Autism Insurance Act 62-Mandates coverage of the “treatment of autism spectrum disorders,” and defines the term to include “medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care”.
What Families need to Do now: Download the Act62 Second Letter To Families.pdf
Autism Insurance Law (ACT 62) Frequently Asked Questions:
What does Autism Insurance Act (Act 62) do?
Broadly speaking, Act 62 does three main things:
- It requires many private insurers to begin covering the costs of diagnostic assessments for autism and of services for individuals with autism who are under the age of 21, up to $36,000 per year.
- It requires the Pennsylvania Department of Public Welfare to cover those costs for eligible individuals who have no private insurance coverage, or for individuals whose costs exceed $36,000 that year.
- It requires the Pennsylvania Department of State to license professional behavior specialists and to establish minimum licensure qualifications for them. The specific terms and provisions of this law are described in more detail in this FAQ document.
Most sections of the Autism Insurance Act go into effect July 1, 2009, including the provisions that require many insurers to cover services for autism spectrum disorder.
Once the Autism Insurance Act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Employers with at least 51 employees and that offer group health insurance coverage are required to offer autism services for children under age 21. If your employer has 50 or fewer employees and you are enrolled in Medical Assistance, the Department of Public Welfare will continue to provide your child’s autism services, through the Medical Assistance program. Your child may also be able to receive services through CHIP or adultBasic, if they qualify.
What happens if we get our insurance through a "small group" employer (50 or fewer) or through an employer that self-insures?
The Department of Public Welfare will provide coverage for your child’s autism services as they currently do through the Medical Assistance program.
Are there limits on what our private insurance is going to be required to cover?
Insurance companies are not required to cover the costs of services that fall outside the mandated services defined in Act 62. For those mandated services though, there will be no limits on the number of visits to a provider. There is a $36,000 annual cap on coverage, after which DPW will pick up coverage. Beginning April 1, 2012, the cap will be adjusted upwards annually to account for inflation. Coverage may be subject to other limitations and exclusions as long as they are allowed under Act 62.
How will the law be enforced?
The Pennsylvania Insurance Department has strong regulatory powers to enforce the law. In addition, each health insurance company doing business in Pennsylvania is required to submit a compliance report to the Insurance Department by January 2011.
What coverage is mandated by the law?
Act 62 requires coverage for diagnostic assessments, pharmacy care, psychiatric care, psychological care, rehabilitative care, and therapeutic care. These categories of mandated services are defined in the law. More specifically, the new act will cover evaluations and tests needed to diagnose your child’s autism disorder, as well as the development of a plan to provide health care services for your child. This plan may include medically necessary prescribed treatments such as behavioral analysis and rehabilitative care, prescription drugs, blood level tests, psychiatric and psychological services, speech/language therapy, occupational therapy and physical therapy.
Is applied behavioral analysis (ABA) covered?
Yes. The law’s definition of rehabilitative care specifically includes ABA.
Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of "autism?"
Any of the pervasive development disorders defined in the current edition of the Diagnostic and Statistical Manual (DSM) are covered. These include: autistic disorder, Asperger Syndrome, Rett Syndrome, Childhood Disintegration Disorder and Pervasive Development Disorder (Not Otherwise Specified).
Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under Act 62?
No, there is no requirement that ASD must be the "primary" diagnosis for the child to qualify for coverage under Act 62. Behavioral Specialist, Mobile Therapy and Therapeutic Staff Support are covered by Pennsylvania’s Medical Assistance program.
Will these services be covered by commercial carriers under Act 62?
Behavioral Specialist Consultation, Mobile Therapy, and Therapeutic Staff Support are all covered services under Act 62 as long as they fall under the definition of "treatment of autism spectrum disorders." This means that they must be determined to be medically necessary and included in a treatment plan. These services could fall into the "rehabilitative care" or "psychological care" categories of care that are included in the Act.
Is Case Management covered?
Case Management is not a mandated service under Act 62.
