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New regulations finalized, licensure bill for ABA providers heading to Governor
(April 23, 2014) -- The Maryland Insurance Administration (MIA) has finalized new regulations that will require coverage of autism benefits, including applied behavior analysis (ABA), for many private plans as well as state employees. Related legislation that would establish a state licensing procedure for ABA providers, meanwhile, is headed to Gov. Martin O'Malley in May.
The new requirements will apply to individual, fully funded small and large group plans, the state employee health plan and coverage purchased through Maryland's health insurance marketplace created under the Affordable Care Act.The coverage includes a minimum of 25 hours weekly of ABA up to agesix, and then 10 hours weekly through age 18.
In addition, psychological care and speech, occupational and physical therapy for the treatment of autism are covered.
However, the regulations require ABA practitioners to be licensed by the state. Because Maryland has no license, legislation was moved through the legislature to create the license and will be sent to the Governor next month. Autism Speaks and other advocacy organizations had urged the state to accept professional certification to speed up the process, but MIA insisted on the need for a state license.
Rather than require autism insurance coverage through legislation, the Maryland Legislature in 2012 chose to create a task force to clarify the state's existing habilitative services statute to provide autism coverage. After a year of study, MIA first proposed regulations in September 2013, then issued a new proposal this year which ultimately was finalized.
Autism Speaks, Pathfinders for Autism and the Maryland Association of Behavior Analysts will host a series of information session in May to familiarize families and providers with the new regulations. Learn more here.
Three different programs serving kids with autism will be rolled into one
WASHINGTON, DC (April22, 2014) -- In a report to Congress,TRICARE announced it will be creating a new Autism Care Demonstration startingJuly 25 that willconsolidate all ABA programs into one uniform benefit for TRICARE beneficiaries with autism.
The new program will launch with the expiration of the current Applied Behavior Analysis (ABA) Pilot for non-active duty family members that has been problematic since its launch last year and has served very few children.
TRICARE intends to transition all beneficiaries receiving ABA services to the new demonstration by the end of 2014.TRICARE reports the new demonstration will extend through December 31, 2016 while the Department of Defense considers coverage of ABA as medical care.
Policy specifics of the new Autism Care Demonstration were not provided in TRICARE's report.Autism Speaks will monitor the release of the program details and encourage TRICARE to publish its proposed policies and seek public input into the process.
"Transparency is important here," said Karen Driscoll, Autism Speaks associate director of federal government affairs and military relations. "Military families need to be able to plan for their healthcare decisions.Engaging with families, service providers, and medical experts is also important to ensure final policies meet the needs of military children in a manner consistent with best practices."
Autism Speaks continues to work with Congressional champions to require ABA coverage for all military children with developmental disabilities, such as Down syndrome,and at medically prescribed levels.Earlier this month, Autism Speaks hosted Congressional briefings for the House and the Senate to highlight the need for the legislation.
Gov. Heineman signs bill requiring certain insurers to cover diagnosis, treatment
LINCOLN (April 21, 2014) -- Nebraska became the 36th state to enact autism insurance reform today when Gov. Dave Heineman signed legislation requiring certain insurers to coverthe diagnosis and treatment of autism up to age 20. The new law, which takes effect with new health policies issued for 2015, requires up to 25 hours a week of behavioral health treatment, including applied behavior analysis (ABA).
Heineman said he was signingthe bill, LB.254, "on behalf of families who meet the challenges of autism every day.” The bill was sponsored bySen. Colby Coash of Lincoln, who has worked for years withfamilies and autism advocacy groups, such as Autism Speaks, in winning autism insurance reform.
“I care about this issue because I have seen the impact that this treatment can have on the future of a child with autism,” saidCoash. “Positive things can happen when they receive life-changing treatment. These families are strong willed and they never gave up on the bill, so I wouldn't either. Today is a special day.”
“This is a great day for Autism families in Nebraska,” said Vicki Depenbusch, Autism Speaks' advocacy chair for Nebraska. “It gives us hope that our children will be the best citizens that they can be.”
Depenbusch's son,Jacob, who has autism, and Heineman (pictured right with Vicki Depenbusch and Coash)metat a parent teacher conferencein 2010. The two have communicated regularly and attended events together over the last four years. Jacob calls himself the “Governor's Buddy.”
