Insurance Coverage for Autism Spectrum Disorder
If you or someone you know is the parent of a child with autism, you need to know about a new law that will change the way your child’s autism-related services are covered. This Act will make changes to the way that autism services are covered through the Medical Assistance program and private health insurers.
The Autism Insurance Act:
- Requires many private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorder and services for children under the age of 21, up to $36,000 per year;
- Requires the Pennsylvania Department of Public Welfare, DPW, to cover the cost of services for individuals who are enrolled in the Medical Assistance program and do not have private insurance coverage, or for individuals whose costs exceed $36,000 in one year; and
- Requires the Pennsylvania Department of State to license professional behavior specialists who provide services to children.
Who is covered by the Autism Insurance Act?
- Children or young adults under age 21 with a diagnosis of an autism spectrum disorder who:
- Are covered under an employer group health insurance policy (including HMOs and PPOs) that has more than 50 employees and the policy is not a "self-insured" or "ERISA" policy;
- Are on Medical Assistance; or
- Are covered by Pennsylvania’s Children’s Health Insurance Program (CHIP).
What does the Autism Insurance Act cover?
- Diagnostic assessment and treatment of autism spectrum disorders, which include:
- Prescription drugs and blood level tests;
- Services of a psychiatrist and/or psychologist (direct or consultation);
- Applied behavioral analysis; and
- Other rehabilitative care and therapies, such as speech and language pathologists, occupational and physical therapists.
- Must be for an autism spectrum disorder;
- Must be medically necessary;
- Must be identified in a treatment plan;
- 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
- Must be provided by an autism service provider or a person, entity or group that works under the direction of an autism service provider.
For additional information and resources for families, insurers and providers as well as answers to Frequently Asked Questions, www.PAAutismInsurance.org. If you have a more specific question or need more clarification about the Autism Insurance Act, email your questions to firstname.lastname@example.org.
About Autism Spectrum Disorders
Autism is a brain-based neurological condition that is usually diagnosed by the time a child is three years old. Children who are diagnosed need intervention as soon as possible. With the right kinds of supports, individuals can make substantive progress. For more information about autism, visit www.autisminpa.org.