Pennsylvania Governor Acts on Insurance

 The Politics of Autism includes an extensive discussion of insurance and Medicaid services.

 A release from Governor Josh Shapiro:

Today, Governor Josh Shapiro and Pennsylvania Insurance Department (PID) Commissioner Michael Humphreys announced that starting on January 1, 2024, the Shapiro Administration will require all commercial insurers to meet their obligations under Pennsylvania law to provide coverage for autism benefits.

The PID published a Notice in the Pennsylvania Bulletin on November 4, 2023 announcing that by no later than January 1, 2024, PID will require insurers offering commercial health insurance policies that include coverage for autism services to handle claims for those services in a manner that complies with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Pennsylvania’s mental health parity requirements.
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The Shapiro Administration is working to make mental health parity a true reality in Pennsylvania – and part of making this a reality includes requiring that commercial insurers comply with all mental health parity laws to cover autism services fairly and consistently. With this action, the Shapiro Administration will require those insurers to fully comply with parity requirements in administering autism coverage, which means recognizing that autism services are mental health benefits.

Some commercial insurers have historically categorized autism services as a physical health benefit while other insurers categorize all services for autism as mental health benefits. Most of the major health insurers offering comprehensive health insurance in Pennsylvania already treat autism as a mental health condition, subject to parity requirements. PID’s Notice directs the remaining insurers to do the same.

In his first budget address, Governor Shapiro called for stronger mental health parity and directed Commissioner Humphreys and the PID to hold insurers accountable to ensure that mental health benefits are covered fairly. As a result, PID announced that it has strengthened its review of mental health and substance use disorder coverage in 2024 health plans and will enhance its compliance review of mental health and substance use disorder parity requirements to prevent potential violations before they have a chance to harm Pennsylvania consumers.

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Categorizing autism as a mental health benefit will make a positive impact on the approximately 55,000 Pennsylvanians with autism by requiring health insurers to adjust their insurance policy form language and claims handling processes to provide Pennsylvanians with autism the protections afforded by the mental health parity provisions. As a result, health insurers may not: charge higher copays or deductibles for autism services than for physical health services, cover fewer autism service visits than they would for other health conditions, impose an annual limit for autism services, as well as other safeguards afforded by state and federal parity laws.

“Parity between coverage for autism-related care and other services has long been a goal of the disability community,” said Rep. Jessica Benham. “I am grateful to Governor Shapiro and his Administration for prioritizing this change, which is a step in the right direction toward ensuring greater access to care for individuals with developmental disabilities.”

Drexel University’s A.J. Drexel Autism Institute is a partner of the Commonwealth’s ASERT (Autism Services, Education, Resources & Training) Collaborative, which is funded by the Pennsylvania Department of Human Services’ Bureau of Supports for Autism and Special Populations. The mission of the ASERT Collaborative is to innovate, collaborate, and lead to improve access to quality services, data, and information; to provide support, training and education in best practices; and to facilitate the connection between individuals with autism, developmental disabilities, and special populations, families and key stakeholders at local, state, and national levels.

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Eagles Autism Foundation Executive Director Ryan Hammond joined the Shapiro Administration and the A.J. Drexel Autism Institute for the announcement. The Eagles Autism Foundation helps to fund innovative research, drive scientific breakthroughs, and provide critical resources to create a major shift from awareness to action in the autism community.

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PID believes that treating autism as a mental health condition is consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, which was in effect at the time of enactment of Act 62 of 2008, state and federal MHPAEA laws, as well as generally recognized independent standards of current medical practice, including both the current edition of the DSM and the current edition of the International Classification of Diseases, as recognized in the federal mental health parity regulatory definition of “mental health benefit.” The DSM is the authoritative source under Pennsylvania’s autism law, Act 62.

Pennsylvania law requires coverage of the diagnostic assessment and treatment of autism spectrum disorders by certain group insurance policies or contracts. Through the Affordable Care Act, that law also applies to individual and small group policies. The Department has monitored the coverage of autism services, including whether they have been covered as a mental health condition subject to the federal MHPAEA law that was adopted into state law in 2010.

For support with insurers, Pennsylvanians can contact PID’s Consumer Services Bureau online or at 1-877-881-6388. For more information on the Shapiro Administration’s commitment to supporting Pennsylvanians with autism, visit pa.gov/autism.

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ABA and Military Families

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  As many posts have discussed, the challenges are especially great for military families.

Dr. Kristi Cabiao, CEO and president of Mission Alpha Advocacy, at Military Times:

ABA is a primary intervention for autism spectrum disorder; it is delivered by a behavior analyst involving multiple sessions several times a week over months or years. In commercial health plans, it’s considered a mental health service and is protected through the Mental Health Parity and Addiction Equity Act, or MHPAEA, of 2008.

