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Pennsylvania Autism Insurance Act Fact Sheet

Proiduced by the state Department of Public Welfare
July 09, 2008

The Autism Insurance Act:

  • Requires many private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorder and services for children under the age of 21, up to $36,000 per year
  • Requires the Pennsylvania Department of Public Welfare (DPW) to cover the cost of services for individuals who are enrolled in the Medical Assistance program and do not have private insurance coverage, or for individuals whose costs exceed $36,000 in one year
  • Requires the Pennsylvania Department of State to license professional behavior specialists who provide services to children

Who is covered by the Autism Insurance Act?

Children or young adults under age 21 with a diagnosis of an autism spectrum disorder who are:

  • Covered under an employer group health insurance policy (including HMOs and PPOs) that has more than 50 employees and the policy is not a "self-insured" or "ERISA" policy
  • On Medical Assistance
  • Ccovered by Pennsylvania’s Children’s Health Insurance Program, CHIP, or adultBasic

What does the Autism Insurance Act cover?

Diagnostic assessment and treatment of autism spectrum disorders, which include:

  • Prescription drugs and blood level tests
  • Services of a psychiatrist and/or psychologist (direct or consultation)
  • Applied behavioral analysis
  • Other rehabilitative care and therapies, such as speech and language pathologists, occupational and physical therapists

Treatment Requirements:

  • Must be for an autism spectrum disorder
  • Must be medically necessary
  • Must be identified in a treatment plan
  • Must be prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner
  • Must be provided by an autism service provider or a person, entity or group that works under the direction of an autism service provider.