ABA and Insurance in Oregon

Previous posts have described policy in Oregon. OPB reports:

In November, Kaiser Permanente issued a statement saying it is now providing ABA services for members with a medical need.

Tobi Rates is the executive director of the Autism Society of Oregon. She says it was welcome news, "We applaud it," she said. "We're thrilled about it. We want the other insurance companies to follow along."

The state has two laws that she says should require insurers to cover ABA therapy -- the 'Mental Health Parity Act' and the' 'Developmental Disabilities Act.'

But she says, there's a catch, "Between those two, it says if you're covering mental health issues, you have to include developmental disabilities, and that includes autism. It doesn't specifically say how you have to cover the autism therapies or what therapies you have to cover."

Hence the current situation where some companies cover ABA, while other's don't.
Kaiser did not make anybody available for an interview with OPB. But the problem for the company now is that if other insurers don't also start offering coverage, Kaiser could end up attracting lots of expensive new customers with autism. That would drive up their costs.

...

The Oregon Insurance Division is thinking about it. Spokeswoman Cheryl Martinis says the division is seeking advice from attorneys at the Department of Justice, "We've asked them whether ABA therapy is required under current Oregon law, and if so, under what circumstances. ... So we're awaiting some guidance."
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State Senator Alan Bates, a doctor from Medford, is working on a bill that would create a certification system for ABA therapists. It would also get ABA included in insurance coverage, and establish which children should receive the therapy.

He says it's understandable why insurance companies want a certification process, "A lot of the work is something it doesn't take a lot of education for, but takes a lot of time and you don't want to be paying someone $100 an hour for doing something that could be done for $15 an hour with the same outcome."

He says if a bill is to pass, he needs parents and insurance companies to come to some agreement.

If they don't, he says, he won't take a proposal to the floor because it simply wouldn't survive.

Study of Bullying

Previous posts have discussed the impact of bullying on ASD children.A release from the Kennedy Krieger Institute:

Nearly 70 percent of children with autism spectrum disorders (ASD) experience emotional trauma as a result of being bullied, according to findings published today in the Journal of Developmental & Behavioral Pediatrics, while a significant portion were concerned for their own safety at school. The study also found that children with ASD who presented with pre-existing psychiatric diagnoses were at increased risk for involvement in bullying, with children diagnosed with ASD and attention deficit hyperactivity disorder (ADHD) or depression at highest risk of being victimized over a one month period. This study was led by researchers from the Interactive Autism Network, a project of the Kennedy Krieger Institute that is the nation’s first online autism registry with participants from 47 states, making it the largest collection of autism data in the world.

“Recent research indicates that children receiving special education services are at risk of being victimized at higher rates than regular education students,” says Dr. Paul Law, senior study author and director of the Interactive Autism Network at Kennedy Krieger. “Our findings show that not only are these children being bullied more, but they are also experiencing significant short-term, and likely long-term, effects of being bullied.”

Participants in the study included parents of 1,221 children with ASD recruited through an online questionnaire. Researchers utilized the Bullying and School Experiences of Children with ASD Survey, a 63-item questionnaire, to collect key data from parents regarding their child’s school environment, involvement in bullying, and the child’s educational and psychological functioning. Additionally, researchers used the Parent Observation of Child Adaptation (POCA) to reflect parents’ ratings of their child’s behaviors and level of psychological distress after a bullying incident. The study’s findings on the characteristics and psychiatric comorbidities most associated with bullying are below.

Kasich Signs Directive

In Columbus, WCMH reports:

Autism advocates refer to it as their Christmas miracle – the day Gov. John Kasich announced he would sign an executive order mandating insurance coverage for autism services. Kasich gathered with supporters Wednesday to celebrate with a ceremonial signing of the new directive.

Opponents of the new policy argue the mandate will increase insurance premium costs for business owners and the Tea Party sponsors of Ohio’s 2011 Health Care Freedom Amendment now say the new mandate also violates the Ohio Constitution.

