Autism Insurance for Oregon

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

Autism Health Insurance Reform: Introducing SB1523 and updates on implementation and enforcement of autism insurance reform

Contents:

  • Support SB1523 – Autism and Mental Health Parity coverage for Public Employees
  • Update on HERC review of ABA coverage in OHP (Medicaid)
  • Providence class action certified and moving forward
  • Review of autism coverage by Oregon insurers
  • New Oregon rules on External Reviews
  • Implementation of SB414 — Restitution

Support SB1523 – Autism and Mental Health Parity coverage for Public Employees

Last summer, the legislature unanimously approved SB365, our Autism Health Insurance Reform bill, which established 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 new, streamlined approval process applies to children who begin treatment before age 9; SB365 preserved more general requirements for coverage of autism treatment under existing Oregon law, including both Mental Health Parity (ORS 743A.168) and a mandate for Children with Pervasive Developmental Disabilities (ORS 743A.190).

SB365 was intended to apply to state employees covered by PEBB and OEBB, but most state employees get their coverage through self-insured plans which are completely exempt from Oregon’s insurance code.  Very few people in the capitol appeared to have been aware that their own plans were exempt from the insurance code – in all of our legislation for the last few years, the fiscal impact assessments have been primarily based on the cost to these state employee self-insured plans – even though those plans were legally out of scope.

SB1523, for the first time, extends coverage requirements for Mental Health Parity (ORS 743A.168), Children with Pervasive Developmental Disabilities (ORS 743A.190), and SB365 to the self-insured plans administered by PEBB and OEBB – and also to employees of OHSU.

You can read more about this bill in the Lund Report here:  http://www.thelundreport.org/resource/ohsu_prescribes_aba_for_autistic_kids_but_keeps_treatment_from_employees

I encourage you to read that article, and “like” it on Facebook to spread the word.

We also ask everyone to write your legislators to ask them to support SB1523 – see the end of this message for guidance and a sample e-mail.

Update on HERC review of ABA coverage in OHP (Medicaid)

We continue to work with the Health Evidence Review Commission (HERC) in its’ evaluation of Applied Behavior Analysis (ABA) for coverage in the Oregon Health Plan (OHP), Oregon’s Medicaid program.  Many of you submitted public comment in December; the HERC staff is now reviewing that, and will provide an updated draft report for discussion in the 2/6/2014 meeting of the Evidence-based Guidelines Subcommittee.

We have had some concerns about the process for review.  In particular, the commission has posted two different standards of evidence on its’ web page – a stricter standard, printed on a Kaiser Permanente letterhead (http://www.oregon.gov/oha/herc/Documents/HERC%20GRADE%20Methodology.pdf); and a more generous standard, published in the official HERC report to the Governor and Legislature, which allows for a broader array of evidence (excerpted here:  http://www.oregon.gov/oha/herc/Documents/submitted-materials.pdf).  We assert that the standard of evidence documented in the HERC report to the Governor and Legislature is binding – and would provide a more realistic assessment of the evidence for ABA.  The HERC staff asserts that they prefer the stricter evidence standard published by HERC on a Kaiser Permanente letterhead.  We look forward to seeing how this is resolved.

As it happens, one of HERC’s primary sources – the Federal Agency for Healthcare Research and Quality (AHRQ) – has just published a new draft report on evidence for ABA which substantially upgrades the evidence rating for ABA, which may make this process debate moot at least for patients ages 0 to 12 (http://effectivehealthcare.ahrq.gov/research-available-for-comment/comment-draft-reports/?pageaction=displaydraftcommentform&topicid=544&productid=1845&documenttype=draftReport).

For older patients, we have provided a substantial body of documentation on research into the effectiveness of ABA, and look forward to HERC’s review of those materials.

Providence class action certified and moving forward

Last May, a class action lawsuit was filed in U.S. District Court against Providence over its’ denial of coverage for treatment of autism, and particularly Applied Behavior Analysis (ABA).

On 12/24/2013, Judge Simon approved certification of the class as requested by the plaintiffs, to include all individuals with an autism diagnosis who are covered by a Providence ERISA (employer-based) health benefit plan subject to Oregon law (doesn’t include self-funded plans) issued since 2007.  At this point, the class is injunctive only – meaning that it is just a request for an order to stop denying coverage of ABA; damage awards, if any, will be determined later.  This suit came after several years of unsuccessful attempts by consumer advocates to work with Providence to resolve the issue out of court.

Providence has taken the position that it can exclude all mental health services related to developmental disabilities – including autism – even though Oregon’s Mental Health Parity act specifically requires it to cover mental health services related to autism “at the same level as, and subject to limitations no more restrictive than, those imposed on coverage … for other medical conditions.”  (Legally, autism is considered to be both a developmental disability and a “mental or nervous condition”).

Despite this plain language, Providence has asserted that Oregon’s Mental Health Parity law isn’t a mandate and doesn’t actually require coverage of treatment for mental health conditions.

