PA Autism Insurance Act (Act 62) requires private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorder (ASD) for children under the age of 21. Act 62 applies to insured employer groups having 51 or more employees, as well as the CHIP program effective with contract renewals beginning July 1, 2009. Members of small employer groups will have access to this benefit through the Department of Public Welfare.
ASD Benefit Highlights
Coverage is subject to a maximum benefit of $40,000 per year, but is not subject to any limits on the number of visits to an autism provider for treatment of autism spectrum disorders. ASD coverage will be subject to copayment, deductible, and coinsurance provisions to the same extent as other covered medical services and any other general exclusion or limitation. Act 62 provides coverage for medically necessary pharmacy supplies, psychiatric care, psychological care, rehabilitative care, and therapeutic care. Once the member has reached the $40,000 annual benefit maximum, he or she may be eligible for additional Medical Assistance (MA) program benefits. For more information about MA, please visit http://www.dpw.state.pa.us.
For employer groups who do not have a pharmacy benefit, Prior Authorization is required and can be obtained by contacting the Express Scripts Customer Service Department at 1-877-603-8399. The most commonly prescribed medication for autism spectrum disorder is Risperdal, and for members whose plan has a pharmacy benefit, no prior authorization is required for this medication.
ASD Benefit Exclusions
Services or treatments for autism spectrum disorders that are not specifically covered by Act 62 may be subject to the same general contract exclusions as other medical services.
Blue Cross of Northeastern Pennsylvania has developed a medical policy to provide guidance and clarification on covered and non-covered services in compliance with the act. This Medical Policy is available online at BCNEPA's Provider Center at www.bcnepa.com or via the link on Navinet. If you do not have access to the internet, please contact your Provider Relations Consultant for a hard copy of the Medical Policy.
Please note the Pennsylvania Insurance Department may issue clarification and guidance regarding coverage under this mandate. For more information, visit the following website:
http://www.dpw.state.pa.us. You are encouraged to visit the DPW's site to become familiar with the legislation, and you may find "Frequently Asked Questions and Answers" particularly helpful. Click here for a summary of the law.
Professional Claims must be submitted on the NUCC-1500 Form, while facility claims are submitted on the NUBC UB-04 form. Remember to include the NPI and Taxonomy Code. Please report only valid diagnosis, procedure and/or revenue codes. Reimbursement rates for ASD services will follow the current BCNEPA/FPH/FPLIC standard fee schedules and contracted rates. Please contact your Provider Relations Consultant for allowed amounts not on these fee schedules.
Providers of autism services are encouraged to contact your Provider Relations Consultant to inquire about credentialing/contracting requirements, claims submission, or any other questions pertaining to Autism Insurance Act 62.