Legislature(2009 - 2010)CAPITOL 106

01/28/2010 03:00 PM House HEALTH & SOCIAL SERVICES

Download Mp3. <- Right click and save file as

* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Moved CSHB 110(HSS) Out of Committee
Heard & Held
         HB 187-INS. COVERAGE: AUTISM SPECTRUM DISORDER                                                                     
3:58:18 PM                                                                                                                    
CO-CHAIR KELLER announced that the  final order of business would                                                               
be HOUSE  BILL NO. 187  "An Act requiring insurance  coverage for                                                               
autism   spectrum   disorders,    describing   the   method   for                                                               
establishing a  treatment plan for those  disorders, and defining                                                               
the treatment required for those  disorders; and providing for an                                                               
effective date."                                                                                                                
3:59:16 PM                                                                                                                    
CO-CHAIR  KELLER reflected  on  testimony  that Applied  Behavior                                                               
Analysis (ABA) was working well,  and had resulted in a financial                                                               
savings.   He commented that  the fiscal impact on  the insurance                                                               
companies needed to be scrutinized.                                                                                             
4:00:47 PM                                                                                                                    
CO-CHAIR KELLER re-opened public testimony.                                                                                     
4:01:13 PM                                                                                                                    
CO-CHAIR HERRON moved to adopt  the proposed committee substitute                                                               
(CS) for  HB 187,  Version 26-LS0641\P,  Bailey, 1/27/10,  as the                                                               
working document.                                                                                                               
4:01:31 PM                                                                                                                    
REPRESENTATIVE SEATON  objected in order to  hear the differences                                                               
from the original bill.                                                                                                         
4:01:45 PM                                                                                                                    
REPRESENTATIVE   PETE   PETERSEN,   Alaska   State   Legislature,                                                               
summarized   the  changes   in  Version   P,  which   included  a                                                               
clarification  that  "medically  necessary" was  applied  to  the                                                               
entire  bill, the  definition of  "autism  service provider"  was                                                               
provided  to be  more specific,  and the  effective date  and the                                                               
date for inflation adjustment were amended.                                                                                     
REPRESENTATIVE SEATON removed his objection.                                                                                    
[Version P was adopted as the working document.]                                                                                
4:03:55 PM                                                                                                                    
REPRESENTATIVE  SEATON  asked  if  insurance  coverage  could  be                                                               
limited to a specific amount for a particular disorder.                                                                         
4:04:51 PM                                                                                                                    
REPRESENTATIVE PETERSEN,  in response,  said that he  would refer                                                               
that question to Linda Hall.                                                                                                    
4:05:14 PM                                                                                                                    
REPRESENTATIVE  SEATON opined  that  an answer  was necessary  in                                                               
order to move forward with this plan.                                                                                           
4:06:08 PM                                                                                                                    
CO-CHAIR  KELLER referenced  the pie  chart, "Health  Coverage of                                                               
Alaska  Population," [Included  in  the  committee packets.]  and                                                               
pointed out that  HB 187 would only mandate  coverage for private                                                               
insurance,  which covered  23 percent  of Alaskans,  and included                                                               
48,000 children.   He directed attention to  an earlier testimony                                                               
from  Mr.  Jim Bouder,  whose  cost  estimate  was based  on  the                                                               
prevalence of autism spectrum disorder,  and he noted a disparity                                                               
between these estimates and the projected cost in Alaska.                                                                       
4:08:07 PM                                                                                                                    
REPRESENTATIVE  PETERSEN replied  that the  cost depended  on the                                                               
number  of parents  seeking  treatment for  their  children.   He                                                               
observed that rural  Alaskans had limited easy  access to medical                                                               
services.   He shared that  the Providence Alaska  Medical Center                                                               
autism  diagnostic network  provided  20 hours  of diagnosis  for                                                               
each  child patient  and the  network evaluated  6 children  each                                                               
week.   He informed the  committee that  this only resulted  in a                                                               
two month  backlog for the  individual treatment  plans, compared                                                               
to a six to eight month backlog  in Seattle.  He opined that this                                                               
backlog could diminish with passage  of HB 187, as typically more                                                               
providers worked in an area where insurance coverage existed.                                                                   
4:11:29 PM                                                                                                                    
