- Provide public comment to HERC on ABA coverage in OHP
- Access to autism coverage under current law and in Cover Oregon
Provide public comment to HERC on ABA coverage in OHP
As I wrote in October, the Health Evidence Review Commission (HERC) is evaluating Applied Behavior Analysis (ABA) therapy for inclusion in the “prioritized list” of treatments in the Oregon Health Plan (OHP), Oregon’s Medicaid program. The “prioritized list” is also the basis for Healthy Kids.
HERC has released an initial draft review of ABA for public comment – which you can find here: http://www.oregon.gov/oha/herc/EvidenceEvaluation/Evaluation%20of%20Evidence%20Applied%20Behavior%20Analysis%20For%20Autism%20Spectrum%20Disorders%2011-14-13.pdf
The review makes a strong recommendation in favor of ABA coverage for children with autism ages 2 through 12. The committee found that quality of evidence was low, but that other favors warranted a strong recommendation. Initial coverage should be for up to six months, followed by reassessment every six months. No specific hour or duration limits were identified, but noted that studies range from 2 to 40 hours per week with durations from 10 weeks to 3 years.
The review makes a weak recommendation against coverage for patients over the age of 12, solely because the report selected by the HERC staff for review didn’t include much evidence for older patients. Many committee members expressed interest in providing coverage for older patients when necessary, if we are able to provide additional evidence, and this is likely to be revisited.
While we have concerns, it is important to recognize that this is a big step forward – currently, OHP and Healthy Kids provide very little coverage of treatment for autism. Many patients even have difficulty accessing speech and occupational therapy, due to confusing requirements, and behavioral health treatment (ABA) is limited to 8 hours per month.
HERC is accepting public comment through Sunday December 15th (technically, until 8:00 AM Monday the 16th). We are making the following recommendations:
- We support the strong recommendation in favor of ABA coverage for younger children
- The quality of evidence is – by HERC’s own standards – Medium or High, and should be revised
- There should be no minimum age for ABA – children under 2 should be given access to ABA upon diagnosis
- Patients over the age of 12 should be given coverage for ABA when medically necessary
- There is sufficient evidence to support the effectiveness of ABA for older patients
- For some patients with severe symptoms, such as self-injurious behaviors, a failure to treat can result in severe disability. By HERC’s own process, this requires a “strong” recommendation in favor of coverage.Patients over the age of 12 should be given coverage for ABA when medically necessary
You can provide submit public comment by submitting an e-mail to HERC.Info@state.or.us by end of day Sunday December 15th.
- The email subject line should read “Public Comment on Applied Behavior Analysis”
- Include your name, profession, address, phone number and email address (only your profession, location, and comments will be made publicly available).
- Comment should not exceed 1000 words.
- You may also include a list of references to journal articles supporting your comments, which are not subject to the 1,000 word limit. You should also attach PDF copies of the articles.
- In encourage you to CC me at paul@AutismInsuranceOR.org to I can track submissions and ensure that we are covering all of the key issues.
For further instructions, see: http://www.oregon.gov/oha/herc/Pages/Coverage-Guidances-Open-for-Comment.aspx
If you are a consumer, I encourage you to write about your experiences – how ABA has helped you or your family, or how an inability to access it has been a hardship.
If you are a provider, write your professional recommendation and attach journal articles that you may find helpful.
If you have any questions about what to write, please send me an e-mail at paul@AutismInsuranceOR.org.
For articles about the HERC review of ABA, see:
Access to autism coverage under current law and in Cover Oregon
Regence External Review Success:
I’m happy to report recent progress in obtaining ABA coverage from Regence Blue Cross Blue Shield of Oregon: last week, we won our first External Review decision overturning a Regence denial of ABA coverage, and Regence has confirmed its’ willingness to comply and begin paying for ABA treatment for that family.
It is Regence’s practice to deny coverage of ABA on grounds that it is “investigational” – i.e., that it is unproven. This is basically untrue, as Regence is well aware, and it allows an appeal to External Review. While I wish Regence would stop making these false denials, I appreciate the fact that they are allowing consumers to access the External Review process. If you have a Regence plan and are interested in ABA coverage, please contact me.
Autism Coverage through Cover Oregon:
As I wrote in October, the best way to get coverage for ABA or other treatment for autism 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).
For Kaiser, I suggest the “KP OR Gold 0/20 HMO 71287OR0420001-01” plan. Without any subsidies, this should cost about $162 / month for a single child, which is roughly the cost of one or two hours of speech or occupational therapy.
You can reach the Cover Oregon website here: http://www.coveroregon.com/
Providence Litigation Update:
The class action lawsuit against Providence for denial of ABA coverage for autism is moving forward; the class certification hearing will be on Wednesday December 11th. It should be interesting; in a legal filing on November 1st, Providence asserted that it had intentionally provoked litigation by consumers out of its’ desire to get a ruling by a judge, and out of its’ frustration with the External Review process. Providence explained to the judge that it had realized that if actual doctors with autism experience were allowed to determine whether or not ABA was a proven, medically necessary treatment for autism it would lose every time, so it adopted a strategy of forcing consumers into court. Seriously.