PHLP and the Autism Insurance Law


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by Patricia Livermore, May 7, 2014

I found two related news articles on the topic of the 2008 Autism Insurance Law, Act 62, announcing the elimination of a dollar limit cap on coverage for autism diagnostic and treatment services.  Pennsylvania’s Health Law Project (PHLP) was responsible for lawsuits in 2013 against both Capital and Highmark Blue Cross insurance plans that triggered both insurers to drop the dollar limit.  More efforts are being sought in Pennsylvania to study the overall implementation of the Autism Insurance Law.  So far, Pennsylvania’s efforts are good news for children and youth in these plans who are seeking autism treatment services.


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Certain Blues Plans Drop Limit on Autism Services

Capital Blue Cross (Capital) and Highmark Blue Cross Blue Shield (Highmark) both recently eliminated the dollar limit on coverage of autism diagnostic and treatment services in their group health policies subject to the Autism Insurance Law known as Act 62. When Act 62 of 2008 was passed, it required certain insurers to cover autism diagnostic and treatment services up to a specific dollar limit (currently $37,710 per year). This spending limit was a political compromise necessary to secure passage of the law.

In 2013, PHLP brought a lawsuit on behalf of a young man living with autism against Capital alleging that the Act 62 spending limit violates the federal Mental Health Parity and Addiction Equity Act. As a result of this lawsuit, Capital eliminated the dollar limit on coverage of autism services starting with their group policies renewing on or after January 1, 2014.

PHLP represented another young man living with autism in an appeal before the PA Insurance Department against Highmark regarding the limit on autism services. Highmark also eliminated the dollar limit on coverage of autism diagnostic and treatment services in their group health insurance policies subject to Act 62. Highmark stated in a letter to Benefits Administrators that the elimination of the dollar limit will have no effect on premiums for 2014.

These changes should save the state money as Medicaid will no longer be billed for services for children and youth in Capitol or Highmark when their autism services exceed $37,710 in a year. It should also assist children and youth in these plans without Medicaid to get the full amount of autism treatment services they need.


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Resolution Introduced to Study Implementation of Autism Insurance Law

In testimony at a hearing held by the PA House of Representatives’ Human Services Committee, PHLP and former Speaker of the House, Councilman Dennis O’Brien, recommended that the House authorize a study of the Autism Insurance Law to determine how well the law is being implemented. Shortly after that testimony, Rep. Murt (R. Montgomery) introduced a resolution to have the PA Legislative Budget and Finance Committee (the state version of the Government Accountability Office) study the law’s implementation. That Resolution, HR 631, has 38 co-sponsors. It is currently in the House Insurance Committee which is chaired by Rep. Tina Pickett (R. Sullivan and parts of Bradford and Susquehanna Counties).


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April 2014