AB6 Autism Insurance Reform claims data and technician rules

Transcription

1 AB6 Autism Insurance Reform claims data and technician rules Daniel R. Unumb, JD Executive Director, Autism Speaks Legal Resource Center Nevada Senate Committee on Commerce, Labor and Energy May 13, 2015

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3 Annual Per Pupil Spending Ratio (disability versus average regular education student)

4 Students with autism (AUT) have the highest annual per pupil expenditures for special services autism = $11,543 speech/language impairment = $4,569 SPED = average special education student; SLD = specific learning disability; SLI = speech/language impairment; OHI = other health impairment; OI = orthopedic impairment; ED = emotional disturbance; MR = mental retardation; HI/D = hearing impairment/deafness; TBI = traumatic brain injury; VI/B = visual impairment/blindness; MD = multiple disabilities; AUT= autism

5 ABA is highly effective when provided at medically necessary levels Gregory S. Chasson et al, Cost Comparison of Early Intensive Behavioral Intervention and Special Education for Children with Autism, 16 J. of Child and Fam. Studies 401,401-13(2007).

6 Service limits in statute are below medically necessary levels hours per week cited by BACB based on scientific research for comprehensive programs* Service caps of hours per year allow for less than 10 hours per week Limit chemotherapy for child with cancer to 25 percent of effective dose? *Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, p. 25, available at

7 Long Term Costs of Failure to Provide Adequate Treatment Jon Hockenyos, Benefit-Cost Analysis of Appropriate Intervention To Treat Autism (2009), Available at lx.us/autism/publications/us AutismCost BenefitAnalysisNovember2009. pdf; see Michael L. Ganz, The Lifetime Distribution of the Incremental Societal Costs of Autism,161Archives of Pediatric and Adolescent Med. 343, (2007).

8 States are increasingly abandoning caps on medically necessary care ACA prohibits dollar value limits on EHB CT has prohibited conversions to visit limits A number of states have determined caps violate federal mental health parity (MHPAEA) e.g. NJ, NH, ME, CA, OR, WA, IL, RI

9 States are increasingly abandoning caps on medically necessary care States have applied ACA prohibition on dollar caps and state mandate prohibitions on visit limits to preclude service caps. E.g. MI, MO Colorado has just passed legislation to eliminate service limits

10 States are increasingly abandoning caps on medically necessary care New York State Employee Health Plan has eliminated 680 hour limit and coverage is now uncapped. DFS has issued form guidance directing that hour limits be removed in 2016 policies.

11 Abandoning service limits will not appreciably affect overall costs Autism is a spectrum disorder and not all children will require the most intensive levels of therapy Utilization rates are a fraction of incidence rates

12 Cost projections Using conservative models, Oliver Wyman has projected increased PMPM costs of between 17 to 99 cents if service limits are removed with a corresponding premium impact of 0.05 to 0.29 percent. Actual claims data from other states suggests the ultimate costs will be on the low end.

13 Cost Data State employee health plans show a per member per month cost averaging 31 cents a month or a small fraction of one percent of premium cost for year 2 of implementation and an average PMPM of 46 cents a month in year 3 data. New Jersey, a high cost state with an uncapped mandate had a PMPM of 63 Cents.

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16 Cost Data Most comprehensive cost data is from Missouri DIFP (DOI) which generates an annual report to the legislature on the costs of Missouri s autism insurance mandate. Missouri DIFP has prohibited service limits based on interaction of ACA (no dollar caps) and state mandate (no visit limits).

17 Cost Data All ASD claims amounted to just two tenths of one percent (.21) of all claims, with ABA claims amounting to just one tenth of a percent (.11). PMPM costs for all ASD claims amounted to 50 cents; PMPM for ABA claims was 26 cents Utilization rate: 1 out of 337 insureds

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19 Cost Data Conclusion: The costs associated with the coverage mandate for the treatment of ASDs and ABA therapy has to date been minimal, even as the mandate has led to dramatically expanded coverage and the delivery of medically beneficial services. Applied behavior analysis therapies have been shown to dramatically reduce long-term costs for a significant proportion of individuals diagnosed with an ASD, and to significantly improve their quality of life. The law has achieved its purposes in an unqualified way for every measureable metric.

20 Expanding Age and Service Limits in Existing Mandate Does Not Require State to Defray Costs under ACA Viewed as in furtherance of antidiscrimination provisions Maine age limits Colorado age limits and hour limits

21 Expanding Age limits The ACA Prohibits Discrimination in Benefit Design Based on Age or Disability. 45 CFR CMS has cautioned issuers and States that age limits in benefit designs may be considered discriminatory when not based on medically necessity or clinical effectiveness. 79 FR ( For example, it would be arbitrary to limit a hearing aid to enrollees who are 6 years of age and younger since there may be some older enrollees for whom a hearing aid is medically necessary. ) New Jersey has recently eliminated age limitations in autism coverage on the basis of substantial evidence demonstrating the effectiveness of ABA in adult populations.

22 Eliminating Certified Autism Interventionist Requirement Other states have not required certification of supervised line therapists Access issues and administrative costs RBT is an available mechanism if desired

23 Line Therapists/Behavior Technicians 22 states other than Nevada with licensure or certification of behavior analysts Only 3 states (Oregon, Louisiana and Wisconsin) regulate behavior technicians

24 Line Therapists/Behavior Technicians 41 states with mandated autism insurance coverage Only 2 states (California and Kansas) provide for behavior technician credentialing as part of mandate

25 Line Therapists/Behavior Technicians RBT (Registered Behavior Technician) provides a cost efficient national credential with training, competency assessment and supervision requirements. Recent Colorado legislation adopts the RBT credential. TRICARE has adopted the RBT credential