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Order issued in wake of state Supreme Court ruling
October 20, 2014 -- Washington state Insurance Commissioner Mike Kreidler has ordered the state's private insurers tostop enforcing blanket exclusions for medically necessary mental health coverage, such as applied behavior analysis (ABA) for autism,and to reconsider all claimsdating back to 2006 that were denied on the basis of a blanket exclusion.
Kriedler's order was issued in the wake of the Washington Supreme Court's unanimous ruling that such blanket exclusions violate bothstate and federal mental health parity law. While Krielder's order does not specifically reference autism or ABA, it was the result of the Supreme Court's decision in O.S.T. v Regence, a class action suit dealingwith denials of ABA on the basis ofblanket exclusionsfor individuals diagnosed with autism.
“The court ruled decisively on behalf of Washington consumers, and I intend to see that insurers doing business in our state follow through on this decision,” Kreidler said. “I expect the insurers to do a thorough review of all policyholders who may have current and past claims that may be impacted by this decision and to start the process immediately.”
Kreidler's office was assailed last week in a Seattle Times editorial for having left enforcement of the mental health parity law to the courts, rather than taking action on its own.
"He has been slow to stand up for the tens of thousands of families struggling to get necessary care for loved ones with mental illness," the Times wrote. "Astoundingly, his office has not taken a single enforcement action on the law, and a proposed rule to strengthen enforcement has languished in his office for two years."
In his letter to insurers issued today, Kreidler directed that claims for medically necessary services could no longer be denied on the basis of blanket or categorical exclusions. If currentinsurance contracts do contain exclusions, then policyholders must be notified of the "correct coverage standard." Health plans to be issued in 2015 will be reviewed for compliance.
In addition, insurers.were given until March 1, 2015 to identify all mental health claims dating back to 2006 that were denied on the basis of a blanket exclusion and to implement aprocess for allowing improperly denied claims to be re-evaluated.
The provision reflects a proposed settlement between Regence Blue Shield in the state andfederal class action lawsuits in which the insurer would establisha $6 million fund to reimburse out-of-pocket expenses incurred by policyholders for improperlydenied claims.
“With this settlement and the recent (state) Supreme Court decision, the standard for coverage in Washington state is clearly established,” said Eleanor Hamburger, of Sirianni Youtz Spoonemore Hamburger, who represented the plaintiffs.
Hamburger has reached settlementswith the state's three largest private insurers and the state employees health plan, and is representing employees suing Boeing for its denialof autism benefits. The federal class action suit against Regence coveredhealth plans regulated under federal ERISA laws and alleged violations of federal mental health parity law. All of the actions are based on denials of ABA coverage for children with autism.
Mental health parity laws do not require mental health coverage; rather, they require health plans that do cover mental health benefits to cover those benefits at parity with physical health benefits.
Regence Blue Shield agrees to cover ABA, other treatments
(October 17, 2014) -- Regence Blue Shield, the largest Washington State health insurer, has agreed to settle a pair ofclass action lawsuits by covering medically necessary autism treatments, including applied behavior analysis (ABA), and establishing a $6 million fund to reimburse policyholders for out-of-pocket expenses incurred as a result of denied claims.
Regence is the last of Washington State's three largest insurers to settle litigation brought under state and federal Mental Health Parity law over lack of coverage for autism treatment.
“With this settlement and the recent (state) Supreme Court decision, the standard for coverage in Washington state is clearly established,” said Eleanor Hamburger, of Sirianni Youtz Spoonemore Hamburger, who prepresented the plaintiffs.“All other Washington health insurers should change their policies now to ensure that children with developmental disabilities get the insurance coverage to which they are entitled.”
Hamburger was referring to a unanimous decision reached last week by the Washington State Supreme Courtin aclass action lawsuit that found Regence's blanket exclusion of treatments on the basis of an autism diagnosis violated the state's 2005 Mental Health Parity Act. Within days, Regence agreed to settle a second class action suit proceding in U.S. District Court affecting its self-insured, or so-called ERISA, plans which are regulated under federal Mental Health Parity law.
The settlement would cover both the state and federalactions and requires approval by both judges.
The proposed settlement wouldrequire coveragefor medically necessary speech, occupational and physical therapies and ABA therapy to treat mental health conditions, including autism.Exclusions,age limits,monetary caps and visit limits would all be prohibited. A $6 million settlement fund would be established by Regence to reimburse policyholders whose previous claims for autism coverage were denied.
"...This proposed Settlement Agreement – now buttressed by the Washington State Supreme Court – fundamentally changes the insurance landscape for all Regence's Washington insureds with developmental disabilities and autism,"according to a motion filed by Hamburger before the state and federal judges hearing the cases. "If approved, the Agreement would expand and align Regence's coverage obligations with the two other large carriers in Washington (Premera and Group Health), resulting in a historic, market-wide expansion of access to medically necessary therapies in Washington State for individuals with developmental disabilities."
Once the two judges issue their preliminary approval, final hearingswill be scheduled in each court and a notice will be sent to all class members about the settlement, the final hearings, and the process for submitting claims for reimbursement of out-of-pocket neurodevelopmental therapy costs.
If the final settlement agreement is approved, Hamburger said sheestimates thatfunds from the $6 million settlement fund could be disbursed to affected families by April or May of 2015.