CO-CHAIR  KELLER asked  about  the projected  cost  of $3.60  per                                                               
member  policy  in Alaska.    He  recalled  that Mr.  Bouder  had                                                               
estimated  a premium  cost  of  $2.24 when  there  was an  autism                                                               
prevalence of  1:400, and $5.81 with  a prevalence of 1:250.   He                                                               
asked the  sponsor about the  projected prevalence of  1:100, and                                                               
how that reconciled with the projected premium cost of $3.60.                                                                   
4:12:58 PM                                                                                                                    
REPRESENTATIVE  PETERSEN referred  to estimates  from the  Center                                                               
for Disease Control (CDC) that  1:100 children would be diagnosed                                                               
with some form  of autism.  He reported the  $3.60 calculation to                                                               
be a mid-range  estimate, which was supported by  an actuary from                                                               
the Division of  Insurance.  He shared that  the prevalence range                                                               
had been  raised, so  that it  might be  necessary to  revise the                                                               
cost calculation.   He opined that it would depend  on the number                                                               
of families  seeking treatment, and,  in response to  a question,                                                               
he said  that few  families sought  treatment out  of state.   He                                                               
commented  that  those  were  often  severe  autism  cases  which                                                               
required a specialist not available in Alaska.                                                                                  
4:14:29 PM                                                                                                                    
CO-CHAIR  KELLER declared  that, although  emotionally difficult,                                                               
it  was  a necessary  responsibility  to  review  the cost.    He                                                               
pointed out that  the cost projections were based  on an existing                                                               
adequate provider  network, and that  this network did  not exist                                                               
in Alaska.  He asked the sponsor for a projection.                                                                              
REPRESENTATIVE  PETERSEN replied  that he  was encouraged  by the                                                               
availability  of   treatment  in  Alaska.     He  referenced  the                                                               
Governor's  Council on  Disabilities &  Special Education,  which                                                               
reported that 15 autism specialists  were currently enrolled in a                                                               
two  year  program.   He  explained  that,  after 1500  hours  of                                                               
supervised field work, they would  be board certified [associate]                                                               
behavior  analysts.   He reported  that Alaska  was projected  to                                                               
need 30 analysts.  He observed  that there were also six graduate                                                               
students working  on the  field work  for the  certification, and                                                               
that more would enter the field as the demand increased.                                                                        
4:17:55 PM                                                                                                                    
REPRESENTATIVE CISSNA  asked for an  estimate to the  increase in                                                               
autism, and  she opined that  parents not trained  in recognizing                                                               
behaviors  could   miss  the   early,  initial   opportunity  for                                                               
treatment.  She  offered support for HB 187, as  it could lead to                                                               
a healthier  workforce.   She suggested  that family  and friends                                                               
could help with the treatment to offset some of the cost.                                                                       
4:20:53 PM                                                                                                                    
REPRESENTATIVE  T.  WILSON  asked   if  any  private  [insurance]                                                               
companies offered  autism coverage,  and why the  state insurance                                                               
plan did not offer autism coverage.                                                                                             
4:21:17 PM                                                                                                                    
REPRESENTATIVE  PETERSEN opined  that the  governor was  aware of                                                               
this legislation.  He offered his  belief that it was not unusual                                                               
for the  state to adopt  a "wait and  see" approach, and,  as the                                                               
effective date for  the bill would be January 1,  2011, the state                                                               
would be able to "sign on."                                                                                                     
4:22:19 PM                                                                                                                    
REPRESENTATIVE SEATON  pointed to  the definition  for "medically                                                               
necessary,"  Section  1, Subsection  (e)(5)  of  Version P.    He                                                               
explained that  for workforce  injuries, any  treatment performed                                                               
was defined  as "medically necessary;" whereas  HB 187 identified                                                               
that anything  could be medically  necessary.  He asked  if there                                                               
was  a  broad spectrum  of  services  that  would be  defined  as                                                               
"medically necessary" under subparagraphs  (A)-(C).  He expressed                                                               
concern that  a lack of  treatment restrictions could add  to the                                                               
4:23:45 PM                                                                                                                    
REPRESENTATIVE  PETERSEN relayed  that Providence  Alaska Medical                                                               
Center reached  a diagnosis, identified the  child's placement on                                                               
