Seven years after families began asking the Oregon Insurance Division to intervene on their behalf, the state’s insurance regulator announced today it will issue a formal bulletin, clarifying that insurers cannot refuse to cover a costly therapy for autistic kids called Applied Behavior Analysis.
The decision comes a week after a federal judge ruled that the Providence Health Plan broke federal and state law by denying coverage for the treatment.
Since 2007, families have won more than 20 appeals to Independent Review Organizations after insurers failed to pay for ABA, which for more than a decade has been considered medically necessary, effective and the national standard of care to treat children with autism.
In 2013, a senior analyst in the division drafted a policy memo that echoed the argument of insurance companies: covering ABA treatment is not required by law. He then shared that draft with industry executives. That position was later adopted by Gov. John Kitzhaber’s heath care advisor Sean Kolmer, says Paul Terdal, the father of two autistic children. Terdal met repeatedly with Kolmer in his campaign to get the state to force insurers into compliance.
But Terdal says Kolmer did not help. Kolmer declined to be interviewed.
Terdal applauds the insurance division's directive.
“It’s great. I’m really glad [Insurance Commissioner Laura] Cali is moving forward with this. It’s time. Let’s go,” Terdal says. “What’s going to be tricky, she’s now going against the governor’s office. Because the [Public Employees' Benefit Board] is now doing exactly what Providence has been doing. So they are pretty exposed."
Gov. John Kitzhaber says he's prepared to adjust the state's health plans to reflect his insurance division policy.
"I support the Oregon Insurance Division providing clarity to families and providers on insurers’ responsibility to cover this treatment for autism," he tells WW through spokeswoman Melissa Navas. "Once the insurance division's work is done, I expect PEBB will review the bulletin and adjust plans to achieve consistency."