In an “amicus curiae” brief filed by Disability Rights Oregon last Friday, DRO advised the court:

“Should this Court rule that Providence can avoid coverage for ABA, a medically necessary service for children with autism, despite state and federal laws requiring parity in the provision of coverage for mental disabilities, the implications would devastating for all with mental health conditions – not just for children with autism. The same reasoning as that used by Providence to avoid its obligations under state and federal law to provide ABA to children with autism on the same basis as medically necessary services to those with other medical conditions would be used to deny medically necessary services for people with other mental illnesses in the community. The availability of individual therapy, or group therapy, or drug therapies could be arbitrarily limited, and highly effective treatments such as DBT would be routinely denied. As a result, people with mental illnesses throughout would continue to suffer unnecessarily because of the unavailability of medically sound, proven therapies.”

We are expecting a ruling on the request for an injunction by about May of this year.

The Lund Report has written several good articles on this case, including this one:  http://www.thelundreport.org/resource/judge_in_autism_case_allows_class_action_against_providence

And this:  http://www.thelundreport.org/resource/providence_moves_to_stop_class_action_suit_over_denied_autism_care

Review of autism coverage by Oregon insurers

In general, all Oregon insurers are covering speech, occupational, and physical therapy for autism.  Plans that comply with the “Essential Health Benefits” package under the Affordable Care Act (“Obamacare”) should now be providing up to 60 visits per year for these rehabilitative therapies.

Here’s a quick summary of how Oregon insurers are currently covering treatment of Applied Behavior Analysis (ABA), a leading behavioral health treatment for autism:

Kaiser:

Kaiser continues to be the most cooperative, but in recent months has been tightening its’ criteria for approval of ABA; in some cases we’ve seen denials of coverage on grounds that it wasn’t medically necessary.  So far, all such denials have been overturned through internal appeals without having to apply to external review, but it has been frustrating and has delayed treatment for some patients.

Kaiser has also recently suggested that it will enforce a policy requiring parents to participate directly in 80% of all ABA therapy sessions, and to be physically present 100% of the time.  While it is commonly recommended that parents participate in ABA therapy at some level, most research is based on a 20% parental participation rate to continue therapy out of session with the bulk of therapy being provided by professional providers.  We have attempted to open negotiations with Kaiser to discuss the merits of the policy, but have been rebuffed.  This policy would appear to violate state and federal Mental Health Parity laws, since Kaiser doesn’t refuse coverage of treatment for the predominant medical / surgical conditions unless parents are participating in treatment (say, in surgery or the emergency room).

In a couple of cases, Kaiser has refused coverage of ABA services scheduled during school hours (between 9:00 AM and 2:00 PM) on grounds that it is “educational” purely by the time of day of service.  This appears to violate Mental Health Parity laws, unless the insurer can demonstrate that it refuses to cover all other medical treatment (emergency room visits, pediatric office visits, etc.) during school hours.

Several families – who already have employer-based insurance from other providers who aren’t cooperative – have purchased individual Kaiser plans for their children through Cover Oregon to gain access to coverage for ABA therapy.  Kaiser initially refused to pay claims for these families, asserting that it was improper to have more than one insurance plan, but has recently move forward with approval of coverage.  We’re reviewing this with the Insurance Division, but Kaiser’s recent agreement to provide the coverage that families have paid for is encouraging.

If you have a Cover Oregon policy, and Kaiser is refusing coverage of ABA on grounds that the policy is “secondary” or that it is somehow improper to have more than one plan, please contact me and submit a Consumer Complaint to the Insurance Division.

PacificSource:

We understand that PacificSource continues to pay for ABA provided by BCBAs, but not by paraprofessionals (line therapists).  Since the portions of SB365 regarding licensure took effect upon signature on 8/14/2013 – grandfathering all existing ABA providers to “continue to claim reimbursement from a health benefit plan … without a license” we believe PacificSource’s refusal to reimbursement unlicensed paraprofessionals may be illegal.

Regence:

Regence continues to deny all coverage of ABA on grounds that it is “investigational” (i.e., an unproven treatment).  This is disappointing, since Dr. Csaba Mera – Regence’s Deputy Chief Medical Officer – told a legislative workgroup on 3/15/2011 (almost 3 years ago) 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.”  This suggests that Regence is aware that its’ “investigational” denial is false.

On the other hand, an “investigational” denial allows appeal to External Review.  So far, one Oregon patient has successfully navigated the IRO process to have a Regence ABA denial overturned (as have about 20 others with Kaiser and Providence insurance).  After about two months of threats from Regence to refuse to honor the IRO decision – despite the prospect of a $1 million fine for non-compliance – Regence appears to be ready to approve coverage for that patient, but continues to drag its’ feet.  We’re working on the details; two other Oregon patients are currently in the IRO process with Regence.

We have discussed Regence’s conduct with the Insurance Division, and are confident that we can count on them to help enforce the IRO decisions.

There are two class action lawsuits underway against Regence in Washington State over denials of treatment for autism.  On Friday, 1/24/2014, Regence was given an injunction ordering it to stop imposing age limits on autism treatment for the duration of the trial, based on a conclusion by the judge that the plaintiffs were likely to prevail.

Moda:

We are working with Moda appeals through OEBB, OHSU, and commercial group plans.

Generally, in first round denials, Moda claims that ABA is an educational service, not a medical one.  Upon appeal, Moda drops that argument and issues denials based on licensure or (in the case of OHSU) because the plan has an explicit exclusion for ABA regardless of medical necessity (which violates Mental Health Parity, as argued by Disability Rights Oregon above).

