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

Enforcement

Existing Oregon law already requires coverage for medically necessary treatment for autism – including intensive treatments like Applied Behavior Analysis (ABA) – but most insurers restrict or deny coverage.  Recently, progress has been made in enforcing these laws to obtain medically necessary coverage.

  • PacificSource covers Applied Behavior Analysis on its’ group plans, after a legal victory in McHenry v PacificSource.  See this Oregonian article for details.
  • Kaiser Permanente has been ordered to pay for ABA for more than a half-dozen  children through the administrative appeals process, with support from the Oregon Insurance Division.  See below for details of this process.
  • Providence has been covering Applied Behavior Analysis for one family since 2007; we won another case earlier this year, and more are in process.

If you have questions about enforcing your rights to autism coverage under your existing insurance policy, please leave me a comment on this web page, and I’ll get back to you.  I have numerous templates and examples that you can use to make the process easier.

Kaiser Permanente ABA Appeals Process:

We are winning Applied Behavior Analysis (ABA) coverage from Kaiser through the Outpatient Mental Health Care benefit.  For plans subject to Mental Health Parity Laws (group plans, and some older individual plans), there are no limits on outpatient mental health care – which means there can be no arbitrary limits on ABA approved under this benefit (the insurer can still impose reasonable limits based on medical necessity).

Step 1:  Referral for ABA from a Participating Provider

Call the Mental Health Line at (503)331-6521 to request a referral to the ABA provider of your choice (Play Connections, Building Bridges, Autism Behavioral Consulting, etc.).

If you have any difficulties with this step, please contact me for assistance.

Step 2:  First Round Internal Appeal + Consumer Complaint to Insurance Division

Kaiser will deny the referral, most likely by declaring that ABA isn’t medically necessary. Please consult with me to discuss the exact terms of the denial — most denials follow a standard format, but there are some variations.

Write a letter to Member Services appealing the denial.  I have examples and templates that can be used.  If possible, include copies of any documentation – like after visit summaries, or letters from medical experts – demonstrating the autism diagnosis, and need for ABA.

Send a copy of the appeal letter to the Oregon Insurance Division, and complete a Consumer Complaint form:  http://insurance.oregon.gov/consumer/tomake.html.

Step 3:  External Review

Kaiser will repeat their denial.

For a medical necessity denial, send a letter to Kaiser requesting External Review.  I have a template.

The Oregon Insurance Division will select an Independent Review Organization (IRO) to review the case and make a decision that is binding on Kaiser.

You will need to send a letter to that IRO within 7 days of assignment.  That letter should outline your case for ABA in detail.  For this, you will need as much documentation as possible, including medical records and letters supporting the need for ABA.  I have templates and examples, including information you can send about medical evidence to support the effectiveness of ABA.

The IRO will make a decision within 30 days.  So far, nine out of ten IRO decisions have ruled in favor of ABA, overturning denials.  The one case in ten that wasn’t successful was for my own son — and was ultimately overturned by another IRO.

Step 4:  Implementation

If you win the External Review decision by the IRO, then Kaiser will send you a letter outlining their plans to cooperate.  You can also call Member Services.  Kaiser has negotiated a provider relationship with a Portland-area Board Certified Behavior Analyst.

2 Responses to Enforcement

  1. Michelle Vo says:

    Regence is denying ABA therapy coverage for my son, what is your experience in getting them to cover it?

    • terdal says:

      Regence’s denials are based on their assertion that ABA is “investigational” (i.e., unproven). As reported on this website in 2011, Dr. Csaba Mera, Regence’s Chief Medical Officer, has stated that “there is sufficient evidence that children between ages 3 and 11 are helped (by ABA) – we’re not arguing about that…. It works in younger children – it really does make a difference in their lives.” You should appeal the denial, and after exhausting your 2 rounds of internal appeals, request External Review to an outside expert appointed by the Insurance Division. I encourage to work with me on your appeal. You can reach me at paul@AutismInsuranceOR.org.

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