The Great Insurance Debate-It's Time for the North Carolina General Assembly to Act

When Charlie was diagnosed as being on the autism spectrum, one of the first great sources of comfort that Caroline and I had was that autism therapies had progressed so far and that studies were showing that early intervention therapies do make a dramatic difference.  With that in mind, Caroline and I sought to get Charlie involved in as many therapies as possible as quick as possible. What we quickly came to learn was that therapies work wonders but they are not cheap. We also learned that most insurance plans, including ours at the time, did not cover the therapies that we saw were making such a dramatic difference with Charlie's development.  Upon learning that insurance didn't typically cover therapies, my first question was "Why Not?"

Nexsen Pruet, the law firm of which I am a member, has offices in North Carolina and South Carolina.  As I researched to find out why our insurance was not covering these therapies that worked so well I learned that my firm's insurance plan was self funded.  Because it is a self funded plan, our plan fell under federal ERISA laws rather than under any specific state laws.  This distinction was important for us because if our plan fell under state laws it would be subject to South Carolina law, which does require coverage for autism therapies.  Because our plan was subject to ERISA and ERISA does not have the requirements for coverage, our plan did not have to provide the coverage. This lead me to great disappointment

Alas, I found a source of great information on the Autism Speaks website.  Autism Speaks has put together a comprehensive library of information on its website here where one can get all the information they need to learn about the issue of insurance coverage of autism therapies. Important for me at the time was the "Self Funded Employer Tool Kit," which provides information for companies with self funded plans, like my law firm, that want to do the right thing and provide coverage for their employees.  With this information in hand, I approached the powers that be at my law firm with the request that our firm add the coverage.  I was happy to hear that I had a receptive audience and to find out that my firm voluntarily added coverage of autism therapies within six (6) months of my request.  I am now proud to see Nexsen Pruet listed in the Tool Kit alongside companies such as Wells Fargo, Bank of America, Eli Lilly, Microsoft, Oracle, Apple, and Merck as companies who have voluntarily taken the steps to do what is right by their employees and voluntarily adopt coverage of autism therapies.  If you want to read more about my story in this regard, here is a post I wrote for Autism Speaks last summer.

I was happy that my family had gotten the coverage that we needed, but I was still disappointed to see that my home state, North Carolina, was among the minority of states that does not require insurance coverage for autism therapies.  I'm never one to just sit with my disappointment so I decided to get involved in the mission to push North Carolina from the minority to the majority.  I quickly learned that one of those who was leading the cause was Lorri Unumb with Autism Speaks. I had a connection with Lorri because one of my roommates from law school clerked for the same judge that Lorri had clerked for in the past.  I used this connection to get in touch with Lorri and join the cause for change in North Carolina in the summer of 2013.

In April of 2013, a bill was introduced in the North Carolina House of Representatives to require coverage for autism therapies.  This bill gained traction with the help of some caring sponsors and was eventually heard in Committee and before the  House.  I was pleased to see the bill pass rather easily in the House. Unfortunately, that was the end of that bills movement for the following two years. The 2013 session of the North Caroline Senate came and went without as much as a hearing on the bill.  We were hopeful for 2014 that the North Carolina Senate would finally come around and give the bill the hearing it deserved. I traveled to Raleigh on two occasions, including one time with Charlie and Keller in tow, to ask the Senators to give our bill a hearing. Unfortunately, that hearing never happened and the bill eventually died.

2015 has brought better news for autism families in this regard, but the news is not perfect. SB 676 was introduced by Senator Apodaca in the North Carolina Senate on March 26, 2015.  The bill made it through the Senate and is now in the House. This bill does provide for insurance coverage of autism therapy but unfortunately it also has some rather large holes in it that were carved by the insurance lobby. Most notably, SB 676 exempts Autism Spectrum Disorders from the protections of the Mental Health Equity requirements. Interestingly, the only other two types of mental health illnesses that are exempted from these protections are "substance-related disorders" and "sexual dysfunctions not due to organic diseases." 