Since the licensure provisions of SB365 have already taken effect – grandfathering existing ABA providers to practice without a license until 2016 – Moda’s licensure objection is invalid.

I understand that the Insurance Division is prepared to enforce the licensing provisions of SB365, and to assist consumers facing this type of denial.

Conclusion:

Please let me know what problems you are encountering with insurance coverage for treatment of symptoms associated with autism.  Denials asserting that ABA is investigational, not medically necessary, not a medical / mental health service, or that the providers aren’t licensed should now be easy to overcome with help from the Insurance Division, and I’m happy to help facilitate communication.

New Oregon rules on External Reviews

The External Review process has been an incredibly important tool for consumers to overcome insurer denials of treatment for autism, including ABA.  When an insurer claims that a treatment is “investigational” or not medically necessary, a consumer can ask the Insurance Division to appoint an Independent Review Organization (IRO) to have a neutral expert review the case and make a binding decision.  For insurer denials of autism, we have now made about 20 appeals to IRO – and all but 2 have overturned insurer denials of ABA therapy, usually with sharp words for the insurer criticizing their policies. In both of the cases that we’ve lost, subsequent investigations by the Insurance Division concluded that the IROs failed to comply with the laws governing the review process – such as those regarding the kinds of evidence that they must consider, need to provide references supporting their decision, or the credentials for the reviewers.  Up until now, there has been no recourse for a consumer when the IRO fails to follow the rules.

The Oregon Insurance Division has now adopted new Administrative Rules on External Reviews that allow consumers to challenge a decision by an Independent Review Organization (IRO) if the IRO doesn’t follow the rules, and potentially have the appeal redone.  (See:  http://insurance.oregon.gov/rules/attachments/recently%20proposed/2013/id09-2013_rule.pdf, OAR 836-053-1325, subsections (8) to (15)).

If you are making an appeal to External Review, I would love to hear from you and would be happy to talk about how to use these rules if you have a problem with an IRO decision.

Implementation of SB414 — Restitution

In addition to our Autism Health Insurance Reform bill (SB365), the legislature also passed SB414, our Restitution bill, which allows the Insurance Division to “seek restitution on a consumer’s behalf for actual damages the consumer suffers as a result of the insurer’s violation of a provision of the Insurance Code or applicable federal law or the insurer’s breach of an insurance contract….”  This took effect on 1/1/2014.

We continue to discuss the full meaning and implementation of SB414; the insurance industry as you might imagine seeks to define “actual damages” in the most minimal way possible, so as to avoid financial responsibility.  The intent was to require an insurer that breaks the law to pay for the consequences of its’ illegal activity – for instance, if an insurer unlawfully withholds coverage of cardiac care, then the insurer should be financially liable for the consequences (“actual damages”) if the consumer suffers a heart attack.  The insurers appear to be arguing that, even if they are found to have broken the law, they should only be required to pay minimal contractual damages – e.g., after you’ve died, they’ll pay for the cost of the care that would have prevented your death, rather than for the impact to your family of your demise.

The Insurance Division has issued draft rules (http://insurance.oregon.gov/rules/attachments/recently%20proposed/2013/id12-2013-temp_rule.pdf) while we continue to haggle over the final terms, which should be done by June.

In the meantime, if you are submitting a Consumer Complaint about your insurance company to the Insurance Division, you should ask for “restitution” and provide an estimate of the “actual damages” you have suffered as a result of the insurer’s conduct.

——–

Sincerely,

 

Paul Terdal

 

 

Sample message in support of SB1523 – Autism and Mental Health Parity coverage for Public Employees:

Here’s a short, simple e-mail message that you can use to get started.  Revise the last paragraph to describe how this affects you, your family, or your patients, and update the greeting and address.

To:

You can find your legislator’s e-mail at:  http://www.leg.state.or.us/findlegsltr/

Subject:

Please Support SB1523 – Mental Health Parity and Autism coverage for Public Employees

Body:

Dear [Senator / Representative x],

I am a constituent in your district.

Please support SB1523, which will require self-insured PEBB, OEBB, and OHSU health benefit plans to comply with the same rules that commercial insurers follow, with respect to Mental Health Parity and (under 2005 SB1) and autism (under 2013 SB365).

Last year’s SB365 (Autism Health Insurance Reform) was intended to apply to self-insured PEBB and OEBB plans – and all other plans subject to state regulation – but those plans are actually completely exempt from the insurance code.

SB1523 is a technical fix that requires these self-insured PEBB and OEBB plans to comply with SB365 as intended, and also requires them to comply with Oregon’s landmark Mental Health Parity law (SB1 from 2005) and the Children with Pervasive Developmental Disabilities law (HB2918 from 2007).  It further extends these coverage requirements to the OHSU employee benefit plan, addressing another unforeseen gap in SB365.

[*** If you wish, you can insert a brief personal story here.  This is especially important if you yourself are on PEBB, OEBB, or an OHSU plan. ***]

Thank you,

 

Your Name

123 SW Main

Hometown, OR  97201

Posted in Uncategorized | Comments Off

Autism Health Insurance Reform: HERC Public Comment on ABA in OHP Due 12/15/2013

Contents:

  • 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.

