LD 1198

An Act To Reform Insurance Coverage to Include Diagnosis and Treatment for Autism Spectrum Disorders

Sponsor: Senator Bowman

Committee of Jurisdiction: Insurance & Financial Services

Contact information of Committee Members: http://www.maine.gov/legis/house/jt_com/ban.htm

Public Hearing: March 30, 2009, 9:30 a.m., Room 427 State House

Next Worksession: February 24, 2010, 11:00 a.m., Room 427 State House

Status: Committee voted Ought to Pass as Amended (unanimous among all present) with Committee Amendment limiting scope to those 5 years of age or under

Draft language of bill:

http://www.mainelegislature.org/legis/bills/bills_124th/billtexts/SP044601.asp

Final language as adopted: N/A

Action Alert: Do you have insurance claims have been denied by your insurance company?
We are hearing more and more from people who thought they had good health insurance coverage only to discover that when they most need it, that Autism Spectrum Disorder-related health care treatment and services are increasingly being denied by their private insurance carrier. This has resulted in these consumers having to self-pay, or for those who are eligible, to fall on MaineCare’s Katie Beckett program to cover.

Last March, we alerted you to an important bill that began to move through the Maine Legislature and was subsequently carried over to this new legislative session. LD 1198: An Act To Reform Insurance Coverage To Include Diagnosis and Treatment for Autism Spectrum Disorders sponsored by Senator Peter Bowman, which had its public hearing last year, is back from study by the Bureau of Insurance and will be going to worksession next week before the Joint Standing Committee on Insurance & Financial Services.

This is the situation: The legislation could greatly benefit those in the autism community by requiring by law that private insurance companies pay for ASD diagnosis and treatment. Have you had claims denied? If so, this is very important to you and your family. Additionally, according to the Bureau of Insurance study and based on actual MaineCare claims data, if LD 1198's mandate were to be applied to all group and individual health insurance policies, it would hold insurance companies accountable for paying up to $4 million per year in costs of services that are currently shifting to MaineCare coverage for payment (which is part-state and part-federally funded, and at a time when the Katie Beckett and other MaineCare services are also again threatened with further cuts.)

Here are some helpful things you can do:

- E-mail a message to Members of the Joint Standing Committee on Insurance & Financial Services AND your Senator or Representative explaining why this bill is important to you. Ask them to please pass LD 1198 (autism coverage for health insurance), and inform them that the Bureau of Insurance estimates that the bill will save money for the state general fund. LD 1198 will save the state about $500,000 as written (that's the state share of costs currently paid by MaineCare that would instead be paid by private insurance as it should be and is now mandated by 19 other states across the country). Ask the committee to amend the bill, as ASM did in our testimony, to cover both small and large groups, which would double the savings to about $1 million.

- Phone your Senator or Representative explaining the importance of the bill to your own personal situation and the above information.

- Forward this e-mail to others who may wish to know about this bill.

- Attend the worksession Joint Standing Committee on Insurance & Financial Services on the afternoon of Tuesday, January 12 at 1:00 p.m. in the IFS Committee Room 427 of the Statehouse. If you have an autism puzzle ribbon, please wear it! (This is not a public hearing, so the public will otherwise not have an opportunity to speak).

We encourage you to make your voice heard on behalf of all those living with ASD.

Autism Society of Maine Testimony:

In Support of:
LD 21 “An Act To Encourage the Diagnosis and Treatment of Autism Spectrum Disorders”
LD 1198 “An Act To Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders”

Dear Chairman Bowman, Chairwoman Treat, and Distinguished Members of the Joint Standing Committee on Insurance & Financial Services:

My name is Janine Collins and I am from Saco. I’m here today to present testimony on behalf of the Members of the Board of Directors of the Autism Society of Maine (ASM). To respect the time of the Committee, we are presenting our support and suggestions related to both LD 21 and LD 1198 in one testimony.

For over 32 years our statewide non-profit organization has served Maine individuals with autism and their families, professionals, and communities by providing education, advocacy, referrals and resource development.

Autism Spectrum Disorders are complex, life-long neurological disorders that affect a person’s ability to communicate, to reason, and to interact with others or become independent members of the community. Autism occurs in approximately one out of every 150 births, typically appearing initially during the first three years of life. Autism Spectrum Disorders manifest with varying degrees of severity, and are often found in combination with other disabilities. Both children and adults with an Autism Spectrum Disorder typically show difficulties in verbal and non-verbal communication, social interactions, and leisure or play activities. Autism Spectrum Disorders are among five disorders that fall under the umbrella of Pervasive Developmental Disorders (PDD), a category of neurological disorders characterized by “severe and pervasive.”  The three Autism Spectrum Disorders are:  Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). The other Pervasive Developmental Disorders that are less common are: Childhood Disintegrative Disorder and Rett’s Disorder. (For more detailed information, see attached.)

