As the July 1 start date approaches, even the managed care folks who deal with insurance issues daily are asking questions about how Act 62 will impact the provision of services for their clients. With such massive cross-system changes taking place all at once, there is no question that the first couple of months are going to be confusing at best and chaotic at worst for families and providers.
Until the passage of Act 62, private insurance companies were not required to pay for autism spectrum services. The insurance reform legislation faced a hard-fought battle in the PA senate, getting stuck in banking committees and mired down in partisan political negotiations. The House passed their version of the bill unanimously more than a year before the Senate was able to bring it to a vote. Insurance companies lobbied hard and argued that rates would be driven higher.
But as more and more people in high places became parents, grandparents, aunts and uncles of children with autism, their voices prevailed and now Pennsylvania has a ground-breaking law that allows thousands more people with autism to receive coverage.
Families of persons with an autism spectrum diagnosis will want to learn all they can about what this law requires and allows. The Bureau of Autism Services has covered Act 62 information very thoroughly for families and providers. A frequently asked questions sheet is now available online.
The following information comes directly from the Bureau’s web site. Please visit the site through the links provided to get up to speed about how this new law will impact your own family.
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.
What coverage is mandated by the law?
Act 62 requires coverage for diagnostic assessments, medicinal 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 childs 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, drugs, blood level tests, psychiatric and psychological services, speech/language therapy, occupational therapy and physical therapy.
Will Medical Assistance cover the cost of the copays and deductibles associated with my commercial coverage for autism services?
Act 62 has no impact on the rules in Pennsylvanias 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.
Parents should be aware that they cannot pay the provider and then ask to be reimbursed by the MA program. Providers bill MA directly and MA determines if they are eligible.
As the system adjusts to the new law, questions in specific cases will undoubtedly arise that must be put to a test against the new insurance reform law. It remains to be seen if Act 62 will fall under the category of “brilliant design” or “be careful what you wish for.”
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