Background: The 1997 Legislature modified the statutory requirements for review of all mandated health insurance benefits. Proposals for additional mandated benefits are subject to a "sunrise review" to be completed by the Department of Health (DOH). Each proposal must be evaluated with criteria established in law that include an assessment of the social impact, the financial impact, and evidence of health care service efficacy.

DOH received a request to complete a sunrise review of a mandated benefit for the treatment of autism spectrum disorders. The final report is available, with a recommendation that the Legislature not enact the proposal. The benefit proposal is reflective of some interest expressed by the Caring for Washington Individuals with Autism Task Force, which issued recommendations in December 2006. The Autism Task Force and the DOH sunrise review recognize autism spectrum disorders as pervasive developmental disorders with a wide range and severity of symptoms. Autism spectrum disorders affect as many as one in 150 children nationally, and three to four times more boys than girls. Treatment can include psychiatric care, neurodevelopmental therapies such as occupational therapy, physical therapy and speech therapy, and treatment for co-occurring medical conditions. Treatment is often not covered or very limited in most insurance plans. Current insurance mandates require neurodevelopmental therapies in group coverage offered through a regulated carrier, with limited coverage for children up through age six.

Summary of Bill: Insurance carriers and health plans offered through the Public Employees Benefits Board program must cover the diagnosis and treatment of autism spectrum disorders for individuals less than 21 years of age. Autism spectrum disorders are defined to mean any of the pervasive developmental disorders defined by the most recent edition of the diagnostic and statistical manual of mental disorders. Coverage must include all medically necessary care which is defined to include any care, treatment, intervention, service, or item that is prescribed, provided, or ordered by a licensed physician or licensed psychologist. Treatment is defined to include any care prescribed, ordered, or provided by a licensed physician or licensed psychologist, including applied behavior analysis and other structured behavior programs, pharmacy care, psychiatric care, psychological care, therapeutic care, and any care determined to be medically necessary in rules developed by DOH.

The coverage may have no limits on the number of provider visits, but is subject to a maximum of $50,000 per year. The limitations are not to impact those benefits available under the mandated mental health benefits. The Insurance Commissioner must adjust the benefit maximum annually for inflation using the medical care component of the United States Department of Labor consumer price index for all urban consumers.

Insurance carriers have the right to request a review of the treatment no more than every six months, except for inpatient services.

DOH must adopt rules establishing standards for qualified autism services providers. Once rules are adopted, payment for the treatment of autism spectrum disorders can be made only to autism service providers who meet the standards.

Staff Summary of Public Testimony: PRO: The limited coverage available today cuts children off at age seven, leaving them no chance to achieve their maximum ability. The impacts of autism create a societal impact that is bigger than our state budget, that leave long-term effects on society. The burden is largely placed on our school districts today and they are not health providers. Autism is a medical condition and requires an appropriate response in the health care arena.

Early intervention for autism is very important, and makes a tremendous difference in skill development and potential for these children. Autism requires a multidisciplinary approach, and years of research and journal articles have documented the success of applied behavioral therapy. Insurance carriers should not be denying this therapy as experimental. It is time to bring these treatments we know work to people that need them. Evidence suggests that the applied behavioral therapy is more effective than the traditional neurodevelopmental therapies: speech, physical therapy, and occupational therapy. Fifty percent of children who have received applied behavioral therapy are indistinguishable from other children by first grade; the early intervention makes a difference.

The lack of coverage for these treatments is discriminatory. Coverage should be similar to coverage for other medical conditions. Coverage would also improve the provider capacity and access to providers. There is a national board that certifies providers, the independent Behavior Analyst Certification Board. This national certification is appropriate for Washington providers, in fact there are 63 nationally board certified analysts in Washington now.

Applied behavioral therapy has no Current Procedural Terminology (CPT) code associated with it, but there is coverage and payment approved for psychotherapy, talk therapy with less evidence of effectiveness. Schools should not be expected to provide the behavioral therapy; teachers are not behavioral therapists and they do not have the necessary time to spend with each child.

OTHER: Insurance carriers already provide coverage for some of these services under two mandated benefits, the neurodevelopmental therapies and the mental health parity requirements. An approach in the House that broadens the neurodevelopmental therapies is a clearer approach. The bill is very broad as to the type of services and quantity of services to be covered, and the type of person that can provide services. Operationally, there is a challenge because there is no CPT code associated with applied behavioral therapy.

Persons Testifying: PRO: Senator Hobbs, prime sponsor; Arzu Forough, parent advocate; Dr. Bryan King, Children's Hospital; Dawn Sidell, Northwest Autism Center; Michael Fabrizio, Families for Effective Treatment of Autism; Laila Praino, child with autism; Denise Fulton, Autism Research Institute; Bryan Krikorian, attorney and parent; Lorri Unumb, Autism Speaks; Ethan Pruett, Angela Fish, Wyatt Holliday Foundation; Dale and Connor Pryor, parent and son; Patty Gee, Autism Society of Washington; Teresa Mundel, Dr. Yi Cau, Brandelyn Bergstedt, parents; Beth Shubert, Washington Autism Advocacy.

OTHER: Mel Sorenson, America's Health Insurance Plans; Sydney Zvarra, Association of Washington Healthcare Plans.

Signed In, Unable to Testify & Submitted Written Testimony: PRO: Leslie Emerick, Tamra Warnke, Association of Advanced Practice Psychiatric Nurses; Dr. Gary Stobbe, Autism Spectrum Treatment and Research; Janelle Hall, Patricia Solano-Fah, parents.