Early diagnosis is critical to obtaining effective medical treatment for an Autism Spectrum Disorder. Depending on the severity of the disorder, individuals may need speech therapy, occupational therapy, physical therapy, or behavioral therapy services to treat their specific areas of impairment.  At the present time, there is no known cure for Autism Spectrum Disorders.  However, research has shown that with the appropriate medical treatments (speech therapy, occupational therapy, physical therapy, and behavioral therapy) improvement in the quality of life and the ability to communicate, interact, control behavior, and become more independent is possible. 

Many private insurance companies are not covering medically necessary treatment for Autism Spectrum Disorders. It is important to note that MaineCare ALREADY recognizes these services as being a medical necessity and covers the needed medical services (as do state Medicaid programs across the country).  So why are we allowing private insurance companies to exclude these services for individuals with Autism Spectrum Disorders? 

Some private insurance companies will not cover services unless the condition or impairment is due to an injury or disease.  Other insurance companies will cover speech therapy, occupational therapy, and physical therapy in combination; however, they place a limit on the total number of sessions allowed.  Most often, for individuals to
make the necessary improvement or gains, they need long-term services, and these services need to be consistent without interruption. For those people with autism who also experience a mental illness (which an Autism Spectrum Disorder is not), they are having more luck getting coverage for mental health services, while struggling to get treatment for autism medical services (again, occupational therapy, speech therapy, etc.) This especially is unfortunate since the stories of adults with Autism Spectrum Disorders point out that their mental illness—if not caused by—is exacerbated by the accumulative effects of not receiving appropriate treatment to address the challenges related to communication, social interaction, and leisure noted above; all necessary for supporting strong mental health.  Moreover, mental health providers generally lack the education and training necessary to effectively support people with neurological disorders such as autism.

The difficulty in getting treatment services covered has prompted several states to enact autism insurance mandates. This has occurred in Arizona, Florida, Illinois, Indiana, Louisiana, Pennsylvania, South Carolina, and Texas. Additionally, mandates have now been introduced in another 24 states (see summary list attached.)
 

ASM recommends to the Committee consideration of the following:

  • The bill titles can be confusing:  LD 21 as drafted is focused solely on diagnosis, where as LD 1198 seems to cover both. Of course, diagnosis is critical.  However, the experience of frequent denials and the greater difficulty in securing coverage lie with the attempts to access necessary medical treatment following diagnosis. We recommend that the diagnosis and treatment mandate components be considered together, not as separate issues.
  • Autism knows no boundaries of socioeconomic status. It impacts people with a diversity of backgrounds -- and insurance coverage plans. LD 1198 as initially drafted focuses on small group plans. As people with autism are also in the large group and/or individual private insurance markets, we ask that this bill be amended to encompass all.
  • We firmly believe that no single type of treatment service will fill the needs of every individual with autism, and that each person should have access to the medical services he/she needs. Selection of the specific treatment needed should be made on the basis of a full assessment of each person's level of functioning and individual needs. We believe that services should be outcome-based to ensure that they result in improving the overall functioning and individualized needs of a person with autism.
  • Autism Spectrum Disorders are neurological conditions. Special attention should be paid to the definitions of Autism Spectrum Disorders and the services for Autism Spectrum Disorders used in the bill(s). We have attached information from the Autism Society of America that discussed this issue and provides model language for your reference.
  • For your convenience, we have attached a sample piece of legislation that was enacted in Pennsylvania that provides model language from which you may wish to borrow as you proceed. We will also make ourselves available for the work session.
  • Cost savings to State of Maine: Currently, instances when people’s private insurance is their primary coverage and MaineCare is their secondary coverage, private insurance denials for needed medical treatment services that are covered by MaineCare result in a cost-shift onto the state. A fiscal note on an insurance mandate in the case of Autism Spectrum Disorders should include the cost savings that would occur when private insurance companies are required to pay their fair share for these medically necessary treatment services.

On behalf of people with autism and their families, ASM offers our strongest support for an autism insurance mandate for Maine, and we urge your votes in securing its passage.

Attachments:

  • About Autism
  • Summary list of states that have enacted and/or introduced autism insurance mandates
  • ASA information on autism insurance mandate definitions
  • Pennsylvania model autism insurance mandate legislation, as enacted