Note: Providence Health lost the federal case over its autism coverage. See this Lund Report story.
The Oregon Department of Consumer and Business Services, Insurance Division announced today it will begin drafting a bulletin to clarify insurers’ responsibility to cover Applied Behavior Analysis (ABA) therapy as a treatment for autism.
“Recent court decisions have brought clarity that coverage for ABA therapy should be required of all insurers,” said Insurance Commissioner Laura Cali. “After evaluating the latest ruling made in Oregon last week, we have determined there are limited circumstances in which denial of coverage for ABA therapy as a treatment for autism may be reasonable. We hope the bulletin will provide more certainty to Oregon families who seek this treatment.”
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. This bulletin will explain that insurers cannot exclude coverage of ABA therapy for autism from their policies. As with other types of medical services, insurers can make coverage decisions based on whether the therapy is deemed appropriate and medically necessary for an individual patient, but they cannot broadly deny payment for ABA therapy. Consumers can appeal medical necessity denials to the company – and ultimately through the Insurance Division – via an independent review organization.
The division will begin drafting the bulletin immediately and share the draft with stakeholders, including consumers, advocates, insurers, and other interested parties, for comment and feedback. The division also will develop a transparent and consistent approach for resolving current and future consumer complaints and enforcing the bulletin.
“We understand this has been a long-standing, complex issue, and we look forward to working with a variety of stakeholders to help carry out our mission of protecting Oregon policyholders,” Cali said.
The Insurance Division is part of the Department of Consumer and Business Services, Oregon’s largest business regulatory and consumer protection agency. Visit www.dcbs.oregon.gov and www.insurance.oregon.gov.
