Landmark court finding: “[U]nder the Mental Health Parity Act private insurers are required to cover medically necessary behavior therapies including Applied Behavior Analysis therapy, as determined on an individualized basis, when provided by licensed providers.”
Washington’s Network Adequacy Statute and Rules require health plans to ensure that enrollees are entitled to sufficient, timely and appropriate health care services and choice among health care providers (this includes behavior therapies). In articular, the statute requires that “[e]ach carrier must provide for appropriate and timely referral of enrollees to a choice of specialists within the plan if specialty care is warranted(such as Applied Behavior Analysis).
If the type of medical specialist needed for a specific condition is not represented on the specialty panel, enrollees must have access to nonparticipating specialty health care providers.Health carriers are required to maintain adequate networks of providers in order to ensure that health plan enrollees can obtain treatment in their local communities without undue delay, traveling onerous distances or incurring additional out-of-pocket expenses:
An example of “reasonable proximity” is provided in the regulations through the Office of Insurance Commissioner:
“For example, a carrier should not require travel of thirty miles or more when a provider who meets carrier standards is available for inclusion in the network and practices within five miles of enrollees.”
The court is asked not to permit health carriers (Washington State Health Care Authority-HCA) to work around the Court’s Order by imposing a new condition of participating in a research study, for coverage of ABA therapy for autism.
Washington’s Mental Health Parity Act and its Network Adequacy statutes and regulations prohibit HCA’s conditions. We will share Judge Carighead’s decision promptly.
In the meanwhile if any individual with ASD’s has been denied coverage for neuro-developmental therapy (speech, physical therapy, occupational therapy, sensory-motor, neuropsychological evaluation etc.), behavioral therapy (including Applied Behavioral Analysis therapy) or mental health therapy based upon exclusions or limitations in their Washington state insurance policies, please contact ehamburger@sylaw.comor call 206-223-0303 for potential free advice and/or representation.
Class Mot. for PSJ re HCA Conditions-112911
Class Mot for PSJ re Certified Counselors-112911
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DF v WHCA Partial Summary Judgment
Group Health decision will be shared once it’s in public records.
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UMP/Regence is referring callers to three sources of information to determine whether UMP/Regence will cover the submitted claims: (1) the Regence outpatient behavioral health guidline -http://blue.regence.com/about/utilization/Outpatient_Treatment_Medical_Necessity_Criteria.pdf; (2) the UMP Certificate of Coverage definition of medical necessity http://www.ump.hca.wa.gov/medical/docs/umpcoc2011.pdf; p. 99; and (3) Regence’s provider coverage criteria http://www.wa.regence.com/provider/contracts-credentialing/credentialing/ (Regence is apparently closed to accepting new licensed mental health providers at this time - http://www.wa.regence.com/provider/contracts-credentialing/provider-types/ ).
In general, claims for behavioral health services submitted to Regence by appropriately credentialed providers will be automatically adjudicated through the first 20 visits. At the 20th visit, UMP/Regence will request a treatment plan from the provider which will be reviewed by the UMP/Regence medical director. The UMP/Regence medical director will deny continued coverage or approve continued service at a particular frequency for a set period of time, after which the service will be reviewed again.
It is almost certain that the claims will be paid at the out-of-network (60%) level, even though we do not know of any Regence in-network providers who are qualified to provide ABA therapy services. It is important that providers and patients let my office know of all claims, whether approved or denied, for ABA therapy and the rate at which the claims were paid. Patient and providers who are paid at the 60% rate should appeal, requesting the in-network rate.
We hope that patients and providers will start sending in claims to UMP/Regence for ABA therapy services consistent with the above three criteria.
Please call or email Ele Hamburger of Sirianni Yountz of Spoonemore with questions.
Telephone: (206) 223-0303
Facsimile: (206) 223-0246
Direct Line: (206) 838-1809
E-mail: ehamburger@sylaw.com
Website: www.symslaw.com
