Pennsylvania Act 62 was passed in 2008 and went into effect in 2009. The intent of the act was to provide greater coverage for autism services by requiring insurance companies to cover up to a certain dollar amount of services.
This seems like a great idea on paper and is definitely a step in the right direction, but there are some “gotchas” for families with autistic children seeking to take advantage of the coverage. Here are some things to watch out for when trying to make sure that services for your child are covered and paid for:
- Check with your insurance company to make sure that any current or future service provider is covered by your insurance. In the Philadelphia region, Independence Blue Cross (IBX) is one of the major providers and many autism services fall under the umbrella of Mental Health which is handled by their Mental Health partner, Magellan. Families who have trouble with claims denied by Independence Blue Cross because the provider appears to be out-of-network should call Magellan to double-check the status of the provider. Make sure that your provider’s status, if corrected, is communicated back to Independence Blue Cross by Magellan or arrange a conference call between your IBX representative and the Magellan representative to make sure that your provider will be covered.
- Make sure that any diagnosis that your child currently has is backed up by a licensed physician, psychologist or psychiatrist. Children who are diagnosed by unlicensed wraparound service providers are not eligible for insurance coverage for autism services. Check with your BSC, TSS or MT or wraparound service evaluator about license status. If your wraparound personnel are not licensed, you may need to get additional evaluations for your child by a licensed physician, psychologist or psychiatrist to be eligible for coverage.
- The cap for coverage by insurance is $36,000 per calendar year as long as your child has an active autism spectrum diagnosis. Medical Assistance will typically pick up the costs, partially or in full after all insurance coverage has been exhausted. Until the cap amount is reached however, Medical Assistance will not kick in, so be sure that your providers are billing to your insurance first and keep an eye on the amount so you know when your claims may be covered by MA.
- Make sure that your providers bill your insurance and bill to Medical Assistance directly. Any payments that you make to your provider directly make not be covered or reimbursable.
- Check to make sure, if you are eligible for coverage, that your insurance provider and/or MA are paying claims submitted by your autism services providers. Some Philadelphia-area families have had problems with insurance passing on payment to Medical Assistance for various reasons including claiming that providers are out-of-network only to have MA pass the payment back to the insurance company because the insurance cap hasn’t been met yet, leaving service providers unpaid for several months. This may result in temporary suspension of services or loss of service.
- Be careful about your insurance selections when you sign up for insurance. High-deductible plans may entail very high out-of-pocket costs when dealing with autism services because they are often categorized as mental health services and the deductibles for mental health services tend to be higher than regular health services. This may result in some very high and unexpected medical bills.
Read more about autism insurance options in Pennsylvania from North Philadelphia Autism & Parenting Examiner Yvonne Jessey.