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The Commonwealth of Pennsylvania autism mandate became effective on July 1,
2009, requiring health insurers to cover the diagnosis and treatment of Autism
Spectrum Disorders (ASD). In addition, a recent court decision held that school
is an eligible place of service for ASD as of January 20, 2016.
The mandate provides coverage for the diagnosis and treatment of ASD for
AmeriHealth Pennsylvania members enrolled in a 51+ fully insured commercial
group product. Coverage is provided for enrolled individuals under age 21 and
requires coverage for the following:
- evaluations and tests needed to diagnose an autism disorder;
- medically necessary prescribed treatments such as applied behavioral
analysis and rehabilitative care, blood level tests, psychiatric and
psychological services, speech/language therapy, occupational therapy, physical
therapy, and prescription drugs.
Services not covered under the mandate include benefits that are normally
excluded from coverage under the member's medical plan, including services that
are not medically necessary.
Services for ASD, including those rendered in a school setting, must be
medically necessary and must have a primary diagnosis of ASD. Depending on the
service that is being requested, the member, or a health care provider on a
member's behalf, may be required to submit a treatment plan to AmeriHealth
Pennsylvania once every six months for review and approval. Services for ASD
will not be subject to any limits on the number of visits. However, services
are subject to applicable member cost-sharing, policy limits, maximums,
exclusions, and precertification and referral requirements under the member's
benefits program.
If you have questions about this mandate, call Customer Service at
1-800-275-2583.
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