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Autism Benefits Available for Large Employer Groups

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Effective July 1, 2009; Act 62 of 2008 called for health insurers to provide coverage for the diagnosis and treatment of autism spectrum disorders (ASD) for members under age 21. The benefit covers up to a maximum of $36,000 for each member, each benefit period and is effective for fully insured groups of 51 or more employees beginning July 1, 2009 upon their annual renewal for coverage. For groups of 50 or fewer employees, or for those with non-group coverage, the Department of Public Welfare will continue to provide autism services through the Medical Assistance program.

Covered Benefits
Act 62 provides coverage for medically necessary psychiatric care, psychological care, rehabilitative care, therapeutic care and certain prescription drugs. The benefit pays after any copayments, deductibles and coinsurance that apply to other covered medical services. However, services covered under Act 62 do not have the same day/visit limits that apply to other covered medical services.

Benefit Exclusions
Services or treatments for autism spectrum disorders that are not specifically included by Act 62 may have the same general contract exclusions as do other covered medical services. For example, BlueCare HMO and BlueCare PPO contracts exclude neurofeedback therapy. So even if an autism provider believes that neurofeedback therapy may provide some benefit to his or her patient, that treatment will not be covered.

Benefit Limits
Excluding day/visit limits, the same general limitations may apply to autism benefits as they do to the other covered medical services. For example, if you must use a preferred provider in order to receive the maximum level of payment for medical services, you must likewise use a preferred provider to receive the maximum level of payment for autism services.

Benefit Maximum
Once your child reaches the $36,000 annual benefit maximum, he or she may be eligible for additional Medical Assistance (MA) program benefits. For more information about Medical Assistance, please visit http://www.dpw.state.pa.us.

More Information
If this mandate applies to your group, you will receive more information closer to your renewal date on or after July 1, 2009. For more information, you can visit http://www.dpw.state.pa.us/ServicesPrograms/Autism/Act62. Or Click here for a summary of the law.

Note:The autism benefit changes applied to CHIP members effective December 2009 and to adultBasic members who are under 21 upon contract renewal of the adultBasic program effective March 1, 2010.