Getting Autism Therapy Covered by Insurance in Pennsylvania

Pennsylvania's Act 62

Pennsylvania enacted Act 62 in 2008, requiring all Pennsylvania-regulated health insurance plans to cover ABA therapy for autism spectrum disorder through age 21. There is no dollar cap on covered services — coverage must include all medically necessary therapy hours.

Coverage ends at age 21:unlike states with no age cap, Pennsylvania's mandate applies through the individual's 21st birthday. Families with young adults transitioning out of Act 62 coverage should explore Medicaid waiver options before that birthday arrives.

Who qualifies: individuals under 21 with an autism diagnosis, with ABA therapy prescribed as medically necessary by a licensed physician or psychologist.

ERISA exemption:self-funded employer plans are generally exempt from Act 62 under federal ERISA law. Confirm your plan type with your HR department if you're unsure.

Prior authorization in Pennsylvania

Pennsylvania insurers almost always require prior authorization for ABA therapy, even under Act 62. Your BCBA or physician will submit the request. Key documents to prepare:

• Autism diagnosis report with DSM-5 criteria documentation
• Letter of medical necessity from the diagnosing physician
• BCBA's treatment plan with recommended hours per week
• BCBA's NPI number and credentials

Intermediate Units:Pennsylvania's 29 Intermediate Units (IUs) provide educational services including behavioral support in school settings. If your child is school-age, contact your local IU to ask about school-based ABA or behavioral support that can complement insurance-funded therapy hours.

Appeals

If your insurer denies ABA coverage or prior authorization in Pennsylvania:

1. Request the denial reason in writing — insurers are required to provide a specific reason for any denial.
2. File a written internal appeal within 30 days of the denial. Include a letter of medical necessity from your provider that directly addresses the denial reason. Keep detailed records of every communication and denial letter.
3. Request external review if the internal appeal is denied — a third-party independent reviewer evaluates the case. Pennsylvania law provides external review rights for fully insured plans.
4. Contact the PA Insurance Department at 1-877-881-6388 if you believe Act 62 is being violated. The Department has enforcement authority over Pennsylvania-regulated plans.

Pennsylvania HealthChoices Medicaid

Pennsylvania's Medicaid managed care program, HealthChoices, covers ABA therapy for children under 21 as a required service. HealthChoices is administered by managed care organizations (MCOs) — prior auth processes vary by MCO.

Enrollment:apply for Medicaid through Pennsylvania's COMPASS system at compass.state.pa.us or contact your county assistance office. Children with disabilities may qualify for SSI-linked Medicaid regardless of household income.

Dual coverage: if your child has both private insurance and Medicaid, private insurance is billed first. Medicaid covers remaining costs, including copays and services not covered by private insurance.