——–

Sincerely,

 

Paul Terdal

Posted in Uncategorized | Comments Off

Autism Health Insurance Reform: Update on implementation

Contents:

  • 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:  http://www.coveroregon.com/

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:  http://www.washingtonautismadvocacy.org/updates/2013/10/10/oic-mental-health-parity-hearing-102213-10-12-pm/

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:  www.ahopeforautism.net

  • 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

——–

Sincerely,

 

Paul Terdal

Posted in Uncategorized | Comments Off

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/

 

——–

Sincerely,

 

Paul Terdal

Posted in Uncategorized | Comments Off

Autism Health Insurance Reform: SB365 Unanimously approved by HOUSE – on to the Governor!

Contents:

  • Update on SB365 – SB365 Unanimously approved by House, too! – On to the Governor!
  • ACTION ALERT:  ask Governor Kitzhaber to sign SB365 – and enforce our existing rights!

Update on SB365 – SB365 Unanimously approved by House, too! – On to the Governor!

Well, that was fast.

This afternoon, the Oregon House of Representatives suspended the rules that normally require a waiting period on votes, and voted UNANIMOUSLY to support SB365, the Autism Health Insurance Reform bill!

In this entire legislative session, not one legislator has ever cast a vote against Autism Health Insurance Reform!

That is the power of all of our e-mails, phone calls, and meetings with legislators.  We spoke, they listened – and voted.

This morning, before the vote, the two top leaders of the House Republican caucus — Rep. Mike McLane, House Republican Leader, and Rep. Julie Parrish, Deputy House Republican Leader – signed on to SB365 as official co-sponsors.  Both are long-standing friends of our cause, and we appreciate their help in explaining the importance of Autism Health Insurance Reform to their caucus and smoothing the way for the fast, unanimous vote.

SB365 will now go the Oregon Governor John Kitzhaber for signature.

ACTION ALERT:  ask Governor Kitzhaber to sign SB365 – and enforce our existing rights!

Please contact Governor Kitzhaber to ask him to SB365 – and also to direct the Insurance Division to enforce our existing Autism insurance mandates.

While SB365 is a great step, the actual insurance mandate doesn’t take effect on commercial insurance plans until 2016 – two and a half years from now.  However, Oregon law (ORS743A.168) already requires insurance companies to cover “expenses arising from treatment” for 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.”

Despite this, most insurers refuse to cover medically necessary, evidence-based treatment for autism – such as Applied Behavior Analysis (ABA).  Providence even claims that it “permanently excludes” treatment for autism from its’ plans, despite these laws.  We need Governor Kitzhaber’s Insurance Division to start enforcing the laws we already have, right now.

ACTION #1:  Call Governor Kitzhaber

Please take 1 minute to call Governor Kitzhaber’s office to ask him to support SB365, Autism Health Insurance Reform.

Call the Governor’s Citizen’s Representative Office:  (503) 378-4582.

The phone will be answered by a staff member, or by voice mail.  Here’s a message you can tell them – but feel free to personalize this:

My name is ____________.

I’m calling to ask the Governor to sign SB365, the Autism Health Insurance Reform bill – which was passed unanimously by both the House and Senate.

Oregon law has required insurance companies to cover medically necessary treatment for autism since 2007 – but most refuse to pay for the nationally accepted standard of care.  Please direct the Insurance Division to enforce the law, and require insurance companies to pay for coverage of autism — today.

Thank you!

ACTION #2:  Send an E-mail to Governor Kitzhaber

Please also send an e-mail to the Governor, using his web page:  http://www.oregon.gov/gov/Pages/ShareYourOpinion.aspx

Step 1)  Enter your personal information

Step 2)  Choose “Health Care” in the “Topic” box

Step 3)  In the comment box, say something like this:

Please sign SB365, the Autism Health Insurance Reform bill, so that Oregonians with autism can get access through their health insurance to the treatments they need, with licensed and registered providers. The House and Senate have both voted UNANIMOUSLY to approve this landmark legislation.

Oregon law (ORS 743A.168) already requires insurance companies to cover “expenses arising from treatment” for 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.” Unfortunately, most insurers refuse to pay for the nationally accepted standard of care.  Please direct the Insurance Division to enforce the law, and require insurance companies to pay for coverage of autism – now, under existing law.

Every year, 600 more children are diagnosed with autism in Oregon. With effective, early intervention many of these children will be able to make substantial gains and require fewer services as they get older. Providing these individuals with the right care at the right time will save the state money.

Please sign SB365 – and enforce the laws we already have. Thank you.

To make your message to the Governor even more effective, add a few words about your personal situation.

——–

Thanks for your help!

 

Paul Terdal

Posted in Call To Action, Legislative | Comments Off

Autism Health Insurance Reform: SB365 Unanimously approved by Senate – House to vote next week!

Contents:

  • Update on SB365 – SB365 Unanimously approved by Senate – House to vote next week!
  • Update on SB414 – Approved by House – on to the Governor!
  • ACTION ALERT:  if you haven’t had the chance yet, please ask your State Representative to support SB365

Update on SB365 – SB365 Unanimously approved by Senate – House to vote next week!

This morning (Saturday), the Oregon Senate voted UNANIMOUSLY to support SB365, the Autism Health Insurance Reform bill!

