Office
of Speaker Dennis M. O’Brien
Pennsylvania House of Representatives
139 Main Capitol Building, Harrisburg
Frequently Asked Questions about
Act 62 of 2008 (formerly House Bill 1150)
Why was House Bill 1150 introduced by Speaker
Dennis O’Brien?
This legislation was introduced to mitigate the heavy burden caused by health insurance
companies’ discrimination against individuals with autism. While its
language has been revised several times, and while other matters were added to the bill before it became law as Act 62, the
essence of the autism insurance reform legislation remains intact.
Where do I find Act 62?
You can find it by visiting the legislature’s website http://www.legis.state.pa.us/ <http://www.legis.state.pa.us/> or by clicking here <http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2007&sessInd=0&billBody=H&billTyp=B&billNbr=1150&pn=4133> .
What does Act 62 do?
In regards to
autism insurance reform, Act 62 does three main things:
1. it requires private health insurance companies to begin covering the costs of diagnostic
assessments for autism and of services for individuals with autism who are under the age of 21;
2. it requires the
PA Department of Public Welfare to cover those costs for individuals who have no insurance coverage, or for individuals whose
costs exceed $36,000 that year; and
3. it requires the PA Department of State to license professional behavior specialists
and to establish minimum licensure qualifications for them.
What coverage is mandated by the law?
Act 62 requires coverage for diagnostic assessments, pharmacy care, psychiatric care, psychological care, rehabilitative
care, and therapeutic care. These categories of mandated services are defined
in the law.
Is applied behavioral analysis (ABA) covered?
Yes. The law’s definition of rehabilitative care specifically
includes ABA.
Will insurance companies be able to deny
services if my child is not making “sufficient progress” or has reached a plateau in his/her progress?
No.
The law specifically requires coverage of services intended to produce progress
as well as those intended to prevent regression.
When
can I start getting private insurance to reimburse for services for my child with autism?
The law applies to
any health insurance policy that is offered, issued, or renewed on or after July 1, 2009 to a person whose employer has over
50 employees. It also applies to health insurance policies issued under
the Adult Basic Insurance Coverage Program and the Children's Health Care Program (CHIP).
What happens if we get our insurance through a “small group” employer (50
or fewer) or through an employer that self-insures?
Act 62 requires DPW to provide coverage for your child’s
autism services.
Which providers and services will be eligible for reimbursement under Act 62?
Reimbursement is required for any mandated service provided pursuant to a comprehensive autism treatment plan and
which are provided by qualified professionals. They include licensed physicians,
licensed physician assistants, licensed psychologists, licensed clinical social workers, certified registered nurse practitioners,
and those who work under their direction. Grandfathering clauses are included to ensure continuity of care for services
provided by certain unlicensed professionals: those who work at the direction of the licensed professionals listed above,
professionals enrolled in the medical assistance program, and behavior specialists pending their licensure.
Are there limits on what our private insurance is going to be required
to cover?
Insurance companies are not required to cover the costs of services that fall outside the mandated
services defined in Act 62. For those mandated services though, there will
be no limits on the number of visits to a provider. There is a $36,000 annual cap on coverage, after which DPW will
pick up coverage. Beginning April 1, 2012, the cap will be adjusted upwards annually to account for inflation. Coverage
may be subject to other limitations and exclusions as long as they are not inconsistent with Act 62.
Can an insurance company question my child’s existing autism diagnosis?
No.
Under Act 62, an autism diagnosis shall be valid for a period of not less than 12 months, unless a licensed physician or licensed psychologist determines
a reassessment is necessary and the reassessment indicates otherwise.
Do I have to give the insurance company a copy of my child’s
IEP?
No. Mandated coverage under Act 62 cannot be made contingent
upon coordination of services with an individualized education program
(IEP). The law does permit coordination of coverage, but only with the consent
of the child’s parent or guardian consistent with state and federal
law.
What happens if an insurance company denies a claim for my child’s services?
Act
62 requires that the insurance company provide an expedited review process for appeals of denied claims. If the insurance company upholds the denial, Act 62 provides for a secondary expedited review process
to be administered by the Insurance Department. If the denial is still upheld, that decision may be challenged in court.
How will the law be enforced?
The PA Department
of Insurance has strong regulatory powers to enforce the law. In addition,
each health insurance company doing business in Pennsylvania is required to submit a compliance report to the Insurance Department
by January 2011.
I have a question that isn’t
answered by this FAQ sheet – where do I get the answer?
You can send in your questions by visiting www.RepObrien.com <http://www.repobrien.com/> and clicking on “contact me.” We are committed to ensuring that the implementation of Act 62 is as smooth as possible – and your input is important
to that. Although we may not be able to respond to each question individually, we will answer as many questions as possible
by issuing FAQ updates.
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Please note: ASCEND
Group is a 501(c)(3) charitable organization. We do not endorse any specific professional or therapeutic treatment. Likewise,
these messages should not be interpreted as endorsements for particular providers. We are not meant to be a replacement for
medical or legal advice. Our mission is to raise public awareness about AS, to advocate for improved education and services,
and to provide support and information to the Asperger community.
