Oregon Requires Insurers to Cover Autism Therapy

Salem, OROregon has become the latest state to require insurers to include autism and other mental health conditions, rather than denying claims for such conditions. Insurance lawsuits have been filed in other states regarding insurers’ refusal to cover applied behavior analysis (ABA) therapy and other treatments linked to autism.

According to a news release, the order was issued by the Oregon Department of Consumer and Business Services, Insurance Division, and is retroactive to August 8, 2014. That is the date the US District Court for the District of Oregon told Providence that it must cover ABA therapy for autism.

The department issued two orders on November 14, 2014, regarding insurance. According to the department’s website (Oregon.gov), the first bulletin (INS 2014-1) “sets out general guidance for policies and claims handling of any mental or nervous condition.” That bulletin requires that any insurer “must determine coverage of services and treatment of mental health and chemical dependency conditions in the same manner as the insurer makes a determination of services and treatment for other medical conditions.”

Furthermore, the department ordered that insurers may not categorically deny a treatment that in some circumstances is deemed medically necessary.

Meanwhile, bulletin INS 2014-2 focused on autism spectrum disorder and ABA therapy. That bulletin required insurers to treat autism spectrum disorder and other pervasive developmental disorders as mental health claims.

“An insurer may not categorically deny treatment for ABA therapy on the basis that the treatment is experimental or investigational,” the department mandated. “Coverage decisions must be made on the basis of individualized determinations of medical necessity and the experimental or investigation character of the treatment in the individual case.”

In other words, insurance companies can still make coverage decisions based on the individual patient, but they cannot simply deem ABA therapy as experimental and deny it in all cases.

“Recent court decisions have made it clear that ABA should be a covered service when it’s appropriate for the patient,” said Insurance Commissioner Laura Cali. “We expect insurers to stop applying blanket exclusions in their policies and claims practices that effectively deny access to medically necessary treatment for mental health conditions.”

Lawsuits have been filed against insurance companies in other states, including Hawaii, alleging that insurers have wrongly denied autism claims and ABA therapy as being an experimental procedure.