Senator Bates, our Chief Sponsor, gave a great introduction to the bill, followed by congratulatory speeches by Sen. Hass and Sen. Edwards – our Chief Sponsors in 2012 and 2011.  My family and I then listened from the balcony as Senator after Senator answered the roll-call vote by declaring “Aye!” or “Yes!” in support of the bill.  Not one single Senator voted against our bill.

We also picked up two new Co-Sponsors, as Sen. Devlin and Sen. Johnson joined Sen. Bates, Sen. Edwards, and Sen. Hass with this extra level of endorsement.

The bill will be introduced into the House on Monday, with a formal vote on Tuesday or Wednesday.

Thank you to everyone who has written your legislators about this bill!  The unanimous vote of support is extra important in demonstrating that insurance coverage for medically necessary treatment of autism isn’t a “controversial” proposition but is something that the entire Legislature is firmly behind.  It protects us against possible future attempts to roll back coverage (which we have already been warned could happen in 2015), and sets the stage for any of our efforts to broaden coverage further – or pursue other legislative efforts in other areas to help the autism community in the future.

Update on SB414 – Approved by House – on to the Governor!

SB414 – our insurance restitution bill – was also approved by the Oregon House of Representatives on Friday, with a 48 to 12 vote (80%) in favor.

SB414 empowers the Insurance Division to “Seek restitution on a consumer’s behalf for actual damages the consumer suffers as a result of the insurer’s violation … of the Insurance Code or applicable federal law….”  Currently, the Insurance Division can issue a fine (payable to the state treasury) – but has no authority to order compensation directly to a consumer.

Since the Oregon Senate had already approved SB414, it is now headed to the Governor for signature.  The restitution authority will take effect on January 1, 2014.  We look forward to working with the Insurance Division as it establishes policies and procedures to carry out this new authority.

ACTION ALERT:  if you haven’t had the chance yet, please ask your State Representative to support SB365

As you can see from our unanimous vote in the Senate, our e-mails to legislators really do make a difference.  We’re hoping for an equally strong showing in the House to demonstrate that Oregon’s legislature is very firmly behind us.

If you haven’t had a chance to do it yet this week, please contact your State Representative to let him or her know that SB365, the Autism Health Insurance Reform bill is coming for a final vote – and to ask for their support.

I have included a sample e-mail message at bottom – but please personalize the message as much as possible, to show the impact that this issue has on you.

——–

Thanks for your help!

 

Paul Terdal

 

Sample E-mail Message in support of SB365 – Autism Health Insurance Reform:

[Please feel free to modify this, or insert details about your own story]

To:

Your own State Representative.  You can find his or her e-mail address at:  http://www.leg.state.or.us/findlegsltr/

Subject:

Please support SB365 – Autism Health Insurance Reform

Body:

Dear Representative (insert your legislator’s name here):

Please support SB365 – the Autism Health Insurance Reform bill.

Autism is a neurobiological condition that now affects 1 in 88 children nationally; the incidence has risen dramatically in the past 20 years – there are now nearly 9,000 Oregon schoolchildren receiving special education services for autism.  Autism is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors; many severely impacted individuals suffer lifelong disability, especially when the condition is untreated.

While Oregon law already requires insurance coverage for treatment of autism, SB365 establishes requirements for insurer approval and management of Applied Behavior Analysis (ABA) – a leading autism treatment recommended by the U.S. Surgeon General, National Institute of Mental Health, American Psychological Association, and many other professional associations.  It also establishes a Behavior Analysis Regulatory Board to license and regulate providers who can deliver the national standard of care at an affordable cost.

[Insert your personal story here about why this legislation is important to you!]

SB365 was unanimously approved by the Senate on Saturday – following unanimous do-pass recommendations in both the Senate Health Care and Human Services committee and the Joint Committee On Ways and Means.  Advocates from the autism community have worked closely with insurance industry representatives and government officials to develop this bill under the leadership of Sen. Bates.  Thirty-three other states have already enacted similar legislation.

Please join me – and your Senate colleagues — in supporting this critical bill so that every Oregonian with autism can access medically necessary care for this treatable condition.

Thank you for your support.

[add your name and physical mailing address]

 

Posted in Call To Action, Legislative | Comments Off

Autism Health Insurance Reform: SB365 Unanimously approved in Ways and Means – on to final floor votes!

Contents:

  • Update on SB365 – Unanimously approved in Ways and Means – on to final House and Senate floor votes!
  • Update on SB414 – Unanimously approved in House Rules – also on to a final House floor vote!
  • ACTION ALERT:  Ask your legislators to support SB365 ONE LAST TIME!

Update on SB365 – Unanimously approved in Ways and Means – on to final House and Senate floor votes!

This afternoon, the full Joint Committee On Ways and Means voted UNANIMOUSLY to approve SB365, the Autism Health Insurance Reform bill!

From here, the final steps are votes on the House and Senate floors, and then signature by the Governor!

The legislature is expected to wrap up its’ session for the year by early next week, so things will come to a close very quickly.  While we’re very confident, we want to make sure we all ask our legislators ONE LAST TIME to support this important bill – see the action alert below for ideas.

Update on SB414 – Unanimously approved in House Rules – also on to a final House floor vote!

