Salem - The Oregon Department of Consumer and Business Services, Insurance
Division today issued two bulletins that require insurers to cover treatment
of autism and other mental health conditions, just as insurers cover treatment
for physical health conditions.
The bulletins take effect retroactively to Aug. 8, 2014, the same day the U.S.
District Court for the District of Oregon ruled that Providence must pay for
Applied Behavior Analysis (ABA) therapy as a treatment for autism. Many Oregon
families seeking autism treatment have had challenges getting coverage for ABA
in recent years.
"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."
For any health condition, insurers can make coverage decisions based on whether
the treatment is deemed medically necessary for an individual patient. The bulletins
clarify that insurers' policies cannot include categorical exclusions that result
in broad denials of mental health treatments. And, specifically, they cannot
deny treatment for ABA therapy on the basis that it is experimental or investigational.
Consumers can appeal medical necessity denials to the company - and ultimately
through the Insurance Division - via an independent review organization.
The Insurance Division has the authority to issue bulletins to clarify requirements
of insurance companies under the Oregon Insurance Code and other state and federal
laws. The division developed the bulletins through a public process and received
feedback from consumers, advocates, insurers, and other interested parties.
Consumers with outstanding claims should contact their insurance company. They
also can call the Insurance Division Consumer Advocacy Unit at 1-888-877-4894
(toll-free) or email firstname.lastname@example.org.
You can find the bulletins and more information on the Insurance Division's
website at http://www.oregon.gov/DCBS/insurance/legal/bulletins/Pages/proposed-bulletin-review.aspx.
The Insurance Division is part of the Department of Consumer and Business Services,
Oregon's largest business regulatory and consumer protection agency. Visit www.dcbs.oregon.gov