For many parents, the autism diagnosis can provide some relief after months, or even years, of not knowing what was wrong. Then they're confronted with the reality that their insurance does not cover the expensive but necessary treatments.

Nixon and Autism

Today would have been Richard Nixon's 100th birthday.  What did he have to do with autism?  Some have speculated that his verbal precocity, social awkwardness, and physical clumsiness may have been signs of Asperger's -- but that proposition is unprovable.  But what is clear is that he signed several measures that shaped policy for people with autism and other disabilities:

• Objecting to parts of the bill, Nixon reluctantly signed the Elementary and Secondary Education Act Amendments of 1970 (P.L. 91-230), which created a separate Act, the Education of the Handicapped Act (EHA). Part B authorized  grants to states to assist them with programs for the education of children with disabilities.  
• Nixon signed the Developmental Disabilities Services and Facilities Construction Amendments of 1970 (P.L. 91-517), which  contained the first legal definition of "developmental disabilities," includedbroad responsibilities for a state planning and advisory council to plan and implement a comprehensive program of services for persons with developmental disabilities.  The law also authorized grants to support interdisciplinary training in institutions of higher education of personnel providing services to persons with developmental disabilities.
• After vetoing earlier versions, Nixon signed the Rehabilitation Act of 1973 (P.L. 93-112). Sections 501, 503 and 504 prohibited discrimination in federal programs and services and all other programs or services receiving federal funds. Section 504: “No otherwise qualified handicapped individual in the United States, shall, solely by reason of his handicap, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

Autism and the Affordable Care Act

Autism Speaks finds that fewer than half the states have planned to include ABA coverage in their new health care exchanges.

"While the picture remains somewhat murky, the unequivocal support needed by families dealing with autism clearly is missing," said Stuart Spielman, Autism Speaks' senior policy advisor and counsel. "We have an autism epidemic. Merely having some form of health insurance available will not address this epidemic."

The analysis was conducted on the "essential health benefits" benchmark plans each state was to submit to the U.S. Department of Health and Human Services (HHS). Autism Speaks reviewed information on the website of the Center for Consumer Information and Insurance Oversight, the part of HHS that wrote the essential health benefit rules, and found that 17 states were including coverage for behavioral health treatments and that coverage was implied by another five states.

In addition, Ohio Governor John Kasich in late December announced that his state would include ABA and other autism therapies as part of its essential health benefits package.

"Failing to categorize behavioral health treatment for autism as a mandatory element of the EHB package is not only bad health policy, but bad statutory construction as well," Autism Speaks told HHS in formal comments. Congress clearly stated when it enacted the ACA in 2010 that coverage for behavioral health treatment had to be one of the 10 essential health benefits each state was required to include as part of their new health care exchanges for the small group and individual markets

The 17 states determined to include behavioral health treatment include:

• Arizona
• Arkansas
• California
• Indiana
• Kentucky
• Louisiana
• Maine
• Massachusetts
• Missouri
• Montana
• Nevada
• New Hampshire
• New York
• Texas
• Vermont
• West Virginia
• Wisconsin

The five states where the coverage may be included, but is unclear, are:

• Colorado
• Connecticut
• Illinois
• New Jersey
• New Mexico

Ava's Law in Georgia

A video in favor of a Ava's Law, a proposed insurance mandate in Georgia:

 

Special Education in California

In California, the Legislative Analyst's Office has issued a report titled Overview of Special Education in California. Over the past decade, the prevalence of specific learning disabilities has dropped 20 percent while the prevalence of autism has increased 241 percent.

As shown in Figure 8, federal IDEA funds typically cover less than 20 percent of overall special education expenditures. This is notably lower than the amount the federal government originally committed to provide in support of special education services. The IDEA expresses intent to appropriate funding for each SWD up to 40 percent of the national average expenditure level per K-12 pupil, which would equate to roughly 40 percent of California’s overall special education expenditures. The federal budget, however, has never come close to providing states with this amount. We estimate that California would receive roughly $2 billion more annually if the federal government were to “fully fund” the intended level articulated in the IDEA.