SB414 – our insurance restitution bill – was also approved unanimously in the House Rules committee today.  SB414 will give the Insurance Division the authority to order restitution or equitable relief if an insurance company violates state or federal law, or the terms of its’ contract.  Currently, the Insurance Division can issue a fine (payable to the state treasury) – but has no authority to order compensation directly to a consumer.  While we would have loved to see even stronger legislation (like HB3160 – to remove the insurance industry’s exemption from Oregon’s anti-fraud laws), SB414 is a great start.

Since that bill has already been approved by the full Senate (on a 19 to 10 vote), it now goes to a final vote on the House floor – and then to the Governor.

We’re very confident of success – since the leadership of both parties joined in the unanimous vote in the House Rules committee, and the Insurance Commissioner joined me in giving very supportive testimony in the House and Senate committee hearings.

ACTION ALERT:  Ask your legislators to support SB365 ONE LAST TIME!

Please contact your State Representative and State Senator to let them know that SB365, the Autism Health Insurance Reform bill is coming for a final vote – and to ask them for their support.  Even if you’ve contacted them before this session, it’s important for them to hear from you again, now that it’s up for a final vote!

I have included a sample e-mail message at bottom – but please personalize the message as much as possible, to show the impact that this issue has on you.

Autism Speaks has also set up a simple, easy-to-use web form – you can use it to send personalized messages to your own legislators really quickly.  You can use it at:  http://www.autismspeaks.org/advocacy/action/oregon-urge-your-lawmakers-vote-yes-autism-insurance-reform

Let’s get SB365 passed this year!

——–

Thanks for your help!

 

Paul Terdal

 

Sample E-mail Message in support of SB365 – Autism Health Insurance Reform:

[Please feel free to modify this, or insert details about your own story]

To:

Your own State Representative and State Senator.  You can find their e-mail addresses at:  http://www.leg.state.or.us/findlegsltr/

Subject:

Please support SB365 – Autism Health Insurance Reform

Body:

Dear Representative / Senator (insert your legislator’s name here):

Please support SB365 – the Autism Health Insurance Reform bill.

Autism is a neurobiological condition that now affects 1 in 88 children nationally; the incidence has risen dramatically in the past 20 years – there are now nearly 9,000 Oregon schoolchildren receiving special education services for autism.  Autism is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors; many severely impacted individuals suffer lifelong disability, especially when the condition is untreated.

While Oregon law already requires insurance coverage for treatment of autism, SB365 establishes requirements for insurer approval and management of Applied Behavior Analysis (ABA) – a leading autism treatment recommended by the U.S. Surgeon General, National Institute of Mental Health, American Psychological Association, and many other professional associations.  It also establishes a Behavior Analysis Regulatory Board to license and regulate providers who can deliver the national standard of care at an affordable cost.

[Insert your personal story here about why this legislation is important to you!]

SB365 received a unanimous do-pass recommendation in both the Senate Health Care and Human Services committee and the Joint Committee On Ways and Means.  Advocates from the autism community have worked closely with insurance industry representatives and government officials to develop this bill under the leadership of Sen. Bates.  Thirty-three other states have already enacted similar legislation.

Please join us in supporting this critical bill – so that every Oregonian with autism can access medically necessary care for this treatable condition.

Thank you for your support.

[add your name and physical mailing address]

 

Posted in Call To Action, Legislative | Comments Off

Autism Health Insurance Reform: SB365 moving forward for a vote on Thursday

Contents:

  • Update on SB365 – Issues resolved, vote in Ways and Means expected Thursday
  • Update on SB414 – Senate floor vote tomorrow, approval in House expected
  • Next Steps

Update on SB365 – Issues resolved, vote in Ways and Means expected Thursday

A big thank you to everyone who has called and e-mailed the Governor’s office, and contacted their legislators and Ways and Means committee members.  IT WORKED – we got their attention, and we’re going to pass our bill.

Yesterday afternoon, Sen. Bates convened a final workgroup meeting to discuss the bill, including high-level representatives from the Governor’s office; the new Insurance Commissioner; Cover Oregon, the health exchange; many insurance companies; autism advocacy organizations, including Autism Speaks, Autism Society of Oregon, Oregon Association for Behavior Analysis; and myself, among others.

We are expecting the bill to move forward largely as written, but the implementation date for commercial insurance plans will be postponed until January 2016.  The Behavior Analysis Regulatory Board will still be launched in late 2013 to begin licensing and registering ABA providers.  Insurance coverage will apply to public employees in PEBB and OEBB beginning in 2015, as expected in the SB365A bill.

In addition, the Health Evidence Review Commission will be directed to begin a reevaluation of the evidence in support of Applied Behavior Analysis (ABA), starting in August 2013 to finish in August 2014.  If HERC concludes that the evidence to support ABA is now sufficient – and everyone participating in yesterday’s meeting anticipated that it would – then OHP coverage would begin in late 2014 or early 2015.

Although the Ways and Means Human Services subcommittee had been expected to close today, we understand that they have agreed to extend the committee by a couple of days to hear SB365 on Thursday June 20th.  We expect a quick vote to approve the bill.

