- Reception for Sen. Bates – autism health insurance reform champion – Wednesday 9/24 in PDX
- LOTS of progress since August – the world has changed
- Request coverage and reimbursement — now
- Summary of press coverage
Reception for Sen. Bates – autism health insurance reform champion – Wednesday 9/24 in PDX
Next Wednesday, September 24th, I will be hosting a reception for Senator Dr. Alan Bates – the lead champion for Autism Health Insurance Reform in Oregon’s legislature – at my home in Northwest Portland.
Senator Dr. Alan Bates — a physician from Medford, Oregon — was the driving force behind SB365, and has been a leader in health care policy in Oregon for more than 20 years. I have personally found him to be a voice of wisdom and reason, and a true advocate for patients and providers in a legislature heavily influenced by the insurance industry. Sen. Bates was able to push our legislation through, driving us past roadblocks that had stymied us in the past.
We invite you to come to meet him, and talk about issues affecting the autism community.
We will also be providing information about recent developments in autism health insurance reform (see below for a summary) – including ways you can start getting coverage right now – and how to request reimbursement for money spent on treatment in the past.
Reception for Sen. Alan Bates:
- Wednesday, September 24th
- 7:00 PM to 8:30 PM
- Home of Paul Terdal in NW Portland
- Reply to this e-mail for directions and to RSVP
Sen. Bates is also facing the toughest race for reelection of any sitting member of the Senate; he is in a swing district, and in his last election, he won by fewer than 300 votes. He needs our help – so that he can continue helping us in the Oregon legislature. I also encourage you to contribute to his reelection campaign in any amount you can – whether that’s $5, $50, or more. Contributions to his campaign qualify for Oregon’s political contributions tax credit of $50 / person or $100 / married couple – so if you haven’t used your tax credit yet this year, your first $50 contribution may be effectively free. If you can come to our reception, you can bring a contribution in person if you wish; you can also donate directly to his campaign – at http://www.alanbates.net/
LOTS of progress since August – the world has changed
A month ago, I wrote to tell you about our success in “AF v Providence” – in which U.S. District Court found that Providence had violated state and federal law in refusing to cover applied behavior analysis (ABA) therapy as a treatment for autism. The judge ruled that Oregon’s mental health parity law in particular required coverage of medically necessary care for mental or nervous conditions – including autism—and that Providence was violating that law by denying coverage whether medically necessary or not. My summary is posted here: http://autisminsuranceor.org/updates/
Shortly after I wrote to you, the news media picked up the story – and both the Willamette Week and the Oregonian ran front-page stories about the case. Both were highly critical of the Insurance Division for not taking stronger action to protect us from unfair and unlawful behavior by the insurance industry. Oregon Public Broadcasting also covered the story heavily.
While I agree with the press that the Insurance Division should really have taken stronger action sooner, they really wanted to help but were under intensive pressure from the Insurance Industry and the Governor’s office NOT to help us. In June of 2013, after we presented our case that Oregon law already required of ABA therapy, several senior Insurance Division officials – including Insurance Commissioner Lou Savage and two senior members of his leadership team – told us that they agreed and were prepared to announce that we were correct.
This was a critical time for our Autism Health Insurance Reform legislation, and the question of whether the law already required ABA coverage was of central significance – under the Affordable Care Act (“Obamacare”), if the state had passed a “new” requirement for coverage, the state would be required to reimburse insurance companies for the cost of coverage – potentially tens of millions of dollars per year. If, as we argued it, was simply a clarification of an existing law, the taxpayers would not be required to pay subsidies to the Insurance Industry.
On June 14, 2013, after learning from us that the Insurance Division had decided to support our position, Governor Kitzhaber’s staff called the Insurance Division and directed them NOT support us. The Governor’s advisors told us a few days later that they feared a “$40 million lawsuit” from the Insurance Industry if they declared that existing law already required coverage of autism. Instead, the Kitzhaber administration wanted the legislature to include massive subsidies to insurance companies in its budget to pay for the coverage we have already been legally entitled to. As a result, SB365 was passed – but the implementation date was postponed to 2016 to allow time for the courts to clarify the law.
So, if you’ve been having trouble getting insurance reimbursement over the last year – it’s not because the Insurance Division didn’t want to help, it’s because they were pressured not to.
In discussions with the Insurance Division over the last year, we agreed to wait until the AF v Providence case was resolved and provided more clarity on the law. I was literally walking into a meeting with Insurance Commissioner Laura Cali and her leadership team when the judge’s decision came back, and I can assure you that they were very happy with the decision, and the freedom it gave them to move forward with their mission of consumer protection.
On Thursday, August 14th, Commissioner Cali announced that she would be drafting a “bulletin” directing all insurers to provide coverage of ABA therapy immediately:
“Recent court decisions have brought clarity that coverage for ABA therapy should be required of all insurers,” said Insurance Commissioner Laura Cali….
This bulletin will explain that insurers cannot exclude coverage of ABA therapy for autism from their policies. As with other types of medical services, insurers can make coverage decisions based on whether the therapy is deemed appropriate and medically necessary for an individual patient, but they cannot broadly deny payment for ABA therapy.