The new law requires coverage for speech, occupational and physical therapy, as well as pharmaceutical care for the treatment of autism. No visit or dollars are imposed on those services.
Behavioral health treatment, however, was cappedat25 hours per week andinsurers will be ableto reviewtreatment plans every six months.Certain state-regulated group and individual health policies, as well as state employees, will be covered.
In addition to Nebraska, Utah has enacted autism insurance reform in 2014 and Kansas expanded its 2010 law, which was limited to state employees, tocover its kids with autism. Similar bills remain active in Hawai'i and North Carolina, and legislation that would raise Maine's age cap from 5 to 10 was just sent to the Governor.
Washington employees accuse aerospace giant of Mental Health Parity violations
(APRIL 20, 2014) --Aerospace giant Boeinghas been hit with a complaint in federal court by its Washington state employees who claim the company's denial of insurance coverage of applied behavior analysis (ABA) for their children withautism violates thefederal Mental Health Parity Act. Filed by two families whose sons have autism, "C.S." and "D.Z.",the suit seeks certification as a class action on behalf of Boeing's 81,000 Washington-based employees.
Listed #30 on the Fortune 500 list as the nation's largest aerospace and defense firm, Boeing reported earning $3.9 billion in profits last year on $81.7 billion in revenues. Headquartered in Chicago, half of Boeing's employees are based in Washington. The suit was filed in U.S. Dstrict Court in Seattle.
The case has added significance because Boeing self-insures its employee health plan and therefore isregulated under federal ERISA lawwhich is immune from state autism insurance reform laws, such asthe law in its headquarters state of Illinois. The suit was filed bySeattle attorneys Ele Hamburger and Richard Spoonemore who have been winning a series of similar federal class action suits in Washington over ABA denials. The complaint alleges Boeing's denial of ABA benefits violates the 2008 Wellstone Domenici Mental HealthParity and Addiction Equity Act as well as its fiduciary responsibilities under ERISA.
Boeingdoes not expressly exclude ABA coverage in its health plan, but ratherhas its claims administrators exclude all coverage of ABA therapy through internal policies and restricted provider networks, the complaint alleges.
Boeing's non-mental health claims administrator, Blue Cross Blue Shield of Illinois (BCBSIL), excludedABA therapy coverage.When a Boeingemployeeoverturned thedenial,according to the complaint,Boeingdirected BCBSIL to classify ABA therapy as a mental health service to be administered by Value Options, which administers Boeing's mentalhealthclaims.
Boeing directed Value Options to limit its provider network in Washington state to exclude licensed ABA agencies, the plaintiffs assert.
"The effect of Boeing/Value Option's failure to include in its network any licensed ABA agencies in Washington state is the same as a blanket exclusion," according to the complaint."It is impossible for plaintiffs and the proposed class to obtain coverage for the ABA therapy services they need because Boeing will not contract with any providers who can deliver it."
The Mental Health ParityActdoesnotrequire Boeing to cover mental health services; rather it requires employers if they do choose to provide mental health coverage -- as the Boeing plan does-- to cover the benefits“at parity” with medical benefits.ERISA requires Boeing to abide by the Mental Health Parity Act and other regulation in administering its plan.
"By applying a blanket, hidden exclusion of ABA therapy to treat (autism), in violation of the Parity Act and its regulations, Boeing is systemically and uniformly failing to properly administer its Plan," according to the complaint. "It is alsobreaching its fiduciary duties to plaintiffs and class members, who have not received the benefits to which they are entitled."
The suit seeks a court order stopping Boeing from denying ABA coverage in its health plan and requiring reimbursement for past claims
This lawsuit seeks remedies for Boeing's breach of fiduciary duty under ERISA and its failure to properly administer the terms of Plan, as modified by the Parity Act and its implementing regulations. It further seeks to recover the benefits that have been wrongfully denied to plaintiffs and the class they seek to represent. It also seeks a court order declaring Boeing's exclusion of coverage for ABA therapy to treat ASD through a restricted network of providers void and unenforceable. The lawsuit further seeks an injunction to prevent any future or ongoing efforts by Boeing to use and enforce any blanket exclusions of ABA therapy to treat ASD.
