Seven years after families began asking the Oregon Insurance Division to intervene on their behalf, the states 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 2010, a federal judge in Portland ordered PacificSource to pay for the treatment after the insurer argued the therapy was experimental and educational. The great majority of the studies in the record indicate that ABA therapy is not only supported by decades of research, but is one of the only autism treatments which has consistently shown measurable success in improving the lives of autistic children, the judge ruled in that case.
California ordered its insured to stop denying coverage in 2011.
Meanwhile the Oregon Insurance Division told families that, while it had authority to take enforcement action, the division does not believe it has authority to enforce mandated coverage for ABA therapy, according to correspondence.
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 Kitzhabers 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.
Its great. Im really glad [Insurance Commissioner Laura] Cali is moving forward with this. Its time. Lets go, Terdal says. Whats going to be tricky, shes now going against the governors office. Because the [Public Employees' Benefit Board] is now doing exactly what Providence has been doing. So they are pretty exposed."
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State Will Tell Insurers to Stop Denying Autism Treatment