Autism Advocates Optimistic Insurance Division Will Assist with Older Claims

A bulletin issued last week from Insurance Commissioner Laura Cali made clear that insurance companies have to pay for applied behavior analysis treatment, but only back to the date of a class-action ruling in August.

A bulletin from the Oregon Insurance Division has decreed that coverage of a controversial but popular treatment for autism is the clear law of the land, following a landmark ruling from a federal district court judge this summer.

But despite earlier reports, the clearly defined mandate for applied behavior analysis from the Insurance Division will only be retroactive to the Judge Michael Simon’s ruling on Aug. 8, 2014 -- not 2008 and the enactment of the state mental health parity law. Any medical claims before the ruling that insurers aren’t paying will have to be worked out through the Insurance Division on a case-by-case basis.

“We’re still looking at older claims and deciding how we want insurers to deal with those,” Lisa Morawski, the Insurance Division spokeswoman, told The Lund Report.

However, advocates still praise the bulletin from Insurance Commissioner Laura Cali and say that all the winds blow in their favor when it comes to getting older claims paid.

“There’s no advantage of an insurer not paying the old claims,” said advocate Paul Terdal, who promised legal action if insurance companies pay for treatment after Aug. 8, but deny payment for any treatment up until that date. “If an insurer does that, they’re inviting a lawsuit.”

For years, insurers in Oregon have fought off attempts to pay for the treatment for children, dismissing it as experimental, even as most other states have mandated coverage, and it’s been seen as the standard of treatment.

But after Providence Health Plan decisively lost a class-action lawsuit this August, there’s little room for insurers to avoid paying for applied behavioral analysis if it’s properly prescribed for a child.

"Recent court decisions have made it clear that ABA should be a covered service when it's appropriate for the patient," said Cali in a press release. "We expect insurers to stop applying blanket exclusions in their policies and claims practices that effectively deny access to medically-necessary treatment for mental health conditions."

The Insurance Division has the authority to issue bulletins to clarify requirements of insurance companies under the Oregon Insurance Code and other state and federal laws, and the bulletin was prepared this fall through a public process and input from stakeholders, including both insurance companies and consumers.

“This has been a long, hard fight, and the Autism Society of Oregon will continue to ​watch closely to see how these policies are being ​implemented,” said Tobi Rates, the executive director of the Autism Society of Oregon. “But, these bulletins are a significant aid in getting people on the autism spectrum the medical supports that they need and have been entitled to all along​.”

Terdal, the Oregon policy chair for Autism Speaks, said consumers now have three actions if an insurer doesn’t immediately pay. They can resolve the issue with the insurance company; they can request that the Insurance Division become involved; or they can take the insurer to court.

He said both of the last two options could get very expensive for the insurers, given their losing streak when it comes to paying for applied behavior analysis. “An insurer would have minimal defense,” he said.

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