The class consists of all individuals who have been, are, or will be Washington state participants or beneficiaries under The Boeing Master Welfare Plan that have been, are or will be in effect or renewed
Denials followed by delays prompts new regulatory enforcement
(April 17, 2014) -- The California Department of Insurance has won the go-ahead to enforce toughnewrequirements to stop private insurers from denying and delayingcoverage forbehavioral health treatments, such as applied behavior analysis (ABA), for autism.
The department based the new regulations on its interpretation of the state's 1999 Mental Health Parity Actand won approval Wednesday from the Office of Administrative Lawto begin enforcement. California is one of 35 states to require certain commercial insurers to cover behavioral health and other treatments for autism by law, yet still encounters widespread non-compliance by the industry.
"Approval of the mental health parity regulation will help end improper insurer delays and denials of medically necessary treatments for autistic individuals," said Insurance Commissioner Dave Jones. "This regulation provides clear guidance to the industry, stakeholders and consumers on the requirements of the Mental Health Parity Act from 1999."
The department proposed the newregulations when it found insurers were able to delay or deny medically necessary treatment for individuals with autism as required under California's 2011 auitism insurance reform law. The regulations further define the circumstances in which insurers must cover behavioral health treatment by specifically applying the requirements under the Mental Health Parity Act.
Since 2009, the Insurance Departmenthas referred23 cases related to denials of behavioral health and other autism treatment to external clinicians for Independent medical review. Of those, 19were overturned.
In another 40 cases that have been closed, the individual delays in obtaining treatment averaged nearly half a year; delays currently average over 10 months, or almost a year, for those cases which are still open. The cumulativedelays on open and closed casestotal 12,864 days, or 35.2 years.
"These lengthy delays all involve treatment that experts agree is most effective when provided in early childhood," the department argued in its regulatory proposal. "The benefits anticipated from the proposed regulation include significantly lessening or eliminating these delays and denials of treatment and substantially improving treatment efficacy and outcomes."
Gov. Brownback enacts law making Kansas 10th state to expand coverage
OVERLAND PARK, KS(April 16, 2014) -- Governor Sam Brownback today signed legislation expanding autism insurance coverage beyond the state employee health benefit program, culminating a six-year campaign to enact more meaningful reform in Kansas. Enactment of the law also made Kansas the 10th state to amend its original autism insurance law to make it stronger.
“Autism Speaks applauds Governor Brownback's support of the autism community," said Mike Wasmer, a Kansas resident who serves as Autism Speaks' director of state government affairs. "This bill is an important step toward providingaccess to medically necessary treatment for allindividuals with autism in Kansas.”
Sponsored by Rep. John Rubin (R-Shawnee), the new law,HB.2744, will require state-regulated large group and "grandfathered" small group individual health plans to cover medically necessary treatments, including applied behavior analysis (ABA), for autism for children up to age 12.
The bill as initially proposed by the House Insurance Committee would have limited ABA coverage to 10 hours per week, but was raised after vigorous opposition from the state's autism community. As enacted, the new law allows for 25 hours per week of ABA for four years from the time of diagnosis and then reduces to 10 hours per week.
The new law is spearate from the state's 2010 autism insurance reform law which applies only to state employees. The 2010 legislation when introduced would have covered the private market, but was amended into a pilot program limited to state employees to gauge the impact on health care costs. When the 2010 law was enacted, Wasmer, then president of the Kansas Coalition for Autism Legislation (KCAL), said, "This is not the end, but rather the start of getting autism treatment to all in need in the state of Kansas."
After being judged a success, the program was made permanent for state employees, but Kansas lawmakers continued to resist efforts to expand the coverage to the private market. In 2012, efforts to force a bill out of a committee fell one vote shy of success.
After Rubin introduced a bill this year that would have provided broader coverage, the insurance lobby filed a second version with much more restrictive terms and would have cut back existing benefits for state workers. After heated opposition from the state's autism community, HB.2744 was introduced as a compromise measure.
Wasmer said the new law marks a step forward, but that efforts will continue to provide the best coverage for the most children. The existing state employee autism benefit will continue unaffected by the new law.