The 2022 Report on MHPAEA to Congress by the Departments of Labor, Health and Human Services, and of the Treasury found egregious violations of the parity law regarding ABA services for autistic individuals. This report was not a surprise to the autism community. But the often-overlooked tragedy is that this federal protection does not apply to military families receiving ABA. The ABA services provided by Tricare are exempt from the MHPAEA laws, and military families are paying the cost.

MHPAEA prohibits health policies placing high co-payments, separate deductibles, and stricter pre-authorization or medical necessity reviews compared to other medical treatments covered by the plan. The Department of Defense policies guiding Tricare oversight of ABA services have clear examples of MHPAEA violations.

Parents seeking ABA services for their children must undergo stress assessments every six months to receive authorization for ABA. This mandate for parent stress assessments does not apply to any other population within the military healthcare system. Now, imagine this exact policy applied to children receiving insulin for diabetes. Children would be denied medically necessary treatment due to the parent’s noncompliance. Mandating parent stress assessments in order to receive ABA is a violation of MHPAEA.

Enforcement of Mental Health Parity Law

The Politics of Autism includes an extensive discussion of insurance and  Medicaid services for adults with intellectual and developmental disabilities.

In his State of the Union last night, President Biden said: "And let’s get all Americans the mental health services they need. More people they can turn to for help, and full parity between physical and mental health care. "

Katie O'Connor at Psychiatric News:

Federal agencies are using recently gained authority to crack down on health plans that are not complying with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. A recent report to Congress outlines the enforcement work that has been done so far and illustrates the extent to which many plans are out of compliance, potentially cutting off thousands of people from the mental and substance use disorder treatments they need.

The report was issued by the departments of Labor (DOL), Health and Human Services (HHS), and Treasury as a requirement of the Consolidated Appropriations Act (CAA), which was enacted in December 2020 and included APA’s priority legislation, the Strengthening Behavioral Health Parity Act. The CAA amended MHPAEA to require health plans to perform and document comparative analyses of their non-quantitative treatment limits (NQTLs), which are the elements of a health plan’s coverage that are not numerical, such as prior authorization and formulary design.

NQTLs have, historically, been difficult to identify, and it is challenging for federal and state agencies to determine whether plans’ NQTLs comply with the parity law (Psychiatric News). The comparative analyses are vital for parity enforcement: Before the CAA, plans were not explicitly required to demonstrate and document that their NQTLs complied with the parity law, which was a major roadblock for enforcement.

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The report includes several examples of enforcement leading to expanded access. EBSA discovered that a large service provider of self-funded plans was excluding applied behavior analysis (ABA) treatment for children with autism spectrum disorder. ABA “can improve the trajectory of a child’s development,” the report noted. After issuing requests for comparative analyses and initial findings of noncompliance to some of those plans, three health plans confirmed that they will now cover ABA therapy for autism, impacting over 18,000 plan participants. [See page 21 of the report.]

ERISA and Autism

The Politics of Autism includes an extensive discussion of insurance.  

Sixty-one percent of Americans with employer-sponsored health insurance are in a self-funded plan, in which the employer takes direct financial responsibility for enrollees’ medical claims. Employers that self-fund typically contract with an insurance company to run the plan. Workers then get cards that bear the name of the insurance company and often look just like those from a traditional plan, so many do not even know that they are in a self-funded plan. Most of the time, the distinction makes little difference -- unless the employees are seeking coverage for a family member with autism. The catch is that the state mandates do not apply to self-funded plans. A federal law (the Employee Retirement Income Security Act of 1974, or ERISA) exempts self-funded plans from most state insurance laws, including mandated benefits.

Peter Felsenfeld at JD Supra:

The extent to which a health plan may exclude coverage for mental health treatment modalities has become an active area in ERISA litigation. In Doe v. United Behavioral Health, 2021 U.S. Dist. LEXIS 43146 (N.D. Cal. March 5, 2021), a California federal court held that a plan that covers autism may not exclude specific treatments for the condition.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (the Parity Act) (29 U.S. C. § 1185a), which seeks to eliminate disparities in health insurance coverage for mental health as compared to other medical or surgical conditions, lays the groundwork for this case. The Parity Act requires group health plans to provide the same aggregate benefits for mental healthcare and substance abuse treatment as they do for medical and surgical benefits.

Doe concerned an employer-sponsored and self-funded group health plan governed by ERISA (the Plan). The employer determined the terms of the Plan and, among other things, explicitly covered autism but excluded coverage for "Intensive Behavioral Therapies such as Applied Behavior Analysis for Autism Spectrum Disorders." 

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First, the court held that Section 1185a(b)(1) allows plans not to cover mental health services at all, but if a plan elects to do so, “the Parity Act prohibits imposing treatment limitations applicable only to mental health benefits.” Thus, the court held, having elected to cover autism, the Plan could not impose a treatment limitation that applied only to that condition. Second, the court held that the “permanent exclusion of all benefits for a particular condition or disorder” language in Section 2590.712(a) means that a plan may exclude coverage for an entire condition (e.g., autism), but not specific treatments within that condition. Accordingly, the court held that the Plan’s exclusion of Applied Behavior Analysis treatments “[o]n its face . . . creates a separate treatment limitation applicable only to services for a mental health condition (Autism). By doing so, the exclusion violates the plain terms of the Parity Act.”

