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(a) A health insurance policy or government program covered under this section shall provide to covered individuals or recipients under twenty-one (21) years of age coverage for the diagnostic assessment of autism spectrum disorders and for the treatment of autism spectrum disorders.
(b) Coverage provided under this section by an insurer shall be subject to a maximum benefit of thirty-six thousand dollars ($36,000) per year but shall not be subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders. After December 30, 2011, the Insurance Commissioner shall, on or before April 1 of each calendar year, publish in the Pennsylvania Bulletin an adjustment to the maximum benefit equal to the change in the United States Department of Labor Consumer Price Index for All Urban Consumers (CPI-U) in the preceding year, and the published adjusted maximum benefit shall be applicable to the following calendar years to health insurance policies issued or renewed in those calendar years. Payments made by an insurer on behalf of a covered individual for treatment of a health condition unrelated to or distinguishable from the individual's autism spectrum disorder shall not be applied toward any maximum benefit established under this subsection.
(c) Coverage under this section shall be subject to copayment, deductible and coinsurance provisions and any other general exclusions or limitations of a health insurance policy or government program to the same extent as other medical services covered by the policy or program are subject to these provisions.
(d) This section shall not be construed as limiting benefits which are otherwise available to an individual under a health insurance policy or government program.
(d.1) This section shall not be construed as requiring coverage by insurers of any service based solely on its inclusion in an individualized education program. Consistent with Federal or State law and upon consent of the parent or guardian of the covered individual, the treatment of autism spectrum disorders may be coordinated with any service included in an individualized education program. Coverage for the treatment of autism spectrum disorders shall not be contingent upon a coordination of services with an individualized education program.
(e)(1) This section shall apply to any health insurance policy offered, issued or renewed on or after July 1, 2009, in this Commonwealth to groups of fifty-one (51) or more employees: Provided, That this section shall not include the following policies:
(i) Accident only.
(ii) Fixed indemnity.
(iii) Limited benefit.
(vii) Specified disease.
(viii) Medicare supplement.
(ix) CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) supplement.
(x) Long-term care or disability income.
(xi) Workers' compensation.
(xii) Automobile medical payment.
(2) This section shall apply to any contract executed on or after July 1, 2009, by the adult basic coverage insurance program established under Chapter 13 1 of the act of June 26, 2001 (P.L. 755, No. 77), known as the “Tobacco Settlement Act,” or by the Children's Health Care Program established under this act, or by any successor program of either of them.
(3) On January 1, 2011, insurers shall make a report to the Insurance Department, in a form and manner as determined by the department, to evaluate the implementation of this section.
(f) As used in this section:
(1) “Applied behavioral analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.
(2) “Autism service provider” means any of the following:
(i) A person, entity or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is licensed or certified in this Commonwealth.
(ii) Any person, entity or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is enrolled in the Commonwealth's medical assistance program on or before the effective date of this section.
(3) “Autism spectrum disorders” means any of the pervasive developmental disorders defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or its successor, including autistic disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified.
(4) “Behavior specialist” means an individual who designs, implements or evaluates a behavior modification intervention component of a treatment plan, including those based on applied behavioral analysis, to produce socially significant improvements in human behavior or to prevent loss of attained skill or function, through skill acquisition and the reduction of problematic behavior.
(5) “Diagnostic assessment of autism spectrum disorders” means medically necessary assessments, evaluations or tests performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner to diagnose whether an individual has an autism spectrum disorder.
(6) “Government program” means any of the following:
(i) The Commonwealth's medical assistance program established under the act of June 13, 1967 (P.L. 31, No. 21), 2 known as the “Public Welfare Code.”
(ii) The adult basic coverage insurance program established under Chapter 13 of the act of June 26, 2001 (P.L. 755, No. 77), known as the “Tobacco Settlement Act.”
(iii) The Children's Health Care Program established under this act.
(7) “Health insurance policy” means any group health, sickness or accident policy, or subscriber contract or certificate offered, issued or renewed by an entity subject to one of the following:
(i) This act.
(ii) The act of December 29, 1972 (P.L. 1701, No. 364), 3 known as the “Health Maintenance Organization Act.”
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).
(8) “Insurer” means any entity offering a health insurance policy as defined in this section.
(9) “Pharmacy care” means medications prescribed by a licensed physician, licensed physician assistant or certified registered nurse practitioner and any assessment, evaluation or test prescribed or ordered by a licensed physician, licensed physician assistant or certified registered nurse practitioner to determine the need or effectiveness of such medications.
(10) “Psychiatric care” means direct or consultative services provided by a physician who specializes in psychiatry.
(11) “Psychological care” means direct or consultative services provided by a psychologist.