the spectrum,  and developed  an individual  treatment plan.   He                                                               
said  that  HB  187  would limit  the  insurance  company  annual                                                               
liability to $36,000.                                                                                                           
4:24:50 PM                                                                                                                    
REPRESENTATIVE SEATON  pointed out that  the wording of  the bill                                                               
would  make  it  a  statutory requirement  that  the  plan  "must                                                               
identify all  the medically necessary pharmacy  care, psychiatric                                                               
care,  psychological care,  rehabilitative care,  and therapeutic                                                               
care required."   [Version P, Section 1, page 1,  lines 13-14 and                                                               
page 2, line 1.]  He expressed  that this might be a much broader                                                               
list  than  a sequential  plan,  and  that  there might  be  some                                                               
unintended consequences.                                                                                                        
4:25:55 PM                                                                                                                    
CO-CHAIR KELLER  referenced a prior testimony  which stated there                                                               
were  no  biological markers  for  autism,  and he  opined  that,                                                               
therefore,  a general  practitioner could  not make  a diagnosis.                                                               
He asked  if any other  statutes defined "medical  necessity" and                                                               
he also expressed concern for any unintended consequences.                                                                      
4:26:38 PM                                                                                                                    
REPRESENTATIVE    PETERSEN   listed    the   autism    diagnostic                                                               
contributors at  Providence Alaska  Medical Center to  include an                                                               
occupational    therapist,   speech    therapist,   developmental                                                               
pediatrician, nurse practitioner, and social worker.                                                                            
4:27:24 PM                                                                                                                    
GWENDOLYN  LEE  expressed  her  support   for  HB  187  as  early                                                               
intervention would  now be eligible  for insurance payment.   She                                                               
established  the critical  necessity for  early diagnosis,  which                                                               
often resulted  in an  enhanced quality  of life  and functioning                                                               
skill level.   She  directed attention  to the  payment cap  as a                                                               
protection for the insurance companies.                                                                                         
4:30:23 PM                                                                                                                    
KATHLEEN  FITZGERALD,  Chair,   Developmental  Disabilities  (DD)                                                               
Committee,  Autism  Ad  Hoc   Committee,  Governor's  Council  on                                                               
Disabilities & Special Education, reported that neuro-                                                                          
psychiatric developmental  clinics were now in  Barrow, Kotzebue,                                                               
Nome, Bethel,  Dillingham, Kodiak, Fairbanks,  Juneau, Ketchikan,                                                               
and  Anchorage.   She  certified that  this had  lead  to a  much                                                               
better  job of  screening  and  diagnosing.   She  shared that  a                                                               
developmental diagnosis  for autism  needed a  multi disciplinary                                                               
team,  as it  was  neuro developmental  without medical  markers.                                                               
She  reported   that  diagnosis  and  treatment   for  a  broader                                                               
spectrum, instead  of just for  severe autism, had  increased the                                                               
statistic  for  reported autism.    She  specified that  not  all                                                               
children  would  need the  most  intensive  services, with  fewer                                                               
using the full  range of treatments.  She relayed  that the group                                                               
had   received  a   federal  grant   which   focused  on   autism                                                               
identification and  diagnosis in rural communities,  to allow for                                                               
quicker, appropriate intervention.                                                                                              
4:35:24 PM                                                                                                                    
MS. FITZGERALD  explained that  it was  now possible  to identify                                                               
experts  to tie  in  with the  Alaska system.    She opined  that                                                               
within  two  years, there  would  be  good in-state  options  for                                                               
families.  She offered her belief  that insurance needed to be an                                                               
integral means  of payment for  the services.  She  mentioned the                                                               
possibility  of  obtaining an  early  intervention  waiver.   She                                                               
emphasized  that a  lot of  time and  thought had  been given  to                                                               
developing a thorough system that  brought appropriate service to                                                               
4:38:04 PM                                                                                                                    
TANJA  UPDIKE,  Governor's  Council  on  Disabilities  &  Special                                                               
Education, declared  that she  was a member  of the  council, but                                                               
more important, she  was a mother with a child  with autism.  She                                                               
shared  some poignant  moments  of his  early  childhood and  the                                                               
obstacles posed for  her family.  She relayed that  she faced on-                                                               
going resistance  to payments  from the  insurance carrier.   She                                                               
