Pennsylvania Governor Ed Rendell has signed legislation requiring coverage for autism be included in all health insurance policies sold within the state. The mandate is effective as of July 2009 and applies to 51 + commercial group customers. Coverage will be provided for enrolled individuals under age 21 with a primary diagnosis of autism.

WHAT THIS MEANS TO YOU AS AN EMPLOYER?

The key points of this legislation are listed below.

Who is covered and when does coverage begin?

• The PA autism mandate applies to 51+ commercial group customers.
• Coverage will be provided for enrolled individuals under age 21 with a primary diagnosis of autism.
• This mandate is effective July 1, 2009.

Are self-funded customers affected by this mandate?

• The mandate applies to self-funded employers that are not subject to, or governed by, ERISA.
• Self-funded employers that are subject to ERISA have the ability to exclude the autism mandate.

What is covered under the mandate?

• Evaluations and tests to diagnose an autism spectrum 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.
• Coverage is capped at $36,000 per benefit period (Beginning January 1, 2013, the limit for ASD coverage will be adjusted annually for inflation).
• There are no limits on the number of diagnostic/treatment visits (until the $36,000 cap is reached).
• Coverage is subject to applicable member cost-sharing (such as copays, coinsurance, and deductibles), policy limits, maximums, exclusions, and precertification and referral requirements under the member’s benefits program.

What services are not covered under the mandate?

• Benefits that are excluded from coverage under the medical plan, including services that are not medically necessary.
• Services provided by an individualized education program and delivered in a school.
• Services in excess of the $36,000 benefit period maximum.

How do individuals obtain coverage?

• Services for ASD must be medically necessary and must have a primary diagnosis of ASD.

Can members get coverage for services in excess of the benefit maximum or not covered by the plan?

• Once a member reaches the $36,000 benefit period maximum, additional services may be eligible for coverage through a government agency. Expenses not eligible under the plan and any member cost sharing paid may also be eligible for coverage through a government agency. Pennsylvania residents should check with the Pennsylvania Department of Public Welfare. Members who reside outside of Pennsylvania should contact similar government agencies in their area.

ERISA policies would be exempt for this state mandate.

WHAT SHOULD I DO NEXT?

Corporate Synergies will continue to release information and guidance as to how the carriers will be administering this new legislation as it is released.

If you have any additional questions regarding the information within this eCommunication, please call Corporate Synergies at 1.866.CSG.1719 or CLICK HERE to contact us today.