Florida Appeals Court Order

The Miami Herald reports:

Already facing sharp criticism over policies that have resulted in the rationing of care to severely disabled children, Florida healthcare regulators are challenging a federal judge’s order that the state provide a costly — but potentially life-changing — treatment to children with autism.

Last spring, U.S. District Judge Joan Lenard struck down the state’s refusal to pay for applied behavior analysis (ABA) for autistic children, calling the state’s policy “arbitrary, capricious and unreasonable.”

The court case involved three autistic youngsters — then-5-year-old K.G., 2-year-old I.G. and 4-year-old C.C. — whose efforts to obtain behavioral therapy had been denied by the state’s Medicaid insurance program for needy and disabled people. Lenard ordered that the three children be given the care they sought — and that the state provide such care to other autistic children, as well.

The state Agency for Health Care Administration has appealed the order, and, in a pleading submitted in November, argued that the ruling strips the state of its ability to weigh requests for the therapy on a case-by-case basis to ensure the treatments are “medically necessary.”

“There is no evidentiary support for the district court’s conclusion that [behavior analysis] services are medically necessary for all autistic Medicaid recipients under 21,” the brief said. “In fact, the evidence established that ABA treatment is not medically necessary, or even effective, in all cases. Some children do not respond to ABA treatment at all, and, in all other cases, the efficacy of ABA treatment diminishes rapidly after early age.”

Miss Montana and a Vote

KRTV in Great Falls, Montana, reports:

On Saturday, Cut Bank resident Alexis Wineman will take the stage in the Miss America Pageant, but for now she is hoping to garner enough votes online to become a finalist in the contest.

In the Miss America online video contest, Wineman explained why she feels she should be the next Miss America.

Wineman's platform issue, titled "Normal is Just a Dryer Setting: Living with Autism," focuses on her life since she was diagnosed with a form of it in 7th grade. She said she hopes to bring national awareness to it.

"Most people do not understand what autism is, and one in 88 people having some form of autism, this understanding is becoming more and more necessary," Wineman said in the video.
Wineman is also keeping friends, family and fans up to date on her Facebook page, where she said she has enjoyed walking the runway at the Fashion Show Mall in Las Vegas and making appearances at various events.

She has also been chosen as one of 14 contestants to be featured on the show "20/20."
Click here to see her video and cast your vote.

Problems with Public School

At The Atlantic, Amy Mackin writes of her son's problems with the public school system:

Unfortunately, again, no one was paying attention during the most difficult parts of Henry's day—the unsupervised social settings. Henry suffered a serious breakdown that year. He hadn't told anyone, but, as it turned out, he had been bullied on the school bus for months.
...
The autism spectrum is wide and varied, and every autistic person is unique. People like Henry need someone looking out for them, particularly in overwhelming environments like school. The problem is that public schools are mostly worried about academics and test scores. They have to be—their success in those areas dictates the percentage of state and federal funding they get. Few schools have designated psychologists (most often, multiple schools share the same one). Teachers aren't psychologists, and asking them to be is not fair.

This puts kids with Asperger's in a particularly precarious spot. Many of these children are above average academically, even gifted in certain subjects. Special-education departments tend to focus on helping students with learning disabilities. But kids with Asperger's often don't need academic support. They need help navigating social interactions. When typical middle school boys are showing interest in girls and competitive sports, their Asperger's counterparts are often still playing with toys and building with Legos. The Tooth Fairy and Santa Claus are still very real for many of these kids, even as they approach the teen years.

France, Autism, and Psychoanalysis

Previous posts have discussed the dismal state of autism treatment in France.  A film titled "The Wall,"by Sophie Robert, explained the ongoing grip of discredited psychoanalytic theories in that country.  Kristina Chew writes:

Robert’s film has been part of an ongoing effort to change the understanding and treatment of autism in France. After the organization Autism Europe lodged a complaint against France in 2002 for failing to educate autistic children, the European Committee of Social Rights said that “France has failed to achieve sufficient progress” in educating autistic children and had made autistics an “excluded group.”

