PA Autism Insurance Act (Act 62)

In Pennsylvania, your child’s autism-related services may be covered by private health insurance or Medical Assistance (MA) under Pennsylvania’s Autism Insurance Act (ACT 62).

The Department of Human Services (DHS), Pennsylvania Insurance Department (PID), and Department of State (DOS) are working together to fully implement Act 62. The Departments worked together to identify the billing codes for providers to use to bill private insurance and MA for services to diagnose and treat ASD for children and adolescents. Beginning September 30, 2016, private insurance companies may approve services and claims that they may have denied in the past.

What Do I Need to Do?

• Check with your employer’s Human Resources Department to see if your insurance policy is covered under Act 62.
• Show your provider all insurance information, including your private health insurance card and your Medical Assistance card.
• Talk to your provider. Providers play an important role in helping families understand Act 62.
• Ask if your provider is enrolled in your private health insurance company’s network. In order for MA to pay a claim that your private insurance company denies, your provider must be enrolled in the private insurance company’s network and submit a claim for payment to your private insurance company.
• Visit the DHS website for Act 62 information including fact sheets, answers to Frequently Asked Questions, and contact information for DHS and the PID.
• If you receive a denial from your private health insurance company, check out information on how to appeal an insurance denial for the assessment or treatment of ASD and sample appeal letters at the DHS website.

In Pennsylvania, your child’s autism-related services may be covered by private health insurance, Medical Assistance (MA) or the Children’s Health Insurance Program (CHIP) under Pennsylvania’s Autism Insurance Act (ACT 62). ACT 62 is a statewide insurance mandate specific to services provided to children and adolescents with Autism Spectrum Disorder (ASD).

Who is Covered?

Children and adolescents under age 21 with ASD who:

• are covered under an employer group health insurance policy (including HMOs & PPOs)
  issued in PA to groups of 51 or more employees;*
• are on MA; or
• are covered by CHIP.

*Act 62 does not apply to policies issued outside of PA or that are “self-funded” or “ERISA” policies.

What Services are Covered?

Medically necessary services that are for the assessment and treatment of ASD, including:

• pharmacy care;
• psychological care;
• rehabilitative care, which included applied behavioral analysis (ABA);
• and therapeutic care, including services provided by speech language pathologists, occupational therapists, and physical therapists.
• Services must be identified in a treatment plan developed by a licensed physician or licensed psychologist;
• Services must be prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner; and
• Services must be provided by an ASD service provider or a person, entity or group that works under the direction of an ASD service provider. ASD service provider includes behavior specialists licensed by DOS.

Why Does it Matter?

Accessing autism services through private insurance results in significant cost savings to publicly-funded state programs.

Coverage Information & Cap

The maximum amount private health insurance companies are required to pay as a result of Act 62 for the diagnostic assessment and treatment of ASD is known as the “cap.” The amount of the cap is adjusted annually. Coverage is subject to copayment, deductible, coinsurance, and
other exclusions or limitations to the same extent as other medical services covered by the policy. Some plans do not impose any cap. Be sure to check your plan.

Requirements

• Requires certain private health insurance companies to cover some of the costs of the diagnostic assessment and treatment of ASD for children and adolescents under the age of 21.
• Requires the Department of Human Services (DHS) to cover services for children and
  adolescents with ASD who are enrolled in MA and do not have private insurance coverage, or whose cost of services are more than the Act 62 limits in one year.
• DHS will cover any cost sharing applied to services, i.e. out-of-pocket costs such as copays, co-insurance, or deductibles, up to the MA allowable fee.
• Requires the Pennsylvania Department of State (DOS) to license professional behavior specialists who provide services to children and adolescents with ASD.

In Pennsylvania, your child’s autism-related services may be covered by private health insurance,
the Medical Assistance program (Medicaid) or the Children’s Health Insurance Program (CHIP) under Pennsylvania’s Autism Insurance Act (ACT 62).

Private Insurance

Most private insurance plans are provided through an employer or purchased through the Health
Insurance Marketplace. Under the Affordable Care Act (ACA), individuals may be covered under their parent’s insurance until age 26.

Using Your Private Insurance

Premiums: An insurance premium is the amount of money that an individual or business must pay for an insurance policy.

Copays: A copay (copayment) is a fixed amount you pay for covered services, typically when you receive the service.

Coinsurance: Coinsurance is the percentage of costs of a covered health care service that you pay after you’ve paid your deductible.

Deductibles: The amount you pay for covered health care services before your insurance plan starts to pay.

Out-of-Pocket Maximum: The most you have to pay for covered services in a plan year.

Provider Network: The doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members.

Use Your Insurance First

Medicaid is the payer of last resort, meaning any other insurance coverage you may have should be billed first. You should always show your private insurance card, if you have private insurance, as well as your Medicaid card.

Medicaid

Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources.

Obtaining Medicaid

Your child may qualify for Medicaid, better known as Medical Assistance (MA) in PA, if you meet income and other eligibility requirements.

Some children or adolescents (under age 18) may qualify on the basis of their disability, without regard to parental/guardian income or resources.

You may apply online using COMPASS. You can also contact your local county assistance office for an application or you may download an application from the Department of Human Services website to send to your county assistance office. If you need help completing the application form, trained county assistance staff members can help you.

For more information on qualifications, or to download an application visit: www.dhs.pa.gov

Using Medicaid

When children under age 18 have Medicaid and see a Medicaid participating provider, private
insurance costs such as copays, deductibles, and out-of-pocket maximums are not paid for by
the family. Certain Medicaid services provided to children ages 18-20 may be subject to a small MA copay amount.