For the life of me, I cannot figure out why anyone would group autism with these two categories and carve it from these protections. The only partial explanation I can come up with is that it is because people do not understand the ramifications of not affording the protections. So what are the ramifications? Many of them don't have anything to do with insurance whatsoever. Instead, the ramifications include that:        

• A mental illness designation is relevant to a finding that an individual lacks the capacity to manage the individual's own affairs.
•  A mental illness designation is relevant to a determination that an individual is eligible for voluntarily admission (or involuntarily commitment) to a facility for inpatient or outpatient mental health treatment.
• The designation is relevant in a variety of family court contexts pertaining to divorce, custody, guardianship, and conservatorship.
•   A mental illness designation is relevant in a variety of trust and estate matters.
• A mental illness designation helps determine whether an individual is entitled to special protection under NC’s law dealing with “Assaults on handicapped persons.” (G.S. § 14-32.1, creating harsher punishments for an individual who “inflicts serious injury or serious damage to a handicapped person”).
•  If a person with autism has a brush with the law, the “mental illness” legal designation is relevant in determining whether the individual is mentally incompetent to proceed to criminal trial.
•  In the event that an individual does stand criminal trial, the mental illness designation is a precursor to a finding that an individual is “not guilty by reason of insanity.” (There is a case pending now where the defense is that the child with autism was incapable of forming the requisite intent for the “criminal” act.)
• Mental health status is relevant as to insurance issues unrelated to the autism bill; for example, NC law prohibits insurers from refusing to enroll an individual in a physical illness/injury plan or having higher premiums for physical coverage solely because the individual has or had a “mental illness.
• North Carolina law deems “mental illness” relevant in determining whether early repayment of a reverse mortgage loan maybe required (§ 53-267 - Repayment upon borrower's default).
• Eligibility requirements for NC Supportive Housing Program give priority to individuals diagnosed with mental illness.  (G.S. § 122C-20.8)

One of the major ramifications that I have personal experience with is that it allows insurance companies to limit the number of "in network" providers who are allowed to provide covered therapies.  This is an issue that we have run into and worked out with our insurance provider.  In looking to get covered therapies, we soon found that there were barely any "in network" providers we could use to provide Charlie the therapies that he needed.  Because the carve out had not yet occurred, I was able to convince our insurance company to add more providers who we had used as in network providers.  If the carve out was in place, I do not believe I would have been as successful in that regard and we would have been in a position where we had coverage but could not get the services because the providers just did not exist.

I plan to write more on this in the future, but I wanted to get the information out there as it is my hope that the North Carolina House of Representatives will soon take up SB 676 and work to amend it to remove the Mental Health Equity carve out and to fix some other holes.  I am pleased to see that the North Carolina Senate is now seeing the importance of this coverage and its my hope that the Senate will work with the House to structure a bill to provide North Carolina Autism Families with the coverage that they deserve.

If you want to help join the fight, please contact your representative and ask them to help amend SB 676 and get rid of the Mental Health Equity carve out. To find your representative's contact information, click here. 

How As Parents Are We Allowing Bullying to Happen?

I was driving to Raleigh for a hearing yesterday afternoon and listening to Sports Radio as I typically do. The show I was listening to started talking about two stories from the sports world that the host called Chicken Soup for the Sports Soul.  

The first story had to do with Tiger Woods writing a personal letter to a 14 year old boy, yes 14 year old boy, with a stuttering problem who had attempted suicide because of the bullying that he had suffered from classmates. That story is here. 

The second story had to do with Roy Williams, UNC basketball coach, who similarly wrote a personal letter to a boy with Asperger's syndrome who had also been bullied by his classmates.  With respect to this 11 year old boy, yes 11 year old boy, the bullying he endured included threats via social media and culminated in an attack at his school cafeteria that resulted in a concussion and hospitalization. That story is here. 

The host went on to applaud Tiger Woods and Roy Williams.  I agree that Tiger and Roy should be should be commended for their acts in making a difference for these families that are undoubtedly going through some of the most difficult of times. 

I did not take these two stories as "Chicken Soup for the Sports Soul."  In fairness to the host, he prefaced the stories by saying if his kids were ever involved in any of the bad activities there would be big problems in his house.and he went on to say that behavior like that of these kids is completely unacceptable and is the lowest of the low

What the two stories left me with was the burning question, "Is this what Charlie is going to have to go through as he makes his way through elementary school, middle school, and high school?"  As part of that question, I asked myself, "Have kids really gotten to the point where they behave this poorly?"  The answer to that is apparently unfortunately "Yes" so that leads to the questions "Why on earth are parents letting their kids act in this way towards others?" and "What do we do to put an end to this behavior?"

