Federal District Judge Michael H. Simon has found the Catholic Heath provider Providence's exclusion of autism and developmental disabilities exclusion violates Oregon's Mental Health Parity (virtually identical to Washington'sMental Health Parity) and the Federal Mental Health Parity Act.
In a 26 page order issued today, judge Simmons wrote "By stating that it covers autism (a developmental disability), but excluding coverage for all services “related to a developmental disability,” Providence is not covering treatment for mental health conditions in parity with treatment for medical conditions. Providence cannot identify any medical condition covered by its plan where there was an exclusion that could, on its face, deny coverage for all services “related to” the treatment for that condition. Moreover, Providence cannot provide any examples of a medical condition where an exclusion was used to deny coverage of the primary and widely-respected medically necessary treatment for that medical condition. Because of the broad-based Developmental Disability Exclusion, Providence covers mental health conditions at a different level than medical conditions in violation of the parity obligations."
Providence had argued that Oregon’s mental health parity didn’t require coverage of services.
“Court finds that Providence cannot simultaneously purport to cover autism and yet deny coverage for medically necessary ABA therapy through its Developmental Disability Exclusion consistent with the Oregon Mental Health Parity Act”
"That right there pretty much wipes out any ABA exclusion in the State of Oregon." said Paul Tedral, Oregon's lead autism advocate.
On whether Providence was in violation of the Federal Mental Health Parity when denying ABA, Judge Simon wrote: "By stating that it covers autism (a developmental disability), but excluding coverage for all services “related to a developmental disability,” Providence is not covering treatment for mental health conditions in parity with treatment for medical conditions. Providence cannot identify any medical condition covered by its plan where there was an exclusion that could, on its face, deny coverage for all services “related to” the treatment for that condition. Moreover, Providence cannot provide any examples of a medical condition where an exclusion was used to deny coverage of the primary and widely-respected medically necessary treatment for that medical condition. Because of the broad-based Developmental Disability Exclusion, Providence covers mental health conditions at a different level than medical conditions in violation of the parity obligations.
The Developmental Disability Exclusion applies specifically and exclusively to mental health conditions. The Federal Parity Act requires that a plan have “no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.” The plain text of the Federal Parity Act prohibits “separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.” Thus, under the plain text of the statute, Providence’s Developmental Disability Exclusion is prohibited."
A good day for Oregonian with autism and their families and the rest of us around the nation who have federally regulated health plans.