Internal Memo Grants Autism Coverage to Providence Employees

Separately, proposed rules from the Insurance Division on Friday to make insurance companies comply with the recent court decision against Providence forces insurers to pay for claims back to 2008 and lifts a 25-hour cap on coverage for applied behavior analysis.

Providence employees will now have comprehensive autism treatment covered, according to an internal memo to “Providence caregivers” obtained by The Lund Report.

“Earlier this year, the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality updated its findings in respect to the efficacy of this therapy for those with autism spectrum disorder, a report that Providence has been evaluating. Until very recently, this therapy was considered experimental and was not covered by most benefit plan coverage,” the memo reads. “Based on the report findings, Providence will amend the Plan to cover ABA therapy for the treatment of autism spectrum disorder, retroactive to Jan. 1, 2014, subject to all other applicable terms of the plan.”

The move is a complete turnaround for one of the Northwest’s leading health providers and insurance companies, which fought an expensive legal battle against the parents of autistic children rather than pay for treatment voluntarily. Over the course of that court case, Providence slowly began expanding access to the treatment, offering to start coverage in 2015, then offering to pay for the treatment of the children involved in the court case.

The letter is undated, but the copy obtained by The Lund Report was sent to a Providence employee just after Labor Day.

“It’s an important first step, and it’s really going to help a lot and Providence employees need this,” said Paul Terdal, the state director for Autism Speaks.

The Catholic health provider came out on the losing end of a federal class-action lawsuit in early August, which disallowed an exception to coverage of applied behavioral analysis for children with autism, forcing the insurance company to pay for the intensive, sometimes expensive, treatment for the health plans it sells on the Oregon insurance market.

But as The Lund Report later reported, that ruling may not have automatically applied to Providence’s own employees, since the company’s self-insured health plan falls under federal but not state insurance law.

The letter to Providence’s employees makes no mention of the company’s legal woes and instead just affirms the general consensus that applied behavior analysis is the new standard of care for some children with autism. Despite the assertion that the treatment is experimental, applied behavior analysis had already been mandated in more than 30 states, including Washington.

A Providence spokesman did not respond to a request for further comment by press time.

Insurance Division Orders Coverage Back to 2008

In other news, the Insurance Division on Friday released its draft rules for all insurance companies to conform to Federal District Judge Michael Simon’s ruling in A.F. vs. Providence, given his interpretation of the Oregon and federal mental health parity laws regarding autism spectrum disorder. The Insurance Division’s rules should have a more profound impact for families with autistic children.

Under the proposed rules, the 25-hour cap on treatment that was implemented by Senate Bill 365 in 2013 will be void, and patients will be able to receive however many hours they are prescribed. Insurance companies will also be on the hook for claims dating back to Jan. 1, 2008, when the current Oregon mental health parity law took effect.

Treatment had been routinely denied by all insurance companies in Oregon, which pulled up the rear on autism treatment compared to most other states.

Applied behavior analysis refers to a wide spectrum of treatments rooted in behavioral psychology that works to change problematic behaviors in autistic youth and help children learn to relate to other people. If started before a child enters school, the therapy can be very intensive and works on reversing much of the disability. With older kids or adults, the therapy techniques focus primarily on eliminating the worst behaviors.

Terdal said he wanted the Providence employees to be able to pay claims back to 2008 as well, though Providence could be on the hook both for cash payments for treatment as well as treatment that was made available to its employees who purchased an individual health insurance plan from Kaiser Permanente to cover what their employee plan didn’t. “In that case, Providence actually owes Kaiser,” Terdal said.

Again, since Providence’s employee plan is self-insured it is governed only by federal law and the rules handed down by Oregon’s Insurance Division do not apply.

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