Summary of Pennsylvania Law
Pennsylvania Autism Insurance Reform Law Provisions
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Law goes into effect on July 1, 2009
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Requires health insurance policies and the medical assistance program to cover the diagnosis and treatment of autism spectrum disorders in individuals less than 21 years of age. Applies to policies offered, issued, or renewed on or after July 1, 2009, to groups of 51 or more employees.
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Benefit limits -- Coverage is subject to a maximum yearly benefit of $36,000 but no lifetime benefit caps or visit limits. After December 31, 2011, the maximum yearly benefit will be adjusted for inflation. Coverage is subject to co-payment, deductible, coinsurance provisions, and general policy or program limitations and exclusions to the same extent as other medical services.
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Authorized treatment -- The treatment of autism spectrum disorders includes the following medically necessary care identified in a treatment plan:
- Prescribed medications and any test needed to determine their effectiveness;
- Psychiatric care;
- Psychological care;
- Rehabilitative care, including applied behavior analysis; and
- Speech therapy, occupational therapy, and physical therapy.
- A physician or psychologist must develop the treatment plan for autism spectrum disorders. An insurer may review the treatment plan once every six months, unless the insurer and physician or psychologist agree that more or less frequent review is necessary.
- Providers -- The State Board of Regulation, in consultation with the Department of Public Welfare, will set standards for behavior specialists, a newly recognized group of service providers. Insurers are required to contract with and accept as participating providers autism service providers enrolled in the Commonwealth’s medical assistance program who agree to accept the payment terms and conditions that apply to the insurer’s other participating providers.
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Review -- If an insurer denies a claim for diagnosis or treatment of autism spectrum disorders, an insured can seek an expedited internal review followed by an expedited independent external review. An insurer or an insured may appeal to a court an order of an expedited independent external review. While the appeal is pending, an insurer must pay for services that have been authorized or ordered.
- Print out this summary
- Read Pennsylvania House Bill 1150 - As signed into law
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Pennsylvania News
AUTISM SPEAKS APPLAUDS PENNSYLVANIA GOVERNOR ED RENDELL FOR SIGNING INTO LAW THE STRONGEST AUTISM INSURANCE REFORM LEGISLATION IN THE NATION
NEW YORK, NY (July 9, 2008) -- Autism Speaks today commended Pennsylvania Governor Ed Rendell for signing into law the most comprehensive autism insurance bill in the nation. The new law provides $36,000 a year for Applied Behavior Analysis (ABA) and other necessary treatments, and goes beyond many state insurance reform measures by mandating coverage up to age 21 with no lifetime cap. It also creates, for the first time under Pennsylvania law, an expedited appeals procedure for denied claims as a safeguard to ensure compliance by insurance providers. Private insurers will be required to provide coverage beginning in July 2009.
In addition, the legislation turns the existing state welfare program for autism into a statutory requirement, ensuring that those who receive government-provided services can continue to do so. It also allows for the development of a private sector delivery system with insurance reimbursement, offering families an alternative to coverage through Medicaid.
Autism Speaks also praised the elected officials whose support of this legislation was critical to its passage, including: original co-sponsors House Speaker Dennis O’Brien and Senator Jane Orie; Rep. Nick Micozzie and Rep. Tony DeLuca, chairmen of the House Insurance Committee; Senator Don White, chairman, and Senator Mike Stack, minority chairman, of the Senate Banking and Insurance Committee; and Senators Dominic Pileggi, Joseph Scarnati and Robert Mellow.
"This law will have a significant impact on Pennsylvania families’ ability to provide their children with the services they need and deserve,” said Elizabeth Emken, Autism Speaks vice president of government relations. “Governor Rendell and Pennsylvania’s legislators have sent a clear message that discriminatory practices by insurers against individuals with autism and their families must come to an end.”