The Health of Autistic People

The Politics of Autism discusses health care, and explains that autism services can be complicated, creating difficulties for autistic people and their families. 

From Drexel University:

In the recently published sixth report in the National Autism Indicators Report series, researchers from Drexel University’s A.J. Drexel Autism Institute highlight a holistic picture of what health and health care look like across the life course for people on the autism spectrum.

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Researchers found when parents were asked about whether their child had certain health conditions, children with ASD had higher rates of every single condition except for asthma, compared to other children with special health care needs. Conditions included learning disability, behavior or conduct problems, attention deficit hyperactivity disorder (ADHD), speech or language disorder and anxiety.

Similarly, in another set of data, adults with ASD had higher rates of many conditions than a random sample of other adults. Adults with ASD were two to three times as likely to have depression or anxiety, compared to adults without ASD and were also far more likely to have hypertension, epilepsy, ADHD, bipolar disorder or schizophrenia.

When it comes to paying for the health care, almost half (46%) of parents of children with ASD reported that their child’s insurance did not always cover the services they needed. One-fifth of parents of children with ASD reported avoiding changing jobs because of concerns about maintaining health insurance for their child – five times the rate of parents of children with no special health care needs.

Because of the complexity of care, parents either sought help or felt they needed more help with coordinating health care. Of parents whose child with ASD had more than one health care appointment in the past 12 months, 28% reported someone helped coordinate or arrange care among different providers, similar to parents of children with other special health care needs. Another 30% of parents of children with ASD reported they could use more help coordinating care – more than parents of other children with special health care needs.

Democratic Platform on Disabilities

In The Politics of Autism, I discuss the issue's role in presidential campaigns.

From the 2020 Democratic Platform:

One in four American adults live with a disability. Democrats believe people with disabilities deserve to lead full, happy, and healthy lives. Democrats will fully enforce the Americans with Disabilities Act, the Individuals with Disabilities Education Act, the Fair Housing Act, the Civil Rights of Institutionalized Persons Act, Section 504 of the Rehabilitation Act, the Mental Health Parity and Addiction Equity Act, and the Help America Vote Act, among other bedrock statutes protecting the rights of people with disabilities. We will oppose any efforts to weaken enforcement of the Americans with Disabilities Act. We will ensure non-discrimination in access to health care, building on the protections for people with disabilities enshrined in the Affordable Care Act. We will ensure every federal agency aggressively enforces the integration mandate affirmed in the Olmstead decision, and repair the damage done by the Trump Administration.
We will rigorously enforce non-discrimination protections for people with disabilities in health care, employment, education, and housing, and ensure equal access to the ballot box.

Democrats are committed to supporting the millions of Americans on the autism spectrum and their families. We will expand early childhood screening, particularly in underserved communities, and promote equitable treatment of students on the autism spectrum in schools and educational settings, in keeping with our commitment to providing equal educational opportunities for students with disabilities. By eliminating state waiting lists for home and community-based care, ending the institutional bias in Medicaid, and expanding support for informal caregivers, Democrats will enable more individuals with autism to receive the support they need in their homes and communities.

Democrats will phase out the subminimum wage, expand competitive, integrated employment opportunities, and protect and strengthen economic security for people with disabilities. We will take a holistic approach to the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs that are essential for millions of Americans with disabilities by increasing SSI benefits, eliminating waiting periods for SSDI, and eliminating the “benefit cliff” for SSDI benefits. We will increase federal funding to expand accessible transportation and accessible, integrated, and affordable housing. We will protect people with disabilities in emergencies and meet the needs of travelers with disabilities. We will ensure new technologies benefit, and are affordable and accessible for, people with disabilities. We will expand access to tax-advantaged ABLE savings accounts, which provide people with disabilities a way to pay for disability-related expenses like housing, education, and transportation. And Democrats will improve access to home- and community-based care for people with disabilities and older Americans, including by enforcing the Medicaid Home and Community-Based Settings Rule, ending the institutional bias within Medicaid, and expanding the home care workforce to end state waiting lists for long-term services and supports.

Pennsylvania Penalizes United Healthcare

The Politics of Autism includes an extensive discussion of insurance.

A November 4 release from the Pennsylvania Insurance Department:

Insurance Commissioner Jessica Altman today released a market conduct examination report on the practices and procedures of UnitedHealthcare Insurance Company. Based on violations of the Mental Health Parity and Addiction Equity Act (MHPAEA) and other violations contained in the report, UnitedHealthcare has agreed to develop an $800,000 public outreach campaign to educate consumers about their mental health and substance use disorder benefits. The company has also agreed to pay restitution to consumers from claims wrongly denied, overpaid out-of-pocket expenses, and interest on delayed claims. The department levied a $1,000,000 civil penalty for violations found during the examination.