Seeking to help their children, more parents in France have been taking action, lobbying politicians like Daniel Fasquelle, a member of France’s parliament who says in the BBC that it is an “an out-and-out disgrace” that France’s medical community should continue to swear by psychoanalysis as the treatment for autism. David Heurtevent’s Support the Wall project continues the fight for the rights of autistics in France to education and services.

It is perhaps not surprising that the use of psychoanalysis to treat autism should be making its last stand in France, where Freudianism has long been applied not only to the treatment of mental illness but also to the study of literature, philosophy and radical politics. In a new year, it is more than time for the French medical community to acknowledge that it is decades behind the rest of the world in understanding what autism is and in treating and educating autistic individuals in ways that will actually help them achieve all they can.

Obama Signs Bill with TRICARE Provision

Previous posts have discussed a measure enabling retired TRICARE enrolees to get coverage of ABA.  Autism Speaks reports:

President Obama has signed bipartisan legislation creating a one-year pilot program expanding ABA care to all military families through TRICARE, the Pentagon's healthcare program, a critical first step in improving services for military families raising children with autism.

"Autism Speaks thanks President Obama for taking this sensible step for military families, along with our Congressional champions Rep. John Larson of Connecticut and Sen. Kirsten Gillibrand of New York," said Peter Bell, Autism Speaks executive vice president for programs and services. "At the same time, we restate our intention to make these medical services permanent. Military families who sacrifice so much deserve access to the benefits they have earned."

The TRICARE provision was included as an amendment to the National Defense Authorization Act voted out of Congress in December. Both the House and Senate had approved a permanent expansion of ABA benefits providing for prescribed levels of care, but the measure was whittled down to a one-year pilot program when the bill was finalized in conference committee.

The Department of Defense (DoD) currently restricts ABA coverage to active duty members through the supplementary ECHO program which limits annual benefits to $36,000, covering just 6 to 11 hours of therapy a week, well below the recommended level of care. Because of specific policy shortfalls, ABA care terminates upon retirement, including services for children of wounded warriors retired due to injuries sustained in combat.

Service members have said they have re-enlisted for additional tours of duty simply to maintain coverage for their children with autism.

The one-year pilot program, which is for all TRICARE eligible beneficiaries with autism, is to start within 90 days. Within 270 days, DoD will then be required to report to Congress on costs, a comparison of the pilot program with ECHO and any recommended legislative remedies. The legislation offers no guidance on coverage limits or parameters of the program.

"Autism Speaks will closely monitor the DoD’s implementation of the pilot program on a variety of fronts, including its coverage of ABA Technicians and BCaBA’s," said Karen Driscoll, Autism Speaks’ associate director for federal government affairs and military relations, and a Marine Corps spouse.

"Development of effective policy is essential," she said. "It is critical that TRICARE work with stakeholders, including military families and subject matter experts, to ensure the final policies regarding coverage and delivery of ABA care are consistent with best practices."

OPM, ABA, and Maryland

Previous posts have discussed the decision by the federal Office of Personnel Management to allow (but not require) coverage of ABA under the Federal Employee Health Benefits Program.

The Baltimore Sun reports:

Autistic children of federal workers in 22 states begin receiving insurance coverage this month for a key behavioral treatment, under a decision by the Office of Personnel Management.

Maryland, home to the third-largest population of federal workers in the nation, is not one of them.

"These families desperately need the best coverage for their kids," said Stuart Spielman, senior policy adviser and counsel for Autism Speaks. He said the advocacy group would petition the OPM to expand its coverage as quickly as possible.

...
But Jacque Simon, policy director at the American Federation of Government Employees, said the mix of therapies and medication is not a substitute for applied behavior analysis. Simon said the union has fought for decades for coverage. 

"It's long been recognized as the most effective treatment," she said. "It's been absolutely horrible on the part of OPM to delay coverage for this long. It's really a half-measure, but it's better than nothing."