by Paul Terdal
This year’s legislature passed an important bill to greatly improve access by individuals with autism spectrum disorders to medically necessary health care. SB365 establishes specific requirements for health insurance coverage of Applied Behavior Analysis (ABA) therapy, and creates a new Behavior Analysis Regulatory Board to license and register ABA providers.
ABA therapy uses behavioral techniques to increase positive behaviors in a patient and reduce those that may cause harm or interfere with learning. It is widely recognized as a safe and effective treatment for autism, and has been endorsed by the U.S. Surgeon General, National Institute of Mental Health and many other state and federal agencies and professional associations. ABA can be used to help an individual with autism to improve communication skills, cope with sensory processing disorder and control dangerous or self-injurious behavior.
Oregon law has already mandated coverage of 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” on group insurance plans since implementation of Mental Health Parity in 2007. However, compliance and enforcement has been very lax, and most insurers have provided only minimal coverage of treatment for autism. PacificSource was ordered by U.S. District Court to provide ABA coverage in 2010, after a lengthy court case, and Kaiser has been providing ABA coverage since 2012, after losing more than a dozen appeals to Independent Review Organizations (outside experts) appointed by the Insurance Division. Other insurers, however, have refused to comply, and the Insurance Division has declined to assist consumers in enforcement of the law. In May of this year, a class action lawsuit was filed against Providence Health System in U.S. District Court for failure to cover treatment for autism.
SB365 provides very specific requirements for coverage of ABA “and any other mental health or medical services identified” in an “individualized treatment plan” approved by the patient’s psychologist, neurologist, or developmental pediatrician. SB365 applies only to individuals who begin treatment before 9 years of age, and who seek no more than 25 hours of ABA therapy per week. Once therapy begins, coverage continues as long as the patient continues to make progress, and ABA remains medically necessary—regardless of age. For patients who begin treatment after age 9, or who seek more than 25 hours of ABA therapy per week, the existing laws continue to apply.
The new insurance coverage requirements will apply to public employees in the Public Employees’ Benefit Board (PEBB) and the Oregon Educators Benefit Board (OEBB) programs in 2015, and to all state-regulated insurance plans in 2016. In addition, the Oregon Health Plan has been directed to evaluate coverage of ABA therapy as a treatment for autism, and to make changes by late 2014 or early 2015. Self-insured health benefit plans provided by many large employers are, by Federal law, exempt from state regulation and thus out of scope for SB365.
For more information about insurance coverage for treatment of autism–including advice on how to get coverage right now, under the laws that we already have–contact the Autism Society of Oregon at http://autismsocietyoregon.org/ or visit the Autism Insurance for Oregon web page at http://AutismInsuranceOR.org/.