The report, which covers the period from January 2015 through March 2016, found extensive noncompliance with mental health parity and prompt pay laws, as well as concerns with the company's coverage for services relating to autism spectrum disorders and substance use disorders. The examination also covered company operations, handling of consumer complaints, and policyholder services.

"Market conduct examinations provide the department with an opportunity to review a company's practices and procedures, including its compliance with laws requiring parity of coverage for substance use disorders and mental health," Altman said. "The violations within this area were very disappointing as they negatively affected some of our most vulnerable populations."

The department is conducting similar comprehensive market conduct examinations, emphasizing mental health and substance use disorder parity, on all of Pennsylvania's major health insurers, to ensure all Pennsylvania health insurers are in compliance with state and federal law. Previous examination reports were issued to Blue Cross of Northeast Pennsylvania in early 2018 and Aetna in early 2019.

In addition to the mental health and substance use disorder parity violations, the Insurance Department noted the following, among others:

• Inaccurate calculation of consumers' total out-of-pocket costs for autism claims.
• Delayed payment and improper handling of claims. The law requires all uncontested claims and uncontested portions of contested claims be paid within 45 days of receipt.
• Delayed responses to consumer complaints.

UnitedHealthcare has been ordered to address many of the violations through changes in company practices and procedures, and the Insurance Department will be verifying that these corrective actions have taken place through a reexamination process. The department also acknowledges the company has been cooperative in its response to the violations.

"As a result of this report, UnitedHealthcare will improve its procedures to help consumers make better informed decisions about their coverage and their care," Altman said. "The results of this examination will also help the department in its ongoing oversight of the company and ensure that consumers are receiving the benefits they are entitled to under law."

The Mental Health Parity and Addiction Equity Act of 2008 requires health insurance plans to contain equivalent levels of coverage for mental health and substance use disorder care as for medical or surgical care. This coverage includes quantitative limitations (copays, deductibles, and limits on inpatient or outpatient visits that are covered) and non-quantitative limitations (pre-authorizations, providers available through a plan's network, and what a plan deems "medically necessary"). The federal law was incorporated into Pennsylvania law in 2010 through Act 14.

Currently, parity for mental health and substance use disorder coverage is required for individuals with the following health plans:

• Individual and small group health plans, as required by the Affordable Care Act;
• Large group health insurance plans which offer substance use disorder and mental health coverage. Fully insured plans are required to offer this coverage under Pennsylvania Act 106;
• Children's Health Insurance Program (CHIP) and Medicaid Managed Care.

The Insurance Department reviews all individual, small group, and large group policies to ensure those policies contain all state and federal policy requirements, including mental health and substance use disorder parity. However, the Insurance Department has found even in policies containing language meeting all requirements a lack of appropriate administrative oversight or other operational problems have led to mishandling of these important consumer protections.

Consumers who believe their health plans are not in compliance with parity requirements for mental health and substance use disorder coverage, or who have questions about the benefits to which they are entitled, are urged to contact the Insurance Department's Bureau of Consumer Services.

Find more information on substance use disorder and mental health coverage here. More information and videos on parity can be found here.

Insurance in North Dakota

The Politics of Autism includes an extensive discussion of insurance.

Helmut Schmidt at The West Fargo Pioneer:

All insurance companies doing business in North Dakota will soon be required to provide coverage for autism spectrum disorders, the state insurance commissioner announced Wednesday, July 11.

A bulletin was issued Wednesday to insurers telling them that treatments for autism can’t be excluded from their policies, Commissioner Jon Godfread said in a news conference at the North Dakota Autism Center.

Coverage must be in place by Oct. 1 for policies “grandfathered in” under the Affordable Care Act, Godfread said. Coverage for policies purchased on the open market must be available by Jan. 1.

“Today’s a great day!” Godfread said, adding that insurance carriers “are being very cooperative.”North Dakota is the 48th state to require insurance coverage for autism spectrum disorders, said Lorri Unumb, vice president for state government affairs for the national group, Autism Speaks. Only Wyoming and Tennessee don’t require such coverage, she said.

From Autism Speaks:

The insurance bulletin also carries national precedence in clarifying that state-regulated insurance companies should be covering autism treatments under existing federal mental health parity law. Autism Speaks Vice President of State Government Affairs, Lorri Unumb, praised Insurance Commissioner Jon Godfread, noting that "laws are in place to prohibit the kinds of exclusions autism families routinely face; Commissioner Godfread had the guts to issue a bulletin and insist on compliance with the existing law."

 KFGO-AM reports:

In addition, Godfread notified insurance carriers in the Bulletin that they will no longer be allowed to exclude Applied Behavior Analysis (ABA) therapy to treat children with autism on the basis that ABA therapy is experimental or investigative treatment.