Who determines what services are medically necessary?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary; however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If the commercial insurance company denies based on medical necessity, then will the Behavioral Health Managed Care Organization (BHMCO) automatically cover the services through the Medical Assistance program?
If commercial insurers deny based on medical necessity, the decision may be appealed under the expedited review process outlined in Act 62. If the decision to deny services is overturned, then commercial insurers must cover those services. If the decision to deny services is upheld, then the commercial insurer would not have to pay. The Medical Assistance (MA) program (through the BHMCO) would not automatically pay for the service. This determination would depend on if the service was determined to be medically necessary under the MA program. Assuming that the child was eligible for MA and the provider was enrolled in the MA program, the BHMCO would be required to cover a service that met its definition of medical necessity even it did not meet the commercial insurers definition of medical necessity.
Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
Act 62 does not include a "list" of covered services. Rather, the law requires coverage for specific types of services. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as part of the child’s treatment plan by a licensed physician or a licensed psychologist/psychiatrist.
On July 9, 2009, will an insurance company be able to question my child’s existing autism diagnosis?
No. Under Act 62, an autism diagnosis shall be valid for a period of not less than 12 months, unless a licensed physician or licensed psychologist determines a reassessment is necessary and the reassessment indicates otherwise.
Will insurance companies be able to deny services if my child is not making "sufficient progress" or has reached a plateau in his/her progress?
No. The law specifically requires coverage of services intended to produce progress as well as those intended to prevent regression.
Will private insurers be developing their own medical necessity criteria?
Private insurers will use their own medical necessity criteria. The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary; however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If my insurance company denies my child’s autism diagnostic or treatment services, where can I go for help?
Families can appeal any denial or partial denial of an autism diagnostic or treatment service to your insurance company and obtain a decision on an expedited basis. If your appeal is denied by the insurance company, your family can appeal for an independent, external review. If the independent external review denies your appeal, you can further appeal to a court of competent jurisdiction.
If a service is denied by a commercial insurer on medical necessity grounds for a child with dual coverage, will Medical Assistance consider itself bound by that decision?
No. If a service is denied by the private insurer, the family should appeal the decision. However, the Medical Assistance program will review the request for services based on the medical documentation provided and will use the MA program regulatory definition of medical necessity to determine MA approval and payment for services.
If a child is being seen by care paid for and coordinated by the commercial insurer and then the $36,000 cap is reached, will the Behavioral Health Managed Care Organization (BHMCO) be required to approve care for that child with the same provider? At the same rates? What if the provider is not licensed by DPW to provide that service?
Behavioral Health Managed Care Organization under the Health Choices program is required to operate under the definitions and rules of commonwealth’s Medical Assistance (MA) program. Commercial insurers can establish their own medical necessity criteria apart from the MA definition. Act 62 is silent on rates. Providers must be enrolled in the MA program to be eligible for reimbursement the service, Overall, DPW believes that continuity of care will be better served if the definitions and networks of the MA program (and its BH MCOs) and commercial insurers are similar. DPW is working on many fronts, including the implementation of Act 62, to strengthen the network of autism service providers in Pennsylvania.
How will medications be covered for persons under 21 with ASD in Adult Basic (which does not currently cover medications)? Will the covered medications be limited to medications prescribed for autism? If so, how will it be determined whether the medication is for autism or another condition?
New contracts with the adultBasic insurers will not be in place before October 1, 2009 but, will include coverage for medications to treat autism spectrum disorder (ASD) conditions. In terms of what drugs would be covered specifically, we will need assistance by clinical experts involved in the diagnosis and treatment of ASD to assist us in that determination. We would limit coverage to those medications needed to treat ASD, the same as we currently provide for medications associated with diabetes in adultBasic. It is important to note that many 19 and 20 year olds who are not in school and who have this disorder may qualify for SSI since SSA stops deeming parental income to a child at age 18 if they are not in school.
Which providers and services will be eligible for reimbursement under Act 62?