touted  the importance  of early  diagnosis and  treatment.   She                                                               
expressed her strong support of HB 187.                                                                                         
4:42:20 PM                                                                                                                    
MS.  FITZGERALD reiterated  the cost  savings, and  the need  for                                                               
special  education   and  early   intervention.  She   offered  a                                                               
recommendation for  a change  to the  wording of  the bill.   She                                                               
pointed to the  original bill, page 3, line 28,  and suggested to                                                               
add  the word  "administered," after  "delivered," as  this would                                                               
also  cover  the  responsibility   for  out  of  state  insurance                                                               
companies working in Alaska.                                                                                                    
4:43:59 PM                                                                                                                    
REPRESENTATIVE  SEATON requested  that  Ms. Fitzgerald  reference                                                               
her suggestion to Version P.                                                                                                    
4:44:17 PM                                                                                                                    
MILLIE   RYAN,   Executive   Director,  Governor's   Council   on                                                               
Disabilities  &   Special  Education,   offered  to   answer  any                                                               
4:44:53 PM                                                                                                                    
CO-CHAIR KELLER  asked what  was the best  way to  offer coverage                                                               
for autism.                                                                                                                     
4:46:15 PM                                                                                                                    
MS.  RYAN replied  that a  responsibility of  insurance companies                                                               
was to  cover health  costs. She stated  that autism  should have                                                               
the necessary  coverage for  health care  services.   She allowed                                                               
that the family and the state  of Alaska could also pay, but that                                                               
one entity should not bear the entire cost.                                                                                     
4:47:19 PM                                                                                                                    
CO-CHAIR KELLER  said that insurance companies  sold a commodity,                                                               
and he  opined that it  was difficult to get  insurance companies                                                               
to serve Alaska.   He questioned how many  mandates the insurance                                                               
companies in Alaska would accept and continue to offer coverage.                                                                
MS RYAN reported that the  actuarials indicated the cost would be                                                               
$3.60 per  insurance premium, but  she granted that  an unlimited                                                               
number of coverages would not be feasible.                                                                                      
4:48:55 PM                                                                                                                    
REPRESENTATIVE  T. WILSON  asked Ms.  Updike about  her insurance                                                               
MS. UPDIKE replied that her insurance did not pay, but that                                                                     
TEFRA [Tax Equity and Fiscal Responsibility Act] and the state                                                                  
of Alaska offered some coverage.  She explained that her son                                                                    
received minimal therapies, and that many were administered at                                                                  
home.  She reported that without the guidance of a good care                                                                    
provider, many families would not be aware of TEFRA.  She                                                                       
reported that her insurance company told her that autism was "a                                                                 
delay or it's something he will grow out of, so he doesn't need                                                                 
4:50:05 PM                                                                                                                    
REPRESENTATIVE T.  WILSON asked  about the  annual out  of pocket                                                               
JENNIFER CARD,  Licensed Clinical  Social Worker,  disclosed that                                                               
she was  a licensed clinical  social worker  and the mother  of a                                                               
child with  autism.  She reported  that when she moved  to Alaska                                                               
six years  ago, she experienced difficulties  in finding services                                                               
for her son,  so she pursued a Masters degree  in social work and                                                               
certification  in Applied  Behavior  Analysis in  order to  offer                                                               
better care  for her son.   She related that it  was necessary to                                                               
hire support staff to maintain a  home care program, and this was                                                               
not  covered by  TEFRA.   She  shared that  the cost  for a  care                                                               
provider  was $15/hr  for 30  hours a  week.   She expressed  the                                                               
difficulty for families who did not have that money.                                                                            
4:52:35 PM                                                                                                                    
REPRESENTATIVE  CISSNA  expressed  concern with  "not  having  in                                                               
state services  for our children."   She asked  for clarification                                                               
to the number  of autistic Alaskan children being  treated out of                                                               
state.  She questioned the cost of not having in state care.                                                                    
4:53:42 PM                                                                                                                    
MS. RYAN,  in response  to Representative  Cissna, said  that 118                                                               