“Working with our partners at the federal level and with health insurers operating in North Dakota, we can now say that ABA therapies are no longer experimental or investigational and are widely recognized as a leading treatment for children with autism. Therefore, North Dakota families should have access to ABA therapies through their insurance plan” Godfread said.

All grandfathered and transitional health insurance policies regulated by the Department, including the individual, small group, and large group insured markets, must follow the guidance set forth by the Bulletin beginning no later than Oct. 1, 2018. All non-grandfathered health insurance policies and self-funded Multiple Employer Welfare Arrangement health benefit plans regulated by the Department must follow the guidance of the Bulletin beginning no later than Jan. 1, 2019.

For more information or to read the Bulletin in its entirety, visit www.nd.gov/ndins/.

BUT NOTE MY PREVIOUS POST ON THE LIMITS OF STATE INSURANCE MANDATES 

Effects of Insurance Mandates

The Politics of Autism includes an extensive discussion of insurance and the regulation of autism service providers.

Colleen L. Barry, Andrew J. Epstein, Steven C. Marcus, Alene Kennedy-Hendricks, Molly K. Candon, Ming Xie, and David S. Mandell have an article at Health Affairs titled "Effects Of State Insurance Mandates On Health Care Use And Spending For Autism Spectrum Disorder."

The abstract:

Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for mandates to children not subject to mandates using 2008–12 claims data from three national insurers. Increases in service use and spending attributable to state mandates were detected for all outcomes. Mandates were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services. Effects were larger for younger children and increased with the number of years since mandate implementation. These increases suggest that state mandates are an effective tool for broadening access to autism treatment under commercial insurance.

From a release by the Johns Hopkins University Bloomberg School of Public Health:

"The hope of patient advocates and policymakers was that these insurer mandates would increase care for children with autism, and they seem to have done that—in fact, the impact was even larger than we had expected," says Colleen L. Barry, PhD, MPP, the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management at the Bloomberg School.

The results, Barry adds, are important for states that have enacted such mandates to understand their impact, and also helpful for states considering whether to broaden mandates that are already in place. Barry is also affiliated faculty with the Johns Hopkins Wendy Klag Center for Autism and Developmental Disabilities at the Bloomberg School.

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Recent federal laws including the Affordable Care Act have introduced nationwide coverage mandates, including "parity" mandates requiring that coverage of mental health care be equal to coverage of general health care. But how closely these regulations apply to behavioral therapies for ASDs is still being debated—even litigated—among insurers and patient advocacy groups.

"Concern that children with autism were not able to access services through private insurance even in the context of parity laws was one reason why patient advocates have pushed for these state mandates that apply specifically to autism coverage," Barry says.

Dangers of Trumpcare

In The Politics of Autism, I discuss Medicaid services for people with intellectual and developmental disabilities. 

A release from the University of Pennsylvania 

The potential repeal of the Affordable Care Act (ACA) threatens to eliminate critical mental and behavioral health services for people living with autism and other disabilities. Several public health insurance programs and mandates that were protected or extended by the ACA, including Medicaid, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), and the Individuals with Disabilities Education Act (IDEA), are now at risk of being negatively altered or removed, posing a serious threat to the health and well-being of children and adults with disabilities according to a new perspective paper published by researchers in the Perelman School of Medicine and the Johns Hopkins Bloomberg School of Public Health. 

Medicaid is the single largest health care payer for people with autism or developmental disabilities, covering services for approximately 250,000 children with autism in 2013 alone. A repeal of the ACA would eliminate the recent Medicaid expansion, thereby limiting paid services for millions of individuals, many of whom have disabilities.

The paper, authored by David S. Mandell, ScD, a professor of mental health services in the department of Psychiatry and director of the Center for Mental Health Policy and Services Research in the Perelman School of Medicine at the University of Pennsylvania and Colleen L. Barry, PhD, MPP, Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, is published this week in the New England Journal of Medicine.

“We believe it is essential that the scientific community and autism advocates call for the use of evidence to guide policy in this area,” the researchers wrote. “Such a principle would bring needed resources where they are most important, strengthening efforts to support people with autism and other disabilities.”

Mandell and Barry also draw attention to the threats posed to children with autism and other disabilities by defunding the traditional public school system and not enforcing the Individuals with Disabilities [Education] Act, which guarantees children with disabilities the right to a free and appropriate public education. They note that Attorney General Jeff Sessions and Secretary of Education Betsy DeVos both have made statements indicating their intent to change or not enforce these programs and associated regulations.

The authors also point to recent events in which political figures used their platforms to give credence to disproven theories about autism. Mandell and Barry suggest that public comments from President Trump and others about the connection between vaccines and autism are distractions from the real events that are putting children with disabilities in peril.

