Salem, OR—The Oregon Department of Consumer and Business Services (DCBS) has issued proposed enforcement orders to four health insurance companies for violating laws related to coverage of mental health treatments.
Oregon's mental health parity law requires insurers to cover mental health conditions consistent with how they cover physical conditions. The department issued guidance to insurers in 2014 that they cannot categorically deny coverage of mental health treatments, including Applied Behavior Analysis (ABA) therapy, which is used to treat autism.
“Despite our clear guidance to insurance companies on mental health parity, some companies continue to engage in practices that make it difficult for consumers to access treatment,” said Laura Cali Robison, Oregon insurance commissioner and administrator of the DCBS Division of Financial Regulation. “We continue to monitor this issue across the industry and will not hesitate to take strong action if warranted.”
The companies that are subject of the proposed orders are:
• Pioneer Educators Health Trust, which provides health plans to local universities, is fined a proposed $100,000 for several violations, including:
o Applying an annual visitation limit for neurodevelopmental therapy, a mental health treatment, when there was not a similar limit for other medical or surgical benefits.
o Excluding ABA therapy in its 2015 health benefit plan and issuing the plan without receiving approval from the state.
o Denying a consumer's pre-authorization request for ABA therapy and not providing a written response with information about the consumer's right to appeal.
o Denying a claim for ABA therapy with no basis for that denial.
• Regence BlueCross BlueShield of Oregon, in its role as third-party administrator for Pioneer Educators Health Trust, is fined a proposed $100,000. In particular, Regence provided incorrect information to Pioneer and at least one consumer about whether it was required to cover ABA therapy.
• United Healthcare Insurance Company is fined a proposed $110,000 for denying 22 speech therapy claims for children who have been diagnosed with a pervasive developmental disorder (such as autism). Oregon law requires insurers to cover all medical services for a child enrolled in the plan who is younger than 18 years old and who has been diagnosed with a pervasive developmental disorder. Those services include rehabilitation services, such as speech therapy, that are medically necessary and are otherwise covered under the plan.
• Kaiser Foundation Health Plan of the Northwest is fined a proposed $250,000 for providing incorrect and misleading information in its member documents about whether it would pay for members' attorney fees in a lawsuit. Kaiser's documents stated that members would bear their own attorney fees, but Oregon law requires insurers to honor a court award for attorney fees. This order was the result of a complaint from a consumer who has filed a lawsuit against Kaiser related to mental health parity issues.
The division continues to work with the four companies to agree on final consent orders. Terms of the orders may change before a final order is issued.
The Division of Financial Regulation was formed last year after the merger of the Insurance Division and the Division of Finance and Corporate Securities.
“Since the creation of the new division, we have been able to develop a stronger enforcement presence and now have an increased ability to take swift action to protect Oregonians,” said Patrick Allen, director of DCBS.
Consumers who have issues or questions about coverage of mental health treatments claims should contact the DCBS Division of Financial Regulation at 1-888-877-4894 (toll-free) or email firstname.lastname@example.org
For more information:
Lisa Morawski, 503-947-7873