children with  the most  severe issues were  still out  of state,                                                               
and of  these, she estimated  that 25  children had autism.   She                                                               
opined  that  some of  these  kids  might  qualify for  a  mental                                                               
retardation developmental disability waiver.   She explained that                                                               
it would be  best to serve them  in Alaska, which was  a tenet of                                                               
the Bring the  Kids Home program.  She offered  her belief that a                                                               
more specialized provider would be necessary in Alaska.                                                                         
4:55:47 PM                                                                                                                    
REPRESENTATIVE  CISSNA commented  on  the  difficulty of  keeping                                                               
resources  in Alaska.   She  directed  attention to  the cost  to                                                               
society of having a child not get service in Alaska.                                                                            
4:56:38 PM                                                                                                                    
MS. RYAN  referenced a  study done  by Harvard  economist Michael                                                               
Ganz, and she stated that "it  cost about $3.2 million per capita                                                               
to not provide services at the  time when it is most needed which                                                               
is as soon as the child is diagnosed."                                                                                          
4:57:25 PM                                                                                                                    
LORRI UNUMB,  Attorney and Senior Policy  Advisor, Autism Speaks,                                                               
Former Law  Professor, George  Washington University  Law School,                                                               
said that  she became a full  time advocate for kids  with autism                                                               
when she  became aware  of the inequity  in the  insurance arena.                                                               
She  presented a  PowerPoint.   Referring to  slide 2,  she noted                                                               
that the term autism was often  misused to refer to either autism                                                               
spectrum disorder or one of the  disorders.  She pointed to slide                                                               
3, and  explained the umbrella category,  pervasive developmental                                                               
disorders, which  included: autism spectrum disorder.   She noted                                                               
the  three  disorders  included   in  autism  spectrum  disorder:                                                               
autistic   disorder,   asperberger    syndrome,   and   pervasive                                                               
developmental  disorder not  otherwise specified  (PDDNOS), which                                                               
was a milder form of autism.                                                                                                    
MS. UNUMB  noted that there was  treatment for autism, but  not a                                                               
known  cure.   She shared  that Applied  Behavior Analysis  (ABA)                                                               
therapy  resulted  in a  physiological  change,  detectable in  a                                                               
brain scan.  She reported that  although ABA therapy was the most                                                               
commonly prescribed  protocol, it was a  denied coverage, labeled                                                               
by insurance  companies as  experimental.   She pointed  to major                                                               
insurance   company  policies   which  explicitly   excluded  ABA                                                               
therapy.    She  observed  that  the  Surgeon  General,  National                                                               
Research Council,  and American Academy of  Pediatrics all stated                                                               
that ABA  therapy was not  experimental or investigational.   She                                                               
shared studies of ABA therapy  which indicated that 47 percent of                                                               
the kids  overcame the  disabling condition  "to the  extent they                                                               
can go  to first grade  indistinguishable from their peer."   She                                                               
noted  that  the  remaining  53  percent  also  made  significant                                                               
clinical gains.                                                                                                                 
5:02:08 PM                                                                                                                    
MS. UNUMB  disclosed that, as  ABA therapy was intensive,  it was                                                               
also expensive, and  that the treatment for her  son cost $75,000                                                               
per  year,  out  of  their  pockets.   She  revealed  that  these                                                               
extraordinary  medical  expenses  had  resulted  in  three  [tax]                                                               
audits [by the  Internal Revenue Service (IRS)].   She noted that                                                               
children from families that could  not afford this treatment were                                                               
not treated, and  she lamented that a working  treatment was only                                                               
available to  the wealthy.   She opined  that this was  not fair,                                                               
especially to families who had insurance.                                                                                       
5:03:51 PM                                                                                                                    
MS. UNUMB referred to the  Harvard study mentioned earlier, which                                                               
projected  the  direct  and   indirect,  [loss  of  productivity]                                                               
lifetime  costs  of  $3.2  million.     She  pointed  to  a  1998                                                               
Pennsylvania  study which  showed a  direct taxpayer  cost of  $1                                                               
million for each un-treated child with  autism.  She pointed to a                                                               
slide  which charted  an increase  to the  prevalence rate.   She                                                               
opined that this would cost the  state of Alaska a huge amount if                                                               