“Talking about the thoroughly disproven connection between vaccines and autism is a red herring.” Mandell said. “If the current administration really cares about children with disabilities, they will strengthen the programs that safeguard their health and well-being, not tear them apart.”

Keep an Eye on the Affordable Care Act

The Politics of Autism includes an extensive discussion of insurance issues, including the impact of the Affordable Care Act.

At NPR, Michelle Andrews reports:

Since the 10 required benefits are spelled out in the Affordable Care Act, the law would have to be changed to eliminate entire categories or to make them less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate to do that, they will be limited in changes that they can make to the ACA. Still, there's room to "skinny up" the requirements in some areas by changing the regulations that federal officials wrote to implement the law.

Habilitative services

The law requires that plans cover "rehabilitative and habilitative services and devices." Many employer plans don't include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills, via speech or occupational therapy or other support services. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services. Those rules could be changed.

"There is real room for weakening the requirements" for habilitative services, says Dania Palanker, an attorney and assistant research professor at Georgetown University's Center on Health Insurance Reforms, who has reviewed the essential health benefits coverage requirements.
...
Mental health and substance use disorder services

The health law requires all individual and small group plans to cover mental health services and treatments for substance use disorders. In the regulations, the Obama administration said that means those services have to be provided at "parity" with medical and surgical services, meaning plans can't be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.
"They could back off of parity," Palanker says.

Impact of the Mental Health Parity and Addiction Equity Act

The Politics of Autism includes an extensive discussion of insurance.

A release from the Johns Hopkins Bloomberg School of Public Health:

A federal law aimed at requiring equal insurance benefits for both physical and mental health care has increased the use of services by children with autism spectrum disorder without increasing the out-of-pocket costs to their families, new Johns Hopkins Bloomberg School of Public Health-led research suggests.

The increases in health care utilization are admittedly modest. For example, study findings indicate that the Mental Health Parity and Addiction Equity Act of 2008 was associated with an increase in spending on health care services for a child with autism spectrum disorder of only $73 in the first year following its implementation. But the results are still encouraging, researchers say, since the intent of the law was to remove restrictions on mental health treatment, which insurers have historically covered less generously than other types of medical care.

The findings appear in the February issue of Health Affairs.

“We found that kids with autism spectrum disorder are getting more services but their families don’t have to pay more to get them, which is the basic point of having health insurance and why the parity law was passed by Congress,” says the study’s lead author Elizabeth A. Stuart, PhD, a professor in the departments of Mental Health, Biostatistics and Health Policy and Management at the Bloomberg School. “In the past, these families likely would have had to pay more out of their own pockets to get more care and they are already paying an average of $1,250 to $1,500 a year out-of-pocket to cover treatments and therapies for their children.”

“Where parity makes a difference,” says Colleen L. Barry, PhD, MPP, professor and chair of the Department of Health Policy and Management at the Bloomberg School and senior author of the study, “is along this dimension of financial protection for families. These are kids with serious and expensive health care needs and the parity law is helping. At the same time, parents and consumer advocates might have hoped the law would make a larger difference in access to treatment for autism paid for by commercial insurance.”

Autism spectrum disorder is a neurobehavioral syndrome defined by the presence of repetitive behaviors and the disruption of development of social and language abilities. Over the past several decades, the prevalence of autism spectrum disorder has jumped. In the 1980s, it was believed to occur in five of every 10,000 children (0.05 percent). Today, the estimate is that it affects one in 68 children (1.5 percent). Treatment can improve communication skills, address behavioral challenges, and help manage psychiatric disorders that many children with autism spectrum disorder also experience.

The mental health parity law was designed to eliminate discrimination in insurance coverage offered for people seeking treatment for mental illness and addiction, conditions that tend to be costly to treat. While the law requires equivalent treatment, it doesn’t spell out exactly what disorders must be covered. Autism is not explicitly listed as a covered condition under the law and the researchers wanted to see whether children with the disorder were benefitting from the new law. There have been legal cases alleging non-compliance with the law and autism has been one of the disorders involved in litigation.

For the study, the researchers used the Truven Health MarketScan Research Database from the period 2007 to 2012, a database that includes health insurance claims and health care appointments for employees and their dependents from roughly 100 large employers and health plans in the United States, totaling 15 to 22 million enrollees per year. The study included children through age 18 with at least two insurance claims in a calendar year with a primary diagnosis of autism.

The researchers examined various health care services, from mental health visits to speech and language therapy to occupational therapy.

They found a modest increase in the utilization of health care services among children with autism spectrum disorder, comparing trends in the outcomes during the period before parity to trends in the period after. For example, in the first year following parity, this translated into 1.6 additional mental health visits per year, 0.4 additional speech and language therapy visits per year and 0.7 additional occupational and physical therapy visits per year among children using those services.

Children under the age of 12 were most likely to experience increases in the use of services. Barry says the absence of changes following the law among adolescents with autism spectrum disorder is concerning.