While the very slow implementation is a disappointment, it is very important to remember that Oregon law already requires coverage of autism “at the same level as, and subject to limitations no more restrictive than, those imposed on … other medical conditions.”  We are confident that this applies to coverage of ABA therapy as a treatment for autism, as courts have found in Oregon and around the country.  A class action lawsuit has already been filed against Providence, and we expect a decision in early 2014 – well before the implementation date of this new law – and we would hope that the Insurance Industry and Insurance Division would apply rulings in that decision to other insurers.

Update on SB414 – Senate floor vote tomorrow, approval in House expected

One of the other bills we introduced this year was SB414, which gives the Insurance Division the authority to seek restitution on behalf of consumers.

Currently, the Insurance Division can’t order an insurer pay a claim – they can impose fines, or ask insurers nicely to pay claims to consumers, but have no authority to actually require payment of a claim.  Since there is no meaningful “private right of action” for a consumer to sue an insurance company in state court (save for the kinds of major federal litigation we’re pursuing against Providence), it’s nearly impossible to make an insurance company pay a claim if it doesn’t wish to do so.

SB414 is now on a fast track for approval.  We had a great hearing in the Senate Rules committee last week, where Insurance Commissioner Lou Savage joined me in explaining the need for the bill to the Senators.  It is scheduled for a vote in the full Senate tomorrow; we are expecting rapid approval in the House.

I would love to see HB3160 pass as well.  As I have written before, HB3160 would remove the Insurance Industry’s exemption from the Unlawful Trade Practices Act (Oregon’s anti-fraud law), and allow private individuals to sue their insurance company in state court for fraud or other illegal conduct.  HB3160 has already passed the house, but is just one vote short in the Senate.  All Democrats except Sen. Betsy Johnson have confirmed their support; all Republicans remain opposed.  If we can persuade just one of those Senators to support the bill, we can get it passed as well.  See my June 13 update for a sample e-mail you can send to your legislators in support of HB3160:  http://autisminsuranceor.org/2013/06/autism-health-insurance-reform-update-on-sb365-ask-your-senator-to-support-hb3160/

The Lund Report has written a great article about SB414, HB3160, and our work on them:  http://www.thelundreport.org/resource/shields_pushes_to_empower_dcbs_as_effort_to_put_insurance_under_utpa_flounders

Next Steps

We’ll let you know how things go in Thursday’s Ways and Means hearing on SB365.  While we hope for smooth sailing from here, we’ll ask everyone to contact their legislators after the Ways and Means hearing to encourage a Yes vote on the House and Senate floor.

 

——–

Thanks for your help!

 

Paul Terdal

Posted in Uncategorized | Comments Off

Autism Health Insurance Reform: ACTION Alert – Ask Governor Kitzhaber to support SB365!

Contents:

  • Update on SB365 – Insurers want a subsidy; threaten to sue Oregon if it enforces existing law
  • ACTION #1:  Call Governor Kitzhaber
  • ACTION #2:  Send an E-mail to Governor Kitzhaber
  • ACTION #3:  Send an E-mail the Ways and Means committee

Update on SB365 – Insurers want a subsidy; threaten to sue Oregon if it enforces existing law

I wrote last week that several insurance companies testified to the Ways and Means committee in support of SB365, the Autism Health Insurance Reform bill.

Unfortunately, Insurance Industry representatives are also demanding millions of dollars in taxpayer subsidies – and are even threatening to sue the State of Oregon if it attempts to enforce the existing laws that already mandate insurance coverage of autism treatment.

Oregon law has required insurance companies to cover treatment for autism since 2007 “at the same level as, and subject to limitations no more restrictive than, those imposed on coverage … for other medical conditions” (ORS 743A.168).

Despite orders by both State and Federal courts for Oregon; about twenty External Review decisions by Independent Review Organizations appointed by the Oregon Insurance Division; and numerous court orders in other jurisdictions around the country, most Oregon insurers (except Kaiser and PacificSource) flatly refuse to pay for medically necessary behavioral health treatment (Applied Behavior Analysis, or ABA) – and the Oregon Insurance Division refuses to enforce the law.

The principle behind SB365 has always been Autism Health Insurance Reform – we agreed to a clarification in the laws regarding autism coverage; the insurance companies would agree to comply with the revised rules; and the Insurance Division would agree to actually enforce them.  I was abundantly clear in the legislative workgroup’s kick-off meeting more than a year ago that my agreement to participate in negotiations about new legislation did not excuse anyone from compliance with the laws that we already had.

The Insurance Industry is now arguing that SB365 represents a new requirement for autism coverage, and has even threatened to sue the State of Oregon if it attempts to enforce the laws we already have.

On Monday afternoon, we will be meeting with Sen. Bates, our chief sponsor; Insurance Industry representatives; and representatives from the Governor’s office, Insurance Division, and other departments to discuss the final draft of the legislation – and determine whether we can proceed at all.

It is absolutely essential to contact our elected officials to ask them for their support at this critical time.

ACTION #1:  Call Governor Kitzhaber

Please take 1 minute on Monday morning to call Governor Kitzhaber’s office to ask him to support SB365, Autism Health Insurance Reform.

Call the Governor’s Citizen’s Representative Office:  (503) 378-4582.

The phone will be answered by a staff member, or by voice mail.  Here’s a message you can tell them – but feel free to personalize this:

My name is ____________.