Autism insurance reform legislation has now been enacted in eight states across the country, with many others currently considering legislative action. Last week, Louisiana became the latest state to address the tremendous financial burden faced by families affected by autism when Governor Bobby Jindal signed House Bill 958 into law. Print a copy of this press release
AUTISM SPEAKS APPLAUDS PENNSYLVANIA HOUSE SPEAKER DENNIS O’BRIEN AND STATE LAWMAKERS FOR PASSING STRONGEST AUTISM INSURANCE MANDATE IN THE NATION
(NEW YORK, NY - July 3, 2008) Autism Speaks today applauded Pennsylvania House Speaker Dennis O’Brien and state lawmakers for passing the strongest autism insurance reform legislation in the country. The bill (HB 1150) to create a new “Autism Spectrum Disorders Coverage” provision of Pennsylvania insurance law was amended by the House on Tuesday and sent back to the Senate on Wednesday night where it passed 49-1. Autism Speaks thanked bill co-sponsors House Speaker Dennis O’Brien and Senator Jane Orie, and Senators Don White, Dominic Pileggi, Joseph Scarnati, Michael Stack, Robert Mellow and Anthony Williams for their support in helping to protect the children of Pennsylvania with autism spectrum disorders. Read More...
HB 1150 Is Approved by the Pennsylvania House
(Harrisburg, PA - July 2, 2008) Last night, House Bill 1150, the autism insurance reform bill, was passed by the Pennsylvania House with at vote of 203-0. The bill had been returned to the House after being amended and passed by the PA Senate. The bill will now go back to the Senate floor for final passage.
HB 1150 Passes the Pensylvania Senate
(Harrisburg, PA - June 30, 2008) Last night the Pennsylvania Senate passed House Bill 1150, the autism insurance reform bill, with a vote of 49-1. The bill will now go back to the PA House for approval. To read more, see the statement from Autism Speaks below.
Statement from Autism Speaks on the Pennsylvania Autism Insurance Reform Bill, HB 1150
Last evening the Pennsylvania Senate Appropriations Committee passed the autism insurance reform bill, 26-0, with the support of bill sponsor Senator Jane Orie. The Leadership of the Senate pledged a vote on the bill on the Senate floor on Sunday evening.
The vote was unanimous, with the Democrats enthusiastically joining the GOP majority, and the bill now moving forward, if signed into law, would be the strongest autism insurance mandate yet achieved in the nation.
The Pennsylvania bill provides $36,000 a year for Applied Behavior Analysis and other necessary treatments up to age 21, with no lifetime cap. It also creates a first ever, under Pennsylvania law, expedited appeals procedure for denied claims, as a safeguard to ensure the law is followed. The bill also turns the existing state welfare program for autism into a statutory requirement, to ensure that those who receive government provided services can continue to do so, while allowing for the development of a private sector delivery system with insurance reimbursement, offering families an alternative to coverage through Medicaid.
The Pennsylvania bill ends discrimination for individuals with autism, and provides them the same medical necessity standards as afforded individuals with cancer, diabetes, and the common cold, allowing individuals with autism to be treated as all others are in the private insurance market. Individuals with autism deserve the same quality of care that all individuals with chronic and severe health conditions receive.
We have the utmost respect for Speaker of the House Dennis O’Brien. Speaker O’Brien has dedicated his career to improving the lives of individuals with autism. There would be no bill at all without Speaker O’Brien’s passionate leadership for these many years. We trust his judgment as to how the House should respond to the Senate bill.
Please call your own Senator and ask them to support HB 1150. Remind them of how important this is to your family.
For more information on HB 1150 and the latest developments in the Pennsylvania legislature, please stay tuned to www.autismvotes.org/pennsylvania.
Elizabeth Emken,
Vice President of Government Relations
Autism Speaks
Pennsylvania Senate Banking & Insurance Committee Holds Hearing on HB 1150
(Harrisburg, PA - April 2, 2008) The most important day for autism insurance coverage in Pennsylvania took place yesterday, when the Pennsylvania Senate Banking & Insurance Committee, chaired by Senator Don White, held a three hour hearing on House Bill 1150. This bill seeks to require insurance companies to provide health care coverage for autism-related services.
Panelists selected to testify in favor of HB 1150 included:
- Richard M. Foxx, Ph.D., BCBA, Penn State University
- David Gates, Esq., The Pennsylvania Health Law Project
- James N. Bouder, MPA, The Vista School
- Kim Motosicky, Parent
- Rachel Brooks, Miss Pennsylvania 2007
Despite the the three hour hearing, Chairman White Chairman White has said that he wants to wait for more information before he allows this bill to be voted on.
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