“It is not the case that the need for evidence-based treatment disappears once a child hits their teen years,” Barry says. “We know that autism spectrum disorder affects individuals across their life-span, and access to services can make a difference through the high school years and beyond.”

The researchers speculated that one reason that the parity law did not make a difference for adolescents was that often providers only treat younger patients with autism spectrum disorder and locating treatment options can be challenging for older patients, even when private insurance coverage is available.

In addition, the researchers say that more attention to enforcement of the parity law might be needed to ensure that the law is achieving its potential to connect children with autism spectrum disorder with the services they need. “Monitoring and enforcement of the parity law has been a persistent concern,” Stuart says.

“Increased Service Use Among Children With Autism Spectrum Disorder Associated With Mental Health Parity Law” was written by Elizabeth A. Stuart, Emma E. McGinty, Luther Kalb, Haiden A. Huskamp, Susan H. Busch, Teresa B. Gibson, Howard Goldman and Colleen L. Barry.

The study was supported by the National Institutes of Health’s National Institute of Mental Health (MH093414).

Autism Law Summit

At the Autism Law Summit, Judith Ursitti just gave a terrific presentation on housing.  Here are some of the links that she mentioned:

• Massachusetts Autism Housing Think Tank
• Autism Speaks House to Home Prize
• CLO
• Autism Housing Pathways

Michele Trivedi, who did landmark work on the Indiana insurance mandate,just did an equally terrific presentation on insurance appeals.  She emphasized the importance of the Mental Health Parity and Addiction Equity Act.

Ohio, Autism, and Mental Health Parity

At The Columbus Dispatch, Jim Siegel reports on Ohio legislation that would amend the Mental Health Parity Act to include insurance coverage for Autism Spectrum Disorders.

The Ohio Chamber of Commerce and the National Federation of Independent Business/Ohio will make Senate Bill 276 a key vote that they use to score lawmakers if amendments are added dealing with health insurance mandates for brain injuries and autism. Making it a key vote means that lawmakers who vote for the bill will get a negative score from the groups.
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The autism bill would be more costly than the brain injury mandate, [CoC spokesman Keith] Lake said, but the brain injury bill “essentially is being done to the benefit of one company.”

That company is Mentis Neuro Rehabilitation of Houston, Texas, which has testified in support of the bill and runs a facility in Stow, Ohio. The company is represented by Robert Klaffky and Doug Preisse, a pair of influential lobbyists, particularly among House Republican leadership.

Klaffky and Preisse also represent Autism Speaks, a national autism advocacy organization.

The amendments have been drafted and could be offered in the House Health Committee on Wednesday. Committee Chairman Rep. Lynn Wachtmann, R-Napoleon, said he opposes the amendments and was not sure what was going to happen with them.

The request to amend the bill appears to be coming from House leadership. Smith, the prime sponsor of the brain injury bill, said he did not advocate for the amendment. In fact, when asked if the bill is ready for passage, he said, “not at this point, in my opinion.”

Insurance in Washington State

Autism Speaks reported yesterday:

Autism Speaks welcomed Washington as the 38th state to enact autism insurance reform during the 6th annual Autism Law Summit held here today. Washington became the first state to require private insurers to cover medically necessary treatment of autism through litigation; the previous 37 states enacted specific insurance reform laws.

The Washington Autism Alliance & Advocacy (WAAA) teamed up with Seattle attorney Eleanor Hamburger in pursuing a series of successful state and federal class action lawsuits against Washington's major insurance carriers as well as the state employees health benefit plan.

WAAA Founder Arzu Forough [left] and staff attorney Mira Posner celebrate in Nashville

The most recent case, OST v Regence, led to a unanimous state Supreme Court ruling directing Regence Blue Shield, the state's largest private insurer to stop enforcing blanket exclusions for medically necessary mental health coverage, such as applied behavior analysis (ABA) for autism. Hamburger within days then announced she had reached a settlement with Regence of state and federal class action suits.

The proposed settlement would require coverage for 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.

The Supreme Court decision then prompted state Insurance Commissioner Mike Kreidler to direct all state-regulated private health plans to provide coverage in 2015 and to reconsider all claims denied since 2006 on the basis of a blanket exclusion. The order also covers new health plans sold through Washington Healthplanfinder, the state's Marketplace created under the Affordable Care Act.

The state and federal class actions were all brought on the basis that the blanket exclusions violate state and federal mental health parity law.

A Settlement in Washington State

Annie Zak reported last week at the Puget Sound Business Journal that Regence BlueShield, the largest health insurer in Washington state, settled two class-action lawsuits the previous for $6 million over its lack of coverage of ABA.

The suits, filed in federal district court and King County Superior Court by the families of children with autism, makes Regence the final health insurer among the state's three largest to get taken to court over their lack of coverage for such disabilities.The other two – Premera Blue Cross and Group Health Cooperative — also settled their cases.
According to the advocacy group Autism Speaks, Washington is one of 16 statest hat does not require insurance companies to cover behavioral treatments.

