Policy Attachment

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Attachment C to Policy # 10.06.01d Outpatient Speech Therapy


View the policy for this attachment here:

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For members enrolled in a Pennsylvania product, Section 3 of the House Bill 1150 amends The Insurance Law of 1921 (“the Act”) by adding Section 635.2 to provide insurance coverage for the following:

• Individuals under twenty-one (21) years of age who are receiving diagnostic assessment of, and/or treatment for ASD, and who are covered under the following:
  • An insured employer group that has 51 or more employees
  • Medical Assistance
  • Pennsylvania’s Children’s Health Insurance Program (CHIP)
  • AdultBasic coverage

Insurers shall be responsible for the cost of medically necessary treatment up to $36,000 per year but shall not limit the number of visits to an autism service provider for the treatment of ASD. An adjustment to the maximum annual benefit amount will be made equal to the change in the United States Department of Labor Consumer Price Index for All Urban consumers (CPI-U) in the preceding year. Coverage shall be subject to the same terms and conditions that apply to other medical or surgical benefits, copayments, deductibles and coinsurance provisions, and any other general exclusions or limitations, of the health insurance policy.

Diagnostic assessment and treatment of ASD includes pharmacy care, psychiatric care, psychological care, speech, physical, and occupational therapy(ies), and/or applied behavior analysis (ABA). These services may be covered and eligible for reimbursement for the treatment of persons with ASD, provided that the therapy is determined by the Company to be medically necessary and not considered experimental or investigational.

The law does not require coverage of services based solely on their inclusion in an individualized education program (IEP). However, coverage for services in a treatment plan may be coordinated with services included in an IEP. In addition, coverage for ASD may not be contingent on a coordination of services in an IEP.

Unless a provider determines an earlier assessment is required, the results of a diagnostic assessment of ASD shall be valid for twelve (12) months. Insurers may review treatment plans for ASD once every six (6) months, or based on a schedule agreed upon by the insurer and the provider.

ASD is defined as 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:

• Autism disorder
• Rett syndrome
• Childhood disintegrative disorder (CDD)
• Asperger’s syndrome
• Pervasive developmental disorder - not otherwise specified (PDD-NOS)

Medically necessary diagnostic assessment and treatment prescribed, ordered, or provided shall be by an autism service provider or a person, entity, or group that works under the direction of an autism service provider who is licensed or certified in this Commonwealth. The results of the diagnostic assessment of ASD shall be valid for twelve (12) months, unless a licensed physician or licensed psychologist determines an earlier assessment is necessary.

Diagnostic assessment for ASD is defined as medically necessary assessments, evaluations, or tests performed by any of the following:

• Licensed physician
• Licensed physician assistant
• Licensed psychologist
• Certified registered nurse practitioner

Treatment for ASD is defined as medically necessary treatment prescribed, ordered, and/or provided by any of the following:

• Licensed physician
• Licensed physician’s assistant
• Licensed psychologist
• Licensed clinical social worker
• Licensed and/or certified registered nurse practitioner
• Licensed and/or certified behavior specialist
• Licensed speech and language pathologist, occupational and physical therapist
• An unlicensed person, entity, or group who works under the direction of a certified/licensed autism service provider

The treatment plan (a plan for the treatment of ASD) developed by a licensed physician or licensed psychologist must promote a comprehensive evaluation or re-evaluation and be performed in a manner consistent with the most recent clinical report or recommendations of the American Academy of Pediatrics. An insurer may review a treatment plan for the treatment of ASD once every (6) six 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. The treatment plan may include any of the following medically necessary services:

• Pharmacy care
  Medications prescribed or any assessment, evaluation, or test prescribed or ordered to determine the need or effectiveness of such medications
• Psychiatric care
  Direct or consultative services
• Psychological care
  Direct or consultative services
• Rehabilitative care
  Professional services and treatment programs, including applied behavior analysis, provided to produce socially significant improvements in human behavior or to prevent loss of attained skill or function
• Therapeutic care
  Services provided by speech language pathologists, occupational therapists, or physical therapists
  

  Version Effective Date: 11/13/2009