I’m calling to ask the Governor to support SB365, the Autism Health Insurance Reform bill.

Oregon law has required insurance companies to cover medically necessary treatment for autism since 2007 – but most refuse to pay for the nationally accepted standard of care.  Please enforce the law, and support SB365 to streamline access to coverage.

Thank you!

ACTION #2:  Send an E-mail to Governor Kitzhaber

Please also send an e-mail to the Governor, using his web page:  http://www.oregon.gov/gov/Pages/ShareYourOpinion.aspx

 

Step 1)  Enter your personal information

Step 2)  Choose “Health Care” in the “Topic” box

Step 3)  In the comment box, say something like this:

Please support SB365, the Autism Health Insurance Reform bill, so that Oregonians with autism can get access through their health insurance to the treatments they need.

Oregon law has required insurance companies to cover medically necessary treatment for autism since 2007 – but they aren’t doing it.  Please enforce the law, and support SB365 to streamline access to coverage.

SB365 clarifies existing requirements for health benefit plans, including private plans, PEBB and OEBB, to pay for medically necessary, evidence-based treatment for patients with autism. It would also create a licensing board within the Oregon Health Licensing Agency for providers of applied behavior analysis therapy, to ensure that patients receive quality, effective treatment from capable providers.

Every year, 600 more children are diagnosed with autism in Oregon. With effective, early intervention many of these children will be able to make substantial gains and require fewer services as they get older. Providing these individuals with the right care at the right time will save the state money.

Please support SB365. Thank you.

 

To make your message even more effective, add a few words about your personal situation.

ACTION #3:  Send an E-mail the Ways and Means committee

Last week, I wrote to ask everyone to send an e-mail to the Ways and Means committee, asking them to support SB365.  If you haven’t had a chance to do that yet, Autism Speaks has set up a really fast, simple form you can use:

http://www.autismspeaks.org/advocacy/action/oregon-get-autism-insurance-reform-out-committee

——–

Please forward this message to friends and family in Oregon who may want to send emails too.  We’ll let you know how things are going, and what we’ll all need to do next.

Thanks for your help!

 

Paul Terdal

Posted in Uncategorized | Comments Off

Autism Health Insurance Reform: ACTION Alert – Ask Ways and Means to support SB365!

URGENT ACTION:  Ask Ways and Means to support SB365A NOW!

SB365, the autism health insurance bill, passed the Senate Health Care Committee by unanimous vote. It’s now in the Joint Ways and Means SubCommittee On Human Services, to look at the financial impact to the state. Getting SB365 passed out of Ways & Means is the last hurdle before a vote by the full Senate, and we’re optimistic about our chances there.

We’ve been able to get a hearing on SB365 in which several key things went well – the budget estimate came in at a reasonable cost, and several insurance companies testified in support, which we greatly appreciated. Unfortunately, it’s not clear that the committee will agree to schedule a vote – and time is now running out.  The SubCommittee shuts down next Tuesday, June 18th.  We must get the committee’s approval by then, or the bill is dead.

We need EVERYONE to contact the members of the Ways and Means committee NOW to urge them to support SB365.

A sample e-mail message is below, along with the e-mail addresses for the committee members. Please personalize the message if you’d like to show the impact that this issue has on you – but please contact them ASAP.

Please forward this message to friends and family in Oregon who may want to send emails too.We’ll be in touch shortly to let you know how things are going, and what we’ll need you to do next.

Thanks for your help!

 

Paul Terdal

Sample E-mail Message in support of SB365A – Autism Health Insurance Reform:

[Please feel free to modify this, or insert details about your own story]

To:

Sen.AlanBates@state.or.us; Rep.NancyNathanson@state.or.us; Sen.ElizabethSteinerHayward@state.or.us; Sen.JackieWinters@state.or.us; Rep.TimFreeman@state.or.us; Rep.JoeGallegos@state.or.us; Sen.RichardDevlin@state.or.us; Rep.PeterBuckley@state.or.us

Subject:

Please support SB365A – Autism Health Insurance Reform

Body:

Dear members of the Joint Ways and Means committee,

Thank you for hearing SB365, the Autism Health Insurance Reform bill, in Wednesday’s meeting of the Joint Committee On Ways and Means SubCommittee On Human Services.

SB.365 establishes the process by which health benefit plans, including private plans, PEBB, and OEBB, pay for medically necessary, evidence-based treatment for patients with autism. It would also create a licensing board within the Oregon Health Licensing Agency for providers of applied behavior analysis therapy, to ensure that patients receive quality, effective treatment from capable providers.

[insert your own story here about how this has affected you or your family, if you’d like]

There are nearly 9,000 children in Oregon who are on the autism spectrum. Every year, 600 more children are diagnosed with autism in Oregon. The State of Oregon is currently spending $200 million or more, per biennium, on special education and community services for children and adults with autism.

With effective, early intervention many of these children will be able to make substantial gains and require fewer services as they get older. Providing these individuals with the right care at the right time will save the state money.

Please schedule a work session on SB365 – and give it your vote of support.  Thousands of Oregonians on the autism spectrum and their families are counting on you.

Thank you for your support!

[add your name and physical mailing address]

 

Posted in Call To Action, Legislative | Comments Off