Providence Employees Unsure if Judge’s Autism Ruling Applies to Their Kids

Earlier this month, federal district Judge Michael H. Simon ordered Providence Health Plan to cover applied behavior analysis on plans it sells in the Oregon insurance market, but Providence may not be bound to his ruling for its own employees, who are covered by a self-insured plan exempt from state laws. At least one mother wonders if her daughter will get the treatment she’s been prescribed.

A federal judge’s ruling earlier this month paved the way for autistic children who are covered by Providence Health Plan’s fully insured plan to receive needed treatment, but that ruling didn’t automatically open the door for the children of Providence Health & Services’ own employees.

Providence operates a self-insured plan for its employees, which is not bound by the state insurance law. It still has to abide by certain federal statutes, but it’s unclear whether those would compel the health system to cover applied behavior analysis, particularly if the company opts out of providing coverage for autism at all, which is permissible under federal law.

In a statement, Providence spokeswoman Olivia Ramos said her company is still considering options concerning its employee health plan.

“As a self-insured employer, Providence Health & Services is reviewing its medical benefit plan provisions for providing coverage of applied behavior analysis for its caregivers (employees),” Ramos wrote. “We will be communicating this directly with our caregivers in the weeks ahead.”

The ambiguity has Cari Pagan, who has a 2-year-old daughter recently diagnosed with autism, considering the purchase of a Kaiser Permanente health plan off Cover Oregon, even though she already has taken on extra work cleaning houses to get more money coming in.

Pagan, who works part-time as a dental hygienist, is covered along with her daughter by a family health insurance plan through her spouse’s work at Providence St. Vincent. Kaiser was the first health insurer in Oregon to voluntarily offer coverage of applied behavior analysis.

She told The Lund Report that her daughter’s physicians have recommended applied behavior analysis, but some told Pagan not to bother getting Providence to pay for it, since they have traditionally opposed coverage for the treatment. Undaunted, Pagan has just submitted the paperwork for pre-authorization so her daughter can get started with therapy.

Applied behavior analysis refers to a wide spectrum of treatments rooted in behavioral psychology that work 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.

Pagan also contacted Paul Terdal, an autism rights advocate at Autism Speaks. They reviewed the Providence employee handbooks and found the health company deleted significant language regarding its coverage of autism between 2012 and 2013, dropping references that indicated it covered autism at all in its employee plans.

“Providence can legally deny ABA as long as they also deny everything else for autism, too,” said Terdal. “If they cover autism at all, then they must cover it in parity – and probably can’t deny coverage of ABA.”

The change to its employee plans came about the same time the A.F. vs Providence lawsuit began its way through the federal court system. In that case, Providence argued that applied behavior analysis was not covered because it didn’t cover care related to developmental disabilities.

The Catholic health provider and insurer lost that case, but after several months of litigation, had agreed to offer up to 25 hours of the therapy a week for its clients about six months ago. In 2016, all health plans licensed and subject to the Oregon Insurance Division will have to offer the same coverage.

In his ruling, U.S. District Court Judge Michael H. Simon lifted the 25-hour cap on treatment, which the attorneys for the children with autism argued arbitrarily ties the hands of providers to give as much care as needed.

After a month of bad press in every major Oregon media outlet, Providence could still give the green light to Pagan’s child and other children of its employees who need autism treatment, but Pagan remains in a wait-and-see mode.

“They could potentially change course for their employees but it would take a little nudge,” Pagan said. “Providence has the ability to do the right thing.”

Chris can be reached at [email protected].
 
Editor's Note: Since Providence was the defendant in the recent class-action lawsuit, the case is properly titled A.F. vs. Providence. Earlier versions had it the other way. We regret the error.
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