treatment for autism.  Many patients on OHP even have difficulty accessing speech and occupational therapy, due to confusing requirements, and behavioral health treatment is limited to 8 hours per month.

SB365 directed the Health Evidence Review Commission (HERC) to re-evaluate Applied Behavior Analysis (ABA) therapy for inclusion in the “prioritized list” of treatments in OHP by October 2014.  We have organized a national team of experts to support this process and provide expert testimony.  HERC may release a proposal for public comment as early as November.

Once it does, we will encourage everyone to contact HERC with your feedback – so stay tuned.

Autism coverage in Cover Oregon – under the Affordable Care Act (“Obamacare”):

Thanks to the Affordable Care Act – “Obamacare” – it’s now possible for individuals, families, and small businesses to buy health insurance through Cover Oregon, an exchange or marketplace run by the State of Oregon.  Cover Oregon policies offer much better coverage and terms than normal individual plans, and are protected by both state and federal mental health parity laws.  Many families may be able to obtain subsidies to help pay for the cost of insurance.

Oregon’s plans are all based on a PacificSource plan that has been providing coverage for ABA therapy by court order since the 2010 McHenry v PacificSource decision.  Our view – and that of legislative counsel (the legislature’s legal office) – is that plans sold through the exchange must cover ABA therapy.  Insurance companies disagree, and the Insurance Division has not yet taken a stand.  We continue to work on this, and have participated in about 40 hours of meetings over the past two months regarding rules and terms for coverage in the exchange.

In the meantime, if you are seeking coverage for treatment of autism, your safest bet is to buy a Cover Oregon plan sold by Kaiser or PacificSource.  Kaiser has been providing reasonable coverage of ABA, although some families are still being forced through lengthy appeals processes.  PacificSource has been reimbursing ABA therapy provided by BCBAs or licensed providers, but thus far has refused to pay for paraprofessionals (line therapists).  Avoid “Healthy Kids” (even Healthy Kids plans sold by Kaiser and PacificSource), since we understand that Healthy Kids excludes coverage of ABA therapy and may make access to speech and occupational therapy difficult (it’s based on the Oregon Health Plan – see above).

You can reach the Cover Oregon website here:

Behavior Analysis Regulatory Board:

SB365 created a Behavior Analysis Regulatory Board to license and register providers of Applied Behavior Analysis (ABA) services in Oregon.  We have had discussions with many people over the last few months to recruit potential members, assist them with their applications, and advise the Governor’s office on the appointments process.  We expect that the appointments will be made in November, allowing the board to begin the work of developing rules for licensure and registration early next year.

SB414 Restitution Rules:

One of our key legislative victories in this session was the passage of SB414, which gives the Insurance Division the authority to require insurance companies to pay restitution for damages suffered as a result of the insurer’s violation of a provision of the Insurance Code or applicable federal law, or breach of an insurance contract or policy.  Previously, the Insurance Division could impose a civil penalty or revoke a license, but couldn’t actually order an insurer to pay a claim.

SB414 allows restitution for damages resulting from illegal activity.  For instance, if an insurer unlawfully denies coverage of cardiac care, and a patient dies from their inability to access treatment, SB414 empowers the Insurance Division to require an insurer to pay compensation to the heirs.  While this sounds like common sense – that the insurer should be financially liable for the consequences of illegal activity – it’s actually a radical change:  insurers are now largely exempt from liability by Federal law (ERISA), and from Oregon’s unfair trade practices act.  A court can order an insurer to pay a claim, and reimburse attorney’s fees, but can’t order payment of any sort of damages.

Over the past few weeks, we have met with the Insurance Division’s leadership team and representatives from essentially every insurance company doing business in Oregon to discuss implementation.  Temporary rules will be published later this year; the bill will take effect on January 1st.

SB416 – External Review Quality Assurance:

One of the key tools we have used to help people overturn denials of coverage for ABA therapy is the External Review –in which the Insurance Division appoints an Independent Review Organization (IRO) to review the case and make a binding coverage decision.  The good news is that we’ve won nearly every case.  The bad news is that occasionally the IROs don’t follow the proper procedures – for instance, assigning an unqualified reviewer or relying on inappropriate documents that don’t meet the Insurance Division’s strict criteria, such as proprietary reports funded by the insurance industry.  Up until now, IRO decisions have been binding even when the reviewers haven’t complied with the very strict laws governing their conduct.

SB416 would have allowed the Insurance Division to reassign reviews to another IRO if the first reviewer didn’t comply with the law.  During the hearings process on SB416, the Insurance Division realized that it already had the authority to take corrective action if an IRO didn’t comply with the law, and we agreed to drop the bill.

We have been working with the Insurance Division, most of Oregon’s health insurance companies, and several of Oregon’s IROs to draft administrative rules allowing a consumer to report an IRO decision that failed to comply with the legal requirements, and allowing the Insurance Division to require the IRO to redo the review.  The administrative rules will be released later this year.

Washington Insurance Commissioner Hearing on Mental Health Parity – October 22nd, 2013

Over the last few years, an unbroken string of court victories has consistently found that insurers in Washington State have violated that state’s Mental Health Parity laws by refusing to cover Applied Behavior Analysis (ABA) therapy as a treatment for autism, and by restricting treatment for other therapies such as speech and occupational therapy to young children under age 6.

Nevertheless, many Washington insurers continue violate the law.  For the past year, the Insurance Commissioner has been reviewing insurer’s compliance with Mental Health Parity laws, and has been considering issuing an order to force other insurers to comply – but hasn’t done it yet.

Next week, on October 22nd, the Washington Insurance Commissioner will hold a public hearing to seek input on insurer compliance with the mental health parity law.

If you live in Washington – or provide autism treatment in that state – I encourage you to attend and testify about the need to enforce laws requiring coverage of autism.

  • Date / Time: 10/22/13 10 am-12 pm (You can arrive up to 30 min early to sign up to testify).
  • Location: JLOB Hearing Room A, Olympia (You can arrive up to 30 min early to sign up to testify).

For more information, see:

Autumn Fest for Autism – October 19th, 2013

Next Saturday, October 19th, the A Hope For Autism Foundation – which provides a center based program for children K-8 that are effected by autism –  is holding its’ annual benefit gala to provide scholarships for critical treatments and support local center-based programs.  For more information, see:

  • Date / Time:  Saturday, October 19th, 2013, 6:30 PM to 10:30 PM
  • Location:  Madeleine Parish and School, 3123 NE 24th Avenue, Portland
  • Tickets $50 / person or $350 / table for 8




Paul Terdal

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