Editor's Note: This article was corrected from an earlier version. Only the self-insured plans offered by OHSU and PEBB are exempt from the autism law passed last year.
Three years ago, Dr. Michael Kim left his position at the Mayo Clinic in Phoenix and took what he thought was a great career move -- practicing medicine and coming on as a professor of otolaryngology at Oregon Health & Science University.
Kim would be able to raise his family closer to his childhood home in the Seattle suburbs. He could bring his highly specialized skill in the plastic surgery of the face, head and neck to Portland’s highly respected medical college.
But choosing to raise his son while working for OHSU had an unexpected consequence -- to ensure his young son got the proper treatment for autism spectrum disorder, Kim would be forced to shell out $25,000 to $30,000 a year to pay for applied behavior analysis.
The Mayo Clinic’s health insurance plan pays for ABA therapy. OHSU -- one of the leading centers for autism research and prescribers of ABA therapy -- does not cover the treatment in its self-insured medical insurance policy.
“If I would have done more due diligence about what our insurance does cover, I would have thought long and hard about taking this job,” Kim told The Lund Report. “An institution that describes itself as a leader in autism research should be covering the basic treatment that helps kids on the spectrum.”
Sen. Chip Shields, the Portland Democrat and chairman of the Senate Consumer Protection Committee, has sponsored legislation for the February session that would force OHSU to cover ABA therapy, along with the Public Employees Benefit Board and the Oregon Educators Benefit Board. Those boards provide coverage for state employees, school teachers and their dependents.
Last year, the Legislature unanimously passed Senate Bill 365, the measure championed by Sen. Alan Bates, D-Medford, that mandated that private insurance companies in Oregon begin covering the leading treatment for autism in young children by 2016.
A key provision of that bill required PEBB and OEBB to cover ABA in 2015. Little did legislators or advocates know that the law would be moot because self-insured state health plans are exempt from the state insurance code as well as Oregon’s own mental health parity law.
Shields’ legislation will correct that, forcing all PEBB and OEBB as well as OHSU health plans to abide by the mental health law and cover treatment for disorders of the brain the same as it would other physical ailments. SB 365 does still apply to fully insured plans purchased by OEBB and PEBB, such as their Kaiser Permanente policies.
How no one noticed that the self-insured state insurance plans could ignore SB 365 was unclear until the law was passed.
“It seems that we solved this problem, but I didn’t think of the self-insured issue,” said Sen. Laurie Monnes Anderson, D-Gresham, at a legislative hearing last week.
Autism advocate Paul Terdal discovered the oversight when he began asking more and more specific questions of Insurance Commissioner Laura Cali, whom he said had been open to his concerns.
“Self-insured plans are not subject to the insurance code,” Cali told The Lund Report. She said that while she was the chief actuary when SB 365 was debated, she was not involved with the legislation.
She said state self-insured health plans are also exempt from the primary federal health insurance laws as well.
Terdal and the other advocates at Autism Speaks discovered the problem in the nick of time so that legislation could be drafted for the 2014 session. If it passes, PEBB and OEBB will be required to cover ABA next year as Bates intended.
“The [expense of SB 365] was built on the costs to PEBB and OEBB but it didn’t actually require it,” Terdal said, noting that the cost to the state general fund to provide the coverage to government employees was one of the biggest hurdles to passing SB 365. The new legislation, which has not yet been given a bill number, shouldn’t cost the state anything extra since the Legislature already budgeted the money last summer to provide the care in 2015.
Kim and other faculty at OHSU advocated for the hospital to cover ABA for months, to no avail. But with Shields’ legislation pending, OHSU President Joe Robertson finally responded to Kim’s concerns on Jan. 2, directing a human resources officer to arrange for coverage starting in 2015.
“Upon further review, I am instructing that OHSU follow PEBB and OEBB in regard to coverage of Applied Behavior Analysis in the OHSU employee benefit plan,” Robertson told Dan Forbes, in an email retrieved by The Lund Report.
OHSU spokesman Todd Murphy confirmed that OHSU would begin coverage of ABA next year, likely at the same time as OEBB and PEBB, but Murphy was unable to provide any more details by press time on the medical school’s current lack of coverage for its employees.
In the meantime, Kim purchased an individual policy for his son through Kaiser Permanente, which pays for ABA. He’ll have to switch to a Kaiser speech therapist but the family will stop having to pay for all of the intensive behavioral therapy out of pocket.
Kim is still not happy his son’s treatment will not be covered through his employer insurance at OHSU for another year. “If it’s right when it’s mandated, why is it not right to cover right now?” Kim asked. “OHSU’s stance is not to lead but to follow a mandate.”
Christopher David Gray can be reached at firstname.lastname@example.org.