Reimbursement is required for any mandated service provided pursuant to a comprehensive autism treatment plan and which is provided by qualified professionals. These professionals include licensed physicians, licensed physician assistants, licensed psychologists, licensed clinical social workers, certified registered nurse practitioners and those who work under their direction. Grandfathering clauses are included to ensure continuity of care for services provided by certain unlicensed professionals: those who work at the direction of the licensed professionals listed above, professionals enrolled in the Medical Assistance program, and behavior specialists pending their licensure.
"Grandfathering clauses are included to ensure continuity of care for services provided by certain unlicensed professional…” can you please define the grandfather clauses mentioned here?
There are two provisions of Act 62 that deal with the transition of providers from MA to commercial insurer networks. For providers who are currently enrolled in the MA program, Section 635.2(h) states that "an insurer will be required to contract with and to accept as a participating provider any autism service provider within its service area and enrolled in the Commonwealth’s medical assistance program who agrees to accept the payment levels, terms and conditions applicable to the insurer’s other participating providers for such service. In addition, the definition of "Autism service provider" (Section 635.2(f) (2)) covers licensed and unlicensed professionals (including behavior specialists). (i) A person, entity or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is licensed or certified in this Commonwealth. (ii) Any person, entity or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is enrolled in the Commonwealth's medical assistance program on or before the effective date of this section. This second clause is sometimes referred to as the grandfathering provision.
Will current providers be part of the network, and can we stay with the same provider when cap is reached?
Current providers are grandfathered as licensed, but they will need to be part of your insurance company’s network. When the cap is reached, if you want to stay with that same provider, they will need to be part of the MA network.
How can I be sure that the health care provider has the certification or license necessary to diagnose my child’s autism disorder and provide services?
The State Board of Medicine, along with the Department of Public Welfare, will oversee the licensing and certification of autism health care providers. You should check with your health insurance company to be sure that the company recognizes the health care provider you are using as properly certified or licensed. If the provider is not recognized, you may not be covered for the services provided. During the transition period while the bill is being implemented, providers who offer treatment of autism spectrum disorders and who are enrolled in the Medical Assistance
Is "psychological care" limited to licensed psychologists?
Yes, psychological care is defined as care provided by licensed psychologists.
Are licensed speech language pathologists eligible to provide services under the bill?
Licensed speech language pathologists are eligible to provide services under Act 62 pursuant to a treatment plan, if they are enrolled as a Medical Assistance provider. Private insurers are only required to "contract with and accept as a participating provider any autism service provider within its service area who is also enrolled in the Medical Assistance program who agrees to accept the payment levels, terms and conditions applicable to the insurer's other participating providers." Private insurers may choose to but are not required to contract with other practicing providers.
I have a child with a diagnosis of autism and I have commercial insurance. Will Medical Assistance cover the cost of the co pays and deductibles associated with my commercial coverage for autism services?
Act 62 has no impact on the rules in Pennsylvania’s Medical Assistance (MA) program regarding copayments and deductibles. MA will cover copayment, deductible and coinsurance provisions for children with autism exactly as it does today, using the same rules and standards as it does for non-autism related services.
Families should ask themselves two simple questions:
- Is my child eligible for and enrolled in MA? If the answer is no, MA will not pay for co pays or deductibles.
- Is the service provider enrolled in the MA Program? If the answer is no, MA will not pay the co pay because the provider is not part of the MA system. In this case, the family will be responsible for paying the private insurance co pay.
How is the Third Party Liability being handled in the coordination of benefits between public and private insurers?
Third Party Liability and the coordination of benefits between public and private insurers will occur the same way that it does currently for those individuals who have both private insurance coverage and are eligible for Medical Assistance.
Do I have to give the insurance company a copy of my child’s Individualized Education Program?
No. Mandated coverage under Act 62 cannot be made contingent upon coordination of services with an IEP. The law does permit coordination of coverage, but only with the consent of the child’s parent or guardian consistent with state and federal law.
