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Act 62 Autism Insurance Act

Act 62 Autism Insurance Act. April 30, 2009 David Gates, PA Health Law Project Cindy Fillman, Office of Consumer Liaison, PA Insurance Dept. Sherry Peters, OMHSAS Children’s Bureau, PA Dept. of Public Welfare (slides adapted from a presentation by David Gates). Act 62 Autism Insurance Act.

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Act 62 Autism Insurance Act

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  1. Act 62 Autism Insurance Act April 30, 2009 David Gates, PA Health Law Project Cindy Fillman, Office of Consumer Liaison, PA Insurance Dept. Sherry Peters, OMHSAS Children’s Bureau, PA Dept. of Public Welfare (slides adapted from a presentation by David Gates)

  2. Act 62 Autism Insurance Act • Requires certain insurance plans to cover a broad range of medically necessary diagnostic and treatment services for children and adolescents under 21 on the autism spectrum. • Is effective on the plan’s renewal date on or after July 1, 2009

  3. Act 62 Autism Insurance Act Who is covered: Children and young adults under age 21 who are - • covered under an employer group health insurance policy (including HMOs & PPOs) • that covers at least 51 employees • (not Chambers of Commerce or other association plans) - and • the policy is not a “self insured” • the policy was issued or renewed in PA; or • on Medical Assistance, CHIP or adultBasic

  4. Act 62- Who is covered (continued) • Must have diagnosis of autism spectrum disorder • Defined as “any of the pervasive developmental disorders defined by the most recent edition of the DSM or its successor, including autistic disorder, Asperger’s disorder and pervasive developmental disorder not otherwise specified [PDD NOS].”

  5. Act 62 Autism Insurance Act What is covered: • Diagnostic assessments of autism spectrum disorders • Defined as: “medically necessary evaluations, assessments or tests performed by a physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner to diagnose whether an individual has an autism spectrum disorder.” • Treatment of autism spectrum disorders

  6. Act 62 Requirements for Coverage of Autism Treatments • Diagnostic assessment must find ASD • Diagnostic assessment must be done by: • physician, • licensed psychologist, • licensed physician assistant; or • certified registered nurse practitioner [625.2(f)(5)]

  7. Act 62 Requirements for Coverage of Autism Treatments Treatment must be prescribed or ordered by • licensed physician, • licensed physician’s assistant, • licensed psychologist, • licensed clinical social worker; or • certified registered nurse [635.2.(f)(14)(i)]

  8. Act 62 Requirements for Coverage of Autism Treatments • Treatment must be in the treatment plan • Treatment plan must be • Developed by a licensed physician or licensed psychologist • “Pursuant to an comprehensive evaluation or reevaluation” • “consistent with the most recent clinical report of recommendations of the American Academy of Pediatrics” [635.2(f)(15)] • http://aappolicy.aappublications.org/cgi/reprint/pediatrics;120/5/1183.pdf

  9. Act 62 Covered Treatments • Treatment must fit one of the categories of covered services [625.2(f)(14)]: • Prescription medications and blood level tests [625.2(f)(9)] • Psychiatry [625.2(f)(10)] • Psychology [625.2(f)(11)] • Rehabilitation [625.2(f)(12)- • including Applied Behavioral Analysis (“ABA”) [625.2(f)(1)]

  10. Act 62 Covered Treatments • Applied behavioral analysis • “the design, implementation and evaluation or environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.”

  11. Act 62 Covered Treatments • Other “rehabilitative care” • “professional services and treatment programs…provided by an autism service provider to produce socially significant improvements in human behavior or to prevent loss of attained skill or function.” • Therapies [635.2(f)(13)] • Speech/language • Occupational therapy • Physical therapy

  12. Act 62- Medical Necessity • There is no definition of medical necessity in the Act but - • “prevent loss of attained skill or function” is part of the definition of both rehabilitative care [625.2(f)(12)] & ABA [625.2(f)(1)], so it appears that prevention of loss of attained skill or function must be part of the medical necessity criteria for rehabilitative care & ABA.

  13. Qualified providers • an “autism service provider” or • “person, entity or group that works under the direction of an autism service provider” [635.2(f)(14)(ii)&(iii), p.10] • the treatment provider will also have to be enrolled in the child’s insurance plan unless the plan has authorized coverage by a “non-par” provider. Who is a Qualified Provider?

  14. Qualified providers • “autism service provider” is “person, entity or group providing treatment of ASD” who • Is a licensed physician, licensed physician’s assistant, licensed psychologist, licensed clinical social worker; or certified registered nurse; or • Was enrolled in Medical Assistance on or before 7/9/08 [635.2(f)(2)]and • agrees to “the payment levels, terms & conditions applicable to the insurer’s other participating providers for such service.” [635.2(h)]

  15. Qualified providers • “Behavior specialist” [635.2.(f)(4)] • Licensure regs developed by State Board of Medicine • Not limited to Board Certified Behavior Analysts • Persons meeting the statutory requirements (635.2(g)) are covered without licensure/certification for 1 year from promulgation of licensure/ certification regulations or July 9, 2011, whichever is later. [635.2(l)]

  16. Act 62- Coverage Limits • $36,000 per year in autism diagnostic and/or treatment costs (to be adjusted annually for inflation beginning 2012) for commercial insurance - none for MA or CHIP • No limit on number of diagnostic/treatment visits (until $36,000 cap is reached) • Autism coverage “shall be subject to copayment, deductible and coinsurance provisions, and any other general exclusions or limitations…to the same extent as other medical services covered by the policy or program….” • This language appears to give insurers authority to deny some autism treatments (other than ABA) on grounds they are experimental.

  17. Act 62 Appeals • Families can appeal any denial of an autism diagnostic or treatment service to the insurer. • Prescriber can request “expedited review” (decision within 48 hours. • If appeal is denied by the insurer, family can appeal to the PA Insurance Dept. who will have independent physician or psychologist decide. • Provider may be able to request coverage from MA if insurer denies.

  18. Act 62 & Special Ed services • Insurers are not required to cover services just because they are listed in an IEP. • However, coverage may not be contingent upon coordination of insurance covered services with services listed in an IEP.

  19. Act 62- Questions & More Info • Submit questions to: ra-in-autism@state.pa.us • State web site: www.PAAutismInsurance.org

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