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.”

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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.

Washington State Clinicians Committee Recommends Covering ABA For Autism

NEWS RELEASE

FOR IMMEDIATE RELEASE – June 20, 2011

SEA-TAC, Wash. –The Health Technology Assessment committee is an independent panel of 11 practicing health care professionals who make coverage decisions for state-funded programs.  Using independent clinical evidence, the HTCC determines if certain procedures or technologies are safe, effective, and cost-effective.

The committee’s decisions are used to determine whether the procedures will be covered under public-funded health coverage in Medicaid, state employee health benefits, worker compensation or other state-purchased health care.  A HTA Clinical Committee met on Friday afternoon to review Applied Behavior Analysis as a Health Technology for treatment of autism.  46% of all children born in WA are Medicaid recipients, 18% of all WA employees have public benefits.  This was a very broad reaching review.

Prior to the meeting the committee had found that:

  • Most of the reviews generally concluded that the evidence base for EIBI (Early Intensive Behavior Intervention) is inadequate, noting: unacceptable variability in treatment and intervention limited follow up, lack of comparative studies and need for replication, and unclear inclusion and exclusion criteria.
  • Other areas for improvement noted included a need for larger sample sizes; longer follow-up to allow for evaluation of the durability of effects; greater treatment fidelity; improved reporting of methodological and participant characteristics; and greater consistency in treatment approaches and outcomes measurement.

The Agency Medical Director Dr. Jeff Thompson had recommended:

  • The science for ABA types does not have a sufficient base to justify a $29-50K benefit
  • He asked the committee to not recommend ABA type of therapies as a covered benefit
  • He recommended better promotion of existing benefits such as early periodic screening and diagnostics to pediatric and Primary Care Physicians.

At the review committee meeting Dr. Bryan King of Seattle Children’s Hospital Autism Center testified to the efficacy of EIBI and offered to collaborate with the agency to develop guidelines to maximize efficacy while maintaining cost containment.

Arzu Forough testified on the lack of appropriate and effective healthcare for core symptoms of autism in children of all ages as well as the challenges facing medical and clinical experts that families turn to for help:

“Every year we & others like us across the state have gone through the same arduous process with medical panels who could not wrap their minds around a treatment for a neurological disorder that was not a pill, a potion, an elixir or a surgical procedure. In the absence of timely and evidence based intervention, throughout the state patients are suffering and dying.”

Dr. Sara White PhD BCBA-D of Bellingham’s Sendan Center testified on the scientific flaws and limitations of the HTA review process.  She further testified children and adults who don’t receive treatment experience aggression and self-injurious and often debilitating behaviors that are routinely mitigated successfully and humanely through behavior analytic treatment.

Dr. Ilene Schwartz PhD BCBA-D testified to the rigor in education and training of Behavior Analysts and further reinforced the history of efficacy of EIBI for treatment of patients of all ages with ASD’s.

After hearing the public comments, the panel had a lot of unanswered  questions and comments, were perplexed as to the challenges in this particular review and were clearly divided and had mixed reactions as to what they were tasked with.  But one thing was clear to them at the end, they couldn’t in good conscience vote against the insurance coverage.

  • ABA was recommended for coverage with the condition that some entity like UW Autism Center or Seattle Children’s Autism Center or both evaluate the data from the therapies provided.  They want to ensure evidence demonstrates benefit.
  • Conditions will be ironed out in collaboration with Seattle Children’s Autism Center  & UW Autism Center.  The members want to make sure there’s adequate oversight to ensure efficacy and fidelity.

FOR ADDITIONAL information review: HTA ABA review meeting materials

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Shayan’s Law-Autism Insurance Parity-Hearing update

Many thanks to all the families and advocates who packed the hearing room yesterday, dressed in red and carrying pictures of their children or accompanied with their children.

Our hearing was well orchastrated.   Lorri Unumb(Autism Speaks Senior Policy Advisor), Dr’s Bryan King and Gary Stobbe (Seattle Children’s Hospital Autism Center), Kathy George (Harrison, Benis & Spence attorney), Arzu Forough (Washington Autism Alliance & Advocacy) and Chanel Krueger (highly accomplished, articulate young lady with autism) were among those who provided testimony is support of Shayan’s Law, Autism Insurance Parity (AIP). (The hearing can be viewed through TVW archives by clicking here).

The fiscal calculations on the state of WA to cover the public employee’s dependents  was grossly inflated ($141,773,139), so much so that several committee members requested a revised fiscal data from the office of Financial Management (OFM).

The Senate committee members were clearly in favor of Shayan’s Law.  Our next steps is two fold,  provide true cost impact  data from states that have had AIP for over a decade AND to continue to build the momentum of support.

Here’s How YOU Can Help:

1.Call and write all members of the committee (click on text for contact info.) and let them know Washington state can’t afford to bear the cost of autism alone, let them know how much your family (and/or local school district) ia spending on your loved one with autism(on specialized developmental, behavioral and education programs).

2. Multiply your efforts, forward this note to teachers, therapists, friends, any and all supporters and ask them to please get actively involved.

3.Volunteer with us (click here to view volunteering opportunities)


Thank you for your consideration.

Washington Autism Alliance and Advocacy Coalition

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To post questions, comments, inquiries visit:

http://health.groups.yahoo.com/group/Washington-Autism-Advocacy/