(12) “Rehabilitative care” means professional services and treatment programs, including applied behavioral analysis, provided by an autism service provider to produce socially significant improvements in human behavior or to prevent loss of attained skill or function.
(13) “Therapeutic care” means services provided by speech language pathologists, occupational therapists or physical therapists.
(14) “Treatment of autism spectrum disorders” shall be identified in a treatment plan and shall include any of the following medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care that is:
(i) Prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner.
(ii) Provided by an autism service provider.
(iii) Provided by a person, entity or group that works under the direction of an autism service provider.
(15) “Treatment plan” means a plan for the treatment of autism spectrum disorders developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American Academy of Pediatrics.
(g)(1) The State Board of Medicine, in consultation with the Department of Public Welfare, 4 shall promulgate regulations providing for the licensure or certification of behavior specialists. Behavior specialists licensed or certified by the State Board of Medicine shall be subject to all disciplinary provisions applicable to medical doctors as set forth in the act of December 20, 1985 (P.L. 457, No. 112), 5 known as the “Medical Practice Act of 1985.” The State Board of Medicine may charge reasonable fees as set by board regulation for licensure or certificates or applications permitted by the “Medical Practice Act of 1985.”
(2) An applicant applying for a license or certificate as a behavior specialist shall submit a written application on forms provided by the State Board of Medicine evidencing and insuring to the satisfaction of the board that the applicant:
(i) Is of good moral character.
(ii) Has received a master's or higher degree from a board-approved, accredited college or university, including a major course of study in school, clinical or counseling psychology, special education, social work, speech therapy, occupational therapy or another related field.
(iii) Has at least one year of experience involving functional behavior assessments, including the development and implementation of behavioral supports or treatment plans.
(iv) Has completed at least one thousand (1,000) hours in direct clinical experience with individuals with behavioral challenges or at least one thousand (1,000) hours' experience in a related field with individuals with autism spectrum disorders.
(v) Has completed relevant training programs, including professional ethics, autism-specific training, assessments training, instructional strategies and best practices, crisis intervention, comorbidity and medications, family collaboration and addressing specific skill deficits training.
(3) The board shall not issue a license or certificate to an applicant who has been convicted of a felony under the act of April 14, 1972 (P.L. 233, No. 64), 6 known as “The Controlled Substance, Drug, Device and Cosmetic Act,” or if an offense under the laws of another jurisdiction which, if committed in this Commonwealth, would be a felony under “The Controlled Substance, Drug, Device and Cosmetic Act,” unless:
(i) At least ten (10) years have elapsed from the date of conviction.
(ii) The applicant satisfactorily demonstrates to the board that he has made significant progress in personal rehabilitation since the conviction such that licensure of the applicant should not be expected to create a substantial risk of harm to the health and safety of his patients or the public or a substantial risk of further criminal violations.
(iii) The applicant otherwise satisfies the qualifications contained in or authorized by this section.
As used in this paragraph, the term “convicted” shall include a judgment, an admission of guilt or a plea of nolo contendere.
(h) An insurer shall be required to contract with and to accept as a participating provider any autism service provider within its service area and enrolled in the Commonwealth's medical assistance program who agrees to accept the payment levels, terms and conditions applicable to the insurer's other participating providers for such service.
(i) An insurer may review a treatment plan for treatment of autism spectrum disorders once every six (6) months, subject to its utilization review requirements, including case management, concurrent review and other managed care provisions. A more or less frequent review can be agreed upon by the insurer and the licensed physician or licensed psychologist developing the treatment plan.
(j) For purposes of this section, the results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of not less than twelve (12) months unless a licensed physician or licensed psychologist determines an earlier assessment is necessary.
(k)(1) Upon denial or partial denial by an insurer of a claim for diagnostic assessment of autism spectrum disorders or a claim for treatment of autism spectrum disorders, a covered individual or an authorized representative shall be entitled to an expedited internal review process pursuant to the procedures set forth in Article XXI, 7 followed by an expedited independent external review process established and administered by the Insurance Department.
(2) An insurer or covered individual or an authorized representative may appeal to a court of competent jurisdiction an order of an expedited independent external review disapproving a denial or partial denial. Pending a ruling of such court, the insurer shall pay for those services, if any, that have been authorized or ordered until such ruling.
(3) The Insurance Commissioner may promulgate rules and regulations as may be necessary or appropriate to implement and administer this subsection.
(l) For purposes of this section, the term “autism service provider” shall include any behavior specialist in this Commonwealth providing treatment of autism spectrum disorders pursuant to a treatment plan until one (1) year from the time that regulations under subsection (g) are promulgated or until three (3) years from the effective date of this section, whichever is later.
Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 764h. Autism spectrum disorders coverage - last updated January 01, 2019 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-764h.html
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