Getting Autism Therapy Covered by Insurance in Pennsylvania

Pennsylvania's Act 62

Pennsylvania enacted Act 62 in 2008, codified at 40 P.S. section 764h. It requires covered health insurance policies to pay for the diagnostic assessment and treatment of autism spectrum disorder for people under 21 years of age.

Visits cannot be limited. Dollars can. Subsection (b) says coverage is subject to a maximum benefit of $36,000 per year, but may not be subject to any limits on the number of visits to an autism service provider. Those are opposite rules in one sentence, and the difference decides which argument you can win. The Insurance Commissioner publishes an inflation adjustment to that maximum in the Pennsylvania Bulletin on or before 1 April each year, so the figure in force today is higher than $36,000. Ask your insurer for the current adjusted maximum in writing rather than relying on any number you read, this page included.

Act 62 only reaches employers with 51 or more employees. This is the limitation the page used to omit entirely, and it is the one most likely to end a claim before it starts. Subsection (e)(1) applies the section to policies offered, issued or renewed on or after 1 July 2009 to groups of fifty-one or more employees. If you work for a smaller employer, or hold an individual policy, Act 62 is not the statute for you — federal parity rules and your plan's own terms are. The section also excludes accident-only, fixed indemnity, limited benefit, credit, dental, vision, specified disease, Medicare supplement, CHAMPUS supplement, long-term care, disability income and workers' compensation policies.

Coverage ends at 21: families with a young adult approaching that birthday should explore Medicaid waiver options well before it arrives.

Pennsylvania does require a state credential — unusually. An autism service provider under Act 62 must be licensed or certified in this Commonwealth, or have been enrolled in Pennsylvania's medical assistance program on or before the act took effect. Pennsylvania licenses behavior specialists through the State Board of Medicine. This matters because it is genuinely different from most states: Georgia and California, for instance, require national board certification and no state license at all.

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. Federal rules give you at least 180 days from the denial notice, and no 30-day deadline appears in Act 62. 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.