In addition to the Regence, Premera Blue Cross and Group Health Cooperative actions, Hamburger has won a settlement with the Washington Health Care Authority requiring coverage for state employees and has filed an action against Boeing.
Will address enacting insurance reform laws in conservative states
LEXINGTON, SC (October16, 2014) -- Lorri Unumb, Esq., vice president for state government affairs at Autism Speaks, will address the Belmont University School of Lawon "Legislating Autism Coverage: The Conservative Insurance Mandate" at a Law Review Symposium on Health CareFriday, October 17 in Nashville.
Unumb won the fight for autism insurance reform in her native South Carolina in 2006 then went on with Autism Speaks to help manage the enactment of similar laws in 35 other states. Today, 75 percent of the nation's population is covered under state laws barring the insurance industry's practice of excludingany coverage for autism treatment.
In addition to California, Texas and New York, Unumb helped manage the enactment of reform laws inArkansas, Louisiana,Utah, Nebraska, Kansas and Alaska. Arizona Gov. Jan Brewer was persuaded to veto a bill sent to her by the Legislature which would have voided its state mandate.
Tennessee is one of 13 states yet to enact autism insurance reform. Efforts will resume in 2015 with the Legislature to outlaw the insurance industry's exclusionary practices.
Belmont's Annual Symposium will be held on Friday, October 17 at the Baskin Center, home of its College of Law. Unumbis scheduled to speak at9 am.
Autism-specific steps included in plan announced by Governor
(October 10, 2014) -- Connecticut Gov. Dannel Malloy has announced a comprensive overhaul of the state's emergency and lonterm behavioral health care system, includingfour steps specific to upgrading treatment for children with autism. The reforms were required by legislation enacted after the 2012 mass shooting tragedy inNewtown.
“No child in mental health crisis should have to wait days to get access to the treatment they need," Malloy said. "That is why I am announcing a series of strategies that...can be implemented immediately."
The Connecticut plan calls for short-term improvements toemergency care services which, in line with national trends, have experienced increasing admissions of youths with acute behavioral health issues and delays in discharges. Malloy's plan calls for immediate increases in emergencycare capacity with specific accommodations for the autism community.
The longer term changes were developed bythe state Department of Children and Families (DCF) as required under Public Act 13-178, legislation enacted following the Newtown tragedy.
In a review of emergency care services required by children in HUSKY, the state's Medicaid program, nearly half the children with autism enrolled in the programneededto visit anemergency roomover an 18-month period. Nearly half of those visits were because of behavioral, rather than medical, reasons, versus just 7 percent for the overall HUSKY population.
In response, four steps were outlined specific to the autism community:
- Connecticut will implement the federal government's July 7 directive to provide medically necessary treatment through its Medicaid program forchildren with autism up to age 21. An outline of services is expected October 22.
- The state will invest up to $1 million to create up tothreeteams of specially trained practitioners to address the unique needs of children with autismreceiving care in Psychiatric Residential Treatment Facilities and other settings to recommend a successful out-placement.The transition plans may includeevidence-based interventionscovered byprivate insurance or Medicaid,work with children in hospitals orin their homes who are at risk for hospitalization.
- An in-home care program will be created todivert children with autism aged13-21from inpatient and other residential settings.A $300,000 pilot program will serve 10 children with severely challenging behaviors. "This in-home support pilot will assist adolescents who have autism and who are exhibiting severely challenging behaviors to remain in the community and live successfully at home with their families."
- Threespecialized inpatient hospital beds will be providedfor individuals experiencing the most acute and complex autismand co-occurring psychiatric disorders. A small number ofindividualsrequire hospitalization because of intense behavior challenges, but Connecticut has been ill-equipped to handle them.
DCF estimates that 156,000Connecticut children may have behavioral health symptoms that would benefit from treatment.
"Families experience a number of barriers to treatment including a highly fragmented system in which access varies according to such factors as insurance status, involvement in child welfare or juvenile justice, race and ethnicity, language, and geographic location," the Department concluded. "In addition, the array of services lacks sufficient inclusion of supports for all children and families that promote nurturing relationships and environments that foster social, emotional, and behavioral wellness. A comprehensive plan is required to guide the efforts of multiple stakeholders in developing a children's behavioral health system that builds on existing strengths and addresses the many challenges that exist."
The Governor's immediate action plan is HERE.
The DCF longterm plan is HERE.
New program would have cut ABA provider rates in half
WASHINGTON, DC (October 9, 2014) --The Department of Defense has announced it will delay a planned cut in what it pays providers through TRICARE to deliver applied behavior analysis (ABA) treatment to military kids with autism.
The new demonstration program allows coverage of BCBA/BCBA-D direct services and the tiered service delivery model, which includes BCaBAs and Behavior Technicians, by consolidating existing programs under one uniform benefit for all TRICARE beneficiaries with autism.The cut in reimbursement was among a series of changes included in TRICARE's new consolidated ABA benefit for beneficiaries that is scheduled to take effect October 20.
In a statement, a Department of Defense spokesperson confirmed thatTRICARE will delay any ABA reimbursement rate changes until April 20, 2015.
"The Department understands the concerns caused by the rate change," the DoD said. "In order to address these concerns, the Department has commissioned an independent review of the Demonstration."
Autism Speaks responded to the announcement as a positive sign.
"We are encouraged to see the DoD respond to the concerns of families and providers," said Karen Driscoll, Autism Speaks' associate director for federal government affairs & military relations.