(The full press release is here: http://www.oregon.gov/DCBS/insurance/news/Pages/2014/aug142014.aspx)
There are actually two bulletins – a bulletin on ABA therapy, and a more general bulletin on mental health parity. (Our work has now in effect moved beyond autism — we’re revolutionizing ALL mental health coverage in the State of Oregon). The first draft of the bulletin has been released for public comment, and can be found here: http://www.oregon.gov/DCBS/insurance/legal/bulletins/Pages/proposed-bulletin-review.aspx
If you have questions or comments about the bulletin, please send me an e-mail. There will be a public hearing on October 3, as listed on the Insurance Division’s web page at the link above. I’m working with representatives of leading mental health and disability advocacy organizations to coordinate a review and provide feedback, and we’ll meet with the Insurance Division later this month.
In the wake of this legal decision, Providence has agreed to provide ABA coverage for its’ own employees, as has the State of Oregon on its PEBB plan.
Although it’s unrelated to this lawsuit, the Oregon Health Plan has also agreed to provide ABA coverage starting on January 1, 2015 – I’ll write more about OHP later.
Request coverage and reimbursement — now
It’s now pretty clear that every group insurance plan in the state should have been providing ABA coverage since Oregon’s Mental Health Parity law took effect in 2008.
If you have ever paid for ABA therapy, you may possibly be able to get reimbursed for it. Certainly, if you want it now, you should be able to get coverage immediately.
Here is what I suggest:
- If you are interested in ABA therapy, or are already getting it, contact your doctor and submit a preauthorization request to your insurer. If you are denied coverage, please let me know, and submit a complaint to the Insurance Division.
- If you have EVER had ABA therapy (at least since 2008), submit a reimbursement request to your insurance company. You will probably be denied, especially if the claim is more than 1 year old, but please let me know, and submit a complaint to the Insurance Division.
- If you are on a waiting list for ABA therapy, please submit a consumer complaint to the Insurance Division about “network adequacy.” There are several other ABA providers willing to start providing treatment in Oregon – but only if the insurers sign provider network contracts, which they aren’t doing.
If your coverage is through Providence, you should contact the attorneys responsible for the AF v Providence lawsuit, and they may be able to help you. Please contact me and I’ll put you in touch.
Summary of press coverage
Here are some of the recent news stories about our work on autism health insurance reform:
Willamette Week did a particularly thorough job, and actually got started a few days before the judge issued his ruling. I really encourage you to read these and pass them along:
- Core article: http://www.wweek.com/portland/article-22940-state_of_denial.html
- Update: http://www.wweek.com/portland/blog-32039-state_will_tell_insurers_to_stop_denying_autism_treatment.html
Great video interview on KOIN news.
- “Oregon says all insurers will cover autism therapy”: http://koin.com/2014/08/14/oregon-says-all-insurers-will-cover-autism-therapy/
The Oregonian ran their coverage on the top of page 1.
- Initial article “Providence slammed by court for denying autism coverage, Oregon Insurance Division’s role questioned”: http://www.oregonlive.com/health/index.ssf/2014/08/judge_rules_providence_health_1.html
- Follow-up: “Oregon to require health insurance companies to cover children’s autism therapy”: www.oregonlive.com/health/index.ssf/2014/08/oregon_to_require_health_insur.html
Oregon Public Broadcasting:
OPB interviewed me several times, and also Insurance Commissioner Laura Cali.
- OBP News “Judge Rules Providence Health Cannot Deny Coverage To Autistic Children”: http://www.opb.org/news/article/judge-rules-providence-health-cannot-deny-coverage-to-autistic-children/
- OPB News “Oregon Tells Health Insurance Companies: Autism Therapy Should Be Covered”: http://www.opb.org/news/article/oregon-tells-health-insurance-companies-autism-therapy-should-be-covered/
- Think Out Loud: “Exploring The Impact Of A Ruling On Autism Treatment” http://www.opb.org/radio/programs/thinkoutloud/segment/exploring-the-impact-of-a-ruling-on-autism-treatment/
- Think Out Loud: “Oregon Insurance Commissioner Discusses Health Coverage” http://www.opb.org/radio/programs/thinkoutloud/segment/oregon-insurance-commissioner-discusses-health-coverage/
- “Providence Loses Autism Case in Federal District Court”: https://www.thelundreport.org/content/providence-loses-autism-case-federal-district-court
- “Press Release: Insurance Division Bulletin to Clarify Coverage of Autism Treatment”: https://www.thelundreport.org/content/press-release-insurance-division-bulletin-clarify-coverage-autism-treatment
- “Providence Employees Unsure if Judge’s Autism Ruling Applies to Their Kids”: https://www.thelundreport.org/content/providence-employees-unsure-if-judge%E2%80%99s-autism-ruling-applies-their-kids
- “Internal Memo Grants Autism Coverage to Providence Employees”: https://www.thelundreport.org/content/internal-memo-grants-autism-coverage-providence-employees
- “Press Release: Sen. Bates Applauds Autism Community for Victory in Providence Case”: https://www.thelundreport.org/content/press-release-sen-bates-applauds-autism-community-victory-providence-case
- “Insurance Division: Autism therapy must be covered | Mandate follows lawsuit ruling in favor of coverage”: http://www.bendbulletin.com/home/2326789-151/insurance-division-autism-therapy-must-be-covered#