As appalled as I am to hear about these stories, I think the emotion that I have more in hearing the stories is fear.  Charlie continues to make progress and we hope will continue to even make more progress, but, truth be told, he is most likely going to at least be a little bit different than other kids. Caroline and I love those differences and we cherish and will always cherish Charlie for what he is. But, I am enough of a realist to realize when hearing these stories that other kids aren't always going to value and understand those differences as much as Caroline and I will.  Its more likely than not that at some point in our future that those differences are going to lead to Charlie being bullied in some shape or form.  I'd love to be wrong on that, but I fear it won't be the case. And that is why when I heard the story about Drew Summerlin described above as I was driving to Raleigh, my stomach just dropped and I thought, "Something needs to change. I don't want to live in a world where there is even a chance Charlie has to go through something like Drew."

Apparently, bullying has hit a whole new level with the advent of the Internet.  The stories we read about what kids write online about other kids is down right disgusting.  Moreover, the fact that bullying is turning more and more physically aggressive is equally as disgusting and leads me to have even more fear.  

And that takes me back to the question of "How Do We Stop Bullying?"  Seems to me the first step in the equation is for parents to know what their kids are doing and how they are acting.  I know that we as parents and adults have a lot of stuff on our every day plates.  However, there is nothing more important on those plates than our relationships with our children.  As parents we should be asking our kids about their days in an open and honest manner with true care about what their answers are to our questions.  As parents we should be directing our children into healthy and good relationships with all of their classmates no matter those classmates race, religion, financial status, or abilities.  As parents we should be stressing to our kids that they should include all of their classmates and make sure everyone feels welcome at school and gets the most out of school.  As parents we should be ready, willing, and able to reprimand our kids in a fair and healthy manner which will put them back on track when they undertake behavior that is not acceptable.  As parents we should strive to make our kids understand that they should be the kids that we wish that we were when we look back on our childhood.  As parents we should be showing our kids that we care about them not just because they are our kids but also because they are people and as people we should care about all other people.

I can only think that the kids who are undertaking this repulsive bullying are at least doing so in part because they are trying to grab their parents attention.  Certainly any parent who is paying proper attention to their child would never allow their child to knowingly act in this manner.  If they are, there is a fine place in hell for them and they have no business raising children.  

As a second step, I think we need to call on our teachers and school administrators to continue to be involved in the fight against bullying and to place social learning at a higher place on the educational pedestal than it currently resides.  I bet most bullying starts at school. When I hear the stories like those above I can't help but wonder  how did a situation occur in a school where a boy was concussed in the cafeteria and teachers could not stop it.  How did teachers not know this behavior was going on and how was it not stopped?  I understand that our teachers live in a world of underfunded and overcrowded classrooms and they are working hard and doing their best to educate students.  I understand that teachers do not in any way endorse this terrible behavior.  Teachers are of course their to educate. Part of education is what kids learn in their books.  Unfortunately, I think it is that part that has become the sole focus of our schools as teachers are pushed harder and harder to emphasize what academic goals kids must meet.  As a result of this focus,  the part of education that involves social smarts and teaching children how to interact with their peers is going by the wayside. Without this education, kids are missing another layer of social learning and are missing the message that they should treat all kids, no matter how different, with the dignity and respect that they would like to be treated. Without this education, kids are not learning some of life's most valuable lessons.

These are the two things that came to my mind as I have thought about these two stories a lot since yesterday.  I am sure there are other things and I hope those come to mind and that an open and frank discussion is had on the topic of bullying before more kids have to suffer.

I always like to end my blogs on a more positive point so here is today's. I will say that I was blown away by the Top Soccer program that Charlie participated in this spring.  Charlie had played U-4 soccer with the typically developing kids this fall but I saw an advertisement for Top Soccer and thought we would try it out. Top Soccer is a local soccer program for kids with special needs. The way the program works is that the kids spend an hour a week with their "buddy" or "buddies" and participate in soccer drills.  The "buddies" include normally developing high school and middle school kids. As bad as I felt hearing the two stories above, I felt that much better seeing these kids embracing kids like Charlie and relishing the time spent interacting with them.  In fact, Charlie's "buddy" Catroina has even come to a couple of Charlie's U-4 practices because she has such fun playing with him and he has such fun with her.  Those experiences showed me that its not all kids that are these bullies. Nope, there are some good ones out there.