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Eleanor Hamburger, an attorney with the plaintiffs' law firm Sirianni Youtz Spoonemoore Hamburger, said she believes one reason these therapies have been neglected by many insurance companies

"A lot of these plans had an exclusion of developmental disability services, and I think this stems from this historical perspective on people with disabilities, that they can't be cured," Hamburger said. "Research has shown that interventions on people with developmental disabilities have a big impact on their lives."

Another reason contributing to the previous lack of coverage is that the Washington state's 2005 Mental Health Parity Act, while mandating coverage for mental health services, said neurodevelopmental therapies may constitute mental health services if they are "medically necessary," according to the lawsuit. That provision meant some insurers could choose not to include autism and other neurodevelopmental treatment.

Part of that $6 million will be used to create a fund for those involved in the class action suit who paid for their own treatments during the period of the lawsuits.

An Insurance Case in Oregon

In Oregon, Willamette Week reports:

Providence Health Plan failed to follow federal and state law when it for years refused to cover an intensive form of therapy for autistic children, a U.S. District Court judge ruled today in Portland.

The families of two autistic children filed suit last year after being denied coverage for the therapy, called Applied Behavior Analysis. One family was able to pay out of pocket for treatment, but the other family couldn’t afford the costly care.

“We are ecstatic,” says Keith Dubanevich, the Portland lawyer who represented the families in this case. “This is a tremendous victoryfor people with disabilities not just in Oregon but across the country. It clearly says you can’t treat autism any differently. It’s a significant decision."

The 2013 lawsuit argued that Providence violated federal and state mental health parity laws that require mental disabilities to be covered the same way physical disabilities would be covered. Providence has argued that it doesn’t have to cover the treatment because it has a developmental disability exclusion in its policy.

But U.S. District Court Judge Michael H. Simon ruled that the company’s exclusion is illegal.

A few weeks ago, Portland's KGW reported on the case:


 

A Settlement in Washington State

The Seattle Times reports:

Premera Blue Cross and its subsidiary, LifeWise Health Plan of Washington, will remove restrictions on neurodevelopmental therapy for autism and set aside $3.5 million to reimburse policyholders who paid for therapy out of pocket.

Under the settlement agreement, Premera and Lifewise will remove age limits and treatment limitations from any medically necessary speech, occupational and physical therapy. The change will apply to all insured plans issued by Premera and LifeWise in Washington.

The settlement is the latest to emerge from a string of lawsuits brought against insurers, employers and state agencies that restrict or limit neurodevelopmental therapy such as applied behavior analysis.

The final settlement agreement in the Premera case, reached in three class-action lawsuits in King County Superior Court and in U.S. District Court in Seattle, must be preliminarily approved by the three judges.

The lawsuits were brought by five individuals diagnosed with autism and their parents, alleging the restrictions violated the Washington State Mental Health Parity Act, which requires equal coverage for mental and physical services.

ERISA Suit Against Boeing

Autism Speaks reports on a suit in US District Court in Seattle.

Aerospace giant Boeing has 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 with autism violates the federal 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.

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The case has added significance because Boeing self-insures its employee health plan and therefore is regulated under federal ERISA law which is immune from state autism insurance reform laws, such as the law in its headquarters state of Illinois. The suit was filed by Seattle 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 Health Parity and Addiction Equity Act as well as its fiduciary responsibilities under ERISA.

Boeing does not expressly exclude ABA coverage in its health plan, but rather has its claims administrators exclude all coverage of ABA therapy through internal policies and restricted provider networks, the complaint alleges.

Mental Health Parity Regs in California

A release from California's Department of Insurance:

New mental health parity regulations have been approved by the Office of Administrative Law. These regulations drafted and proposed by the California Department of Insurance make sure insurance companies cover medically necessary treatment for children and individuals with autism.

"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."

Prior to these new regulations insurers were able to delay or deny medically necessary treatment for individuals with autism. The regulations further define the circumstances in which insurers must cover behavioral health treatments for autism. The regulations interpret and make specific the Mental Health Parity Act and gives more detailed guidance regarding the scope of the Act's provisions as they relate to autism treatment.

The Initial Statement of Reasons
Mental Health Parity Regulations

At California Healthline, David Gorn writes:

"We have all had frustration with the denials and delays," said Julie Kornack, senior public policy analyst at the Center for Autism and Related Disorders in Tarzana. "This really is making the state law and making the public policy clear."

With clear policy comes more certainty of coverage, she said. "Our hope is, [insurers] will see the laws are in place to ensure coverage."

According to advocates and officials at the Department of Insurance, delays often have come in the demand for more testing, particularly IQ testing.

"That practice creates significant delays," said Kristin Jacobson, president of Autism Deserves Equal Coverage, an advocacy group based in Burlingame. "It's an unnecessary test and it's irrelevant to needing treatment."