Action Alert-Please contact the Office of Insurance Commissioner

Under the Office of Insurance Commissioner(OIC)’s proposed rules(attached below), developmentally disabled children could receive very limited medically necessary therapy before coverage would run out. Under that scenario, children could lose all the progress made as a result of the therapy until they have coverage again the next calendar year.  Please take action asking the OIC to address this disparity.

  • Please call Meg L. Jones (Policy & Rules Manager, Office of Insurance Commissioner) at (360) 725-7170 or e-mail MegJ@OIC.WA.Gov .

Let M. Jones know,  as a constituent,  you need the OIC to add language to the rulemaking section on “Habilitative Services” that the definition of “habilitation services” excludes any service that is a “mental health service” under our state’s Mental Health Parity Act. Without that clarification, health insurers will argue that the OIC intended to allow visit limits to be imposed on neurodevelopmental therapies including those to treat DSM-IV conditions.  Let her know how detrimental this is to your loved one with autism or developmental disability.

Rule making that results in a combined annual 25 visit limit for neurodevelopmental therapies to treat DSM-IV conditions would result in inadequate — even illusory – coverage. Neurodevelopmental therapies are the essential health benefits for developmentally disabled children.

Ideally, the final rule would expressly include ABA and neurodevelopmental therapies to treat DSM-IV conditions as “mental health services” consistent with the Parity Act, as we saw in an earlier version of these rules.

  • Please forward this note to 25  family members, friends, therapists and coworkers and ask them to please do the same.

 

Thank your for your consideration.

Arzu Forough

 

Meg Jones supporting letter from Sirianni Youtz & Spoonemore

Exhs. 1-4 to Meg Jones letter-091112

Proposed Rule Making, p.11 (iii)

Insurance Update

Specialized Behavior therapies (including Applied Behavior Analysis) and neurodevelopmental therapies are “mental health services” designed to treat autism, a DSM (Diagnostic and Statistical Manual of Mental Disorders) category.  Under Mental Health Parity, blanket insurance policy exclusion for services, therapies and supplies (as well as unreasonable caps) related to the treatment of autism spectrum disorders violates Mental Health Parity laws.

Summary of MHP cases 102213 Please contact ehamburger@sylaw.comor call 206-223-0303 for status of these cases.  

If your children’s therapies are unreasonably capped or they have no benefits for treatments of autism, WAAA can help.  Contact 425.894.7231 or  Info@washingtonautismadvocacy.org.  Please indicate whether your child is covered through private insurance or medicaid.  Washington Autism Alliance & Advocacy is committed to ensure timely access to medical benefits designed to treat autism for all children in Washington.”

###

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.

Stephanie Marquis, spokeswoman for the insurance commissioner, has said: “We’re working on a regulation that addresses the issues the courts have ruled on so far that will ensure consumers get the coverage they’re entitled to and insurers understand what they’re required to cover. “The draft language should be ready by the end of the year, she said.

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 WAAA,  425-894-7231 or info@WashingtonAutismAdvocacy.org.

Please call your senator to cosponsor Autism Insurance Parity (Shayan’s Law)!

WAA Coaltion members,

Give a loved one with autism 5 minutes, call your senator and ask them to end autism insurance discrimination by signing on as a cosponsor to Shayan’s Law, Autism Insurance Parity(AIP).

1.     Call your own district’s senator (click here to find their contact information)

If your not sure what to say try this:

“My name is _________ and I’m your constituent.  I am calling to ask Senator______to cosponsor Shayan’s Law (SB5059)-Autism Insurance Parity (Prime Sponsor Sen. Ed. Murray).  Shayan’s law requires private insurance coverage of autism under Washington’s Mental Health Parity.  Individuals with autism are entitled to the full coverage that Mental Health Parity offers.  23 other states have already passed laws that require private insurance to cover autism diagnosis and medically necessary treatments.  This is an extremely important bill for our family and critical to helping my child/grandchild/neice/nephew/other gain access to appropriate health care benefits. Thank you so much for your consideration.  Please let me know when Senator______ has signed on as a cosponsor.”

If they have any questions please refer them to Senator Ed. Murray’s office.

2.     Multiply your efforts! Forward this note to everyone who supports individuals with autism (teachers, therapists, family, coworkers, other community members) and ask them to:

Thank you in advance for your calls.

Peacefully,
Arzu