the services were  not made available.  She  identified 14 states                                                               
which had enacted insurance reform.                                                                                             
5:06:48 PM                                                                                                                    
MS. UNUMB explained  that, in 2005, she wrote  the South Carolina                                                               
autism legislation and she had  seen it successfully implemented.                                                               
She  pointed   out  that  providers   had  joined   networks  and                                                               
negotiated satisfactory reimbursement rates,  and she shared that                                                               
the  number of  certified  behavior analysts  had since  doubled.                                                               
She welcomed  that no insurers  had left South Carolina,  and the                                                               
premium  increase  had  been  miniscule.   She  affirmed  that  a                                                               
similar bill was pending in 19 more states.                                                                                     
5:09:08 PM                                                                                                                    
MS.  UNUMB  referenced  an  annual  report  by  the  Council  for                                                               
Affordable Health Insurance titled  "Health Insurance Mandates in                                                               
the  States" which  listed  all the  insurance  mandates in  each                                                               
state  with  its estimated  impact  on  premiums.   She  directed                                                               
attention  to the  impact from  autism premiums,  which was  less                                                               
than 1  percent.  She  shared that  Autism Speaks had  a contract                                                               
with an independent actuarial firm  to produce studies on pending                                                               
bills, and  she offered for  an independent actuarial on  HB 187.                                                               
She pointed  out that  every state actuarial  study had  shown an                                                               
impact of less  than 1 percent.  She detailed  that the impact to                                                               
Minnesota premiums was  83 cents per month, and  the average cost                                                               
per  patient for  ABA  therapy  was $30,000.    She reminded  the                                                               
committee that Minnesota had an unlimited cap on autism therapy.                                                                
5:10:58 PM                                                                                                                    
MS.  UNUMB  noted that  South  Carolina  had included  the  state                                                               
employee health  plan within the  mandate at an  estimated annual                                                               
cost of  between $9  and $18.9  million.   She observed  that the                                                               
actual  cost  was  $856,371,  which was  a  member  premium  cost                                                               
increase of 20 cents per month.                                                                                                 
5:12:34 PM                                                                                                                    
REPRESENTATIVE SEATON asked for a copy of the PowerPoint.                                                                       
5:13:39 PM                                                                                                                    
JAMES BOUDER, COO, The Vista School and The Vista Foundation,                                                                   
submitted his cost benefit analysis and explained that the                                                                      
Pennsylvania cost for its mandate, which was similar to HB 187,                                                                 
was less than 1 percent.  He pointed out that by applying this                                                                  
same methodology, Alaska could expect an impact of less than 1                                                                  
percent on premiums.  He agreed that once a funding stream was                                                                  
accessible, providers would become more available.  He said a                                                                   
gradual cost increase would be spread over the first five to six                                                                
years.  He discounted the idea that this would dramatically                                                                     
impact premiums.                                                                                                                
5:17:17 PM                                                                                                                    
MR. BOUDER  testified that  actuarial firms  had all  agreed with                                                               
his findings  of a minimal cost  impact.  He estimated  that this                                                               
would cost Alaskan  rate payers about $3.60 month.   He confirmed                                                               
that the mandate was not  a significant cost, but emphasized that                                                               
as  an investment,  extending these  services would  result in  a                                                               
savings  of  $667 million  over  the  lifetime of  children  with                                                               
autism in  Alaska.  He  opined that this  was a low  upfront cost                                                               
with  a  significant   return  on  investment  over   time.    He                                                               
reiterated the  importance of avoiding  the human  service costs,                                                               
and  noted that  people  with  autism will  get  jobs and  become                                                               
5:20:56 PM                                                                                                                    
REPRESENTATIVE SEATON referring to Version P, page 1, lines 9 -                                                                 
13,  asked if  this would  exclude  care normally  provided by  a                                                               
waiver.  He  also asked if Version P would  require that the only                                                               
care providers  would be  those listed  in Section  1, subsection                                                               
(e), paragraph (1)(A)-(E).   He opined that this was  not what he                                                               
believed to be the intent.                                                                                                      
[HB 187 was held over.]                                                                                                         

Document Name Date/Time Subjects
187sup.PDF HHSS 1/28/2010 3:00:00 PM
hb110pkt.PDF HHSS 1/28/2010 3:00:00 PM
HB 110