Group Health Insurance Coverage for Autism
MANDATED BENEFIT FOR MENTAL OR NERVOUS CONDITIONS AND CHEMICAL DEPENDENCY, GROUP HEALTH INSURANCE
On January 1, 2007, Senate Bill 1, Mental Health Parity, went into effect in Oregon. Pervasive Developmental Disorders are now a covered condition. This means that coverage for Pervasive Developmental Disorders are provided “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.”
http://www.cbs.state.or.us/external/ins/rules/attachments/recently%20pro...
SB1, the Mental Health Parity law, does not apply to health benefits provided by a self insured company. The SB1 rules do not apply to individual health insurance policies or the Oregon Health Plan. _The SB1 rules only apply to the 60% of insured Oregonians who have group health insurance_. Your new 2007 group health policy will reflect the new rules. Until then, the old rules remain in effect on your current policy.
Under the SB1 rules, medically necessary treatments for autism such as:
Speech, Occupational Therapy, Physical Therapy and traditional mental health treatment will be covered with no age caps. Applied Behavior Analysis is considered experimental by insurance companies. Insurance companies will continue to deny coverage for this treatment. Behavior Analysts will not be covered either because they are not state licensed.
Only state licensed medical and mental health providers will be covered.
Medical treatments insurance companies consider investigational or experimental for autism, such as chelation, will also continue to be denied coverage by insurance companies. Appeal any denial for coverage of treatment that you believe is medically necessary for your child.
The SB1 rules will be revaluated in 2 years. _Filing a complaint with the Insurance Division as soon as your insurance company denies coverage for any medically necessary treatment is vitally important in all cases._ The Oregon Insurance Division needs this kind of data for the reevaluation. The more complaints the Insurance Division receives, the more likely there will be policy changes in the future. So far, the Insurance Division has only received two complaints about autism coverage in 2007. Two complaints are not enough to sway the revaluation committee to recommend changes in autism coverage. We need hundreds if not thousands of complaints to do this.
If you believe that coverage for medically necessary treatment for autism has been denied, immediately file a complaint with the Insurance Division. Then go through all appeals with your insurance company. If you still have not prevailed, request an external review. You are likely to fair better in external review.
To file a complaint with the Oregon Insurance Division go to:
https://www4.cbs.state.or.us/exs/ins/complaint/
http://www.cbs.state.or.us/ins/consumer/tomake.html
For free help with insurance questions and complaints, download this publication:
http://www.cbs.state.or.us/ins/publications/consumer/3235.pdf
HB 2918 2007 Autism Coverage Bill
HB 2918 was introduced because SB1 fell short in providing parity for autism. Certain providers and the medically necessary treatments they provide were not covered. Unfortunately the bill did not move out of committee and will not pass in this legislative session. Representative Greenlick, the chair of the House Health Committee, felt if Applied Behavior Analysis as a treatment were excluded, the bill would not cover anything more than SB1. Therefore he believed there was no reason for HB 2918. Representative Greenlick said that Applied Behavior Analysis is an intensive, long term therapy that does not fit into the current health insurance model. He also believes that Applied Behavior Analysis does not fit into any current model in the state including Medicaid, the Oregon Health Plan, or in education. He believes that we will have to create an entirely new program in our state to provide behavior analytic treatment to individuals with autism. He is now exploring different avenues for this.
Keeping the issue of full health insurance coverage for autism, including medically necessary experimental treatments, and coverage for Applied Behavior Analysis as a top legislative priority, is up to all of us. This means going to Salem and meeting with your Representative and State Senator and sharing your personal stories with them. This means writing them to tell them how important these issues are to your family. (Remember to include a photo of your child.) With hundreds of us involved in this important groundwork, when autism legislation is introduced again, our elected officials will be more likely to support it.
Thank you to the families and individuals who worked so hard on SB1 and HB 2918. We now have autism coverage that we did not have before. Group health insurance companies doing business in Oregon can never exclude autism again from their policies. That is a major accomplishment!
If you have any questions please contact Michelle Vanderwey. (503) 593-4303 autismalert@hotmail.com