Services for your child can become very costly, even with private insurance. Fortunately, a diagnosis allows parents to seek additional funding through Medical Assistance (MA) in Pennsylvania. Information to help you get started accessing funding for services is provided below.
Medical Assistance Eligibility
- A child with an autism spectrum diagnosis (or related diagnosis) is eligible for Medical Assistance (MA) benefits based on their disability (Category PH95).
- The PH95 category is not based on financial need. Household income does not affect eligibility, unless the income is for the child (survivor’s benefits, trust, etc.).
- MA covers most medical services and therapies, including Applied Behavior Analysis (ABA).
- If you have health insurance through your employer, MA is considered secondary insurance.
- If your child is enrolled in a Children’s Health Insurance Program (CHIP) insurance, he/she cannot be covered by both CHIP and MA. Check with your child’s CHIP plan and their coverage of ABA before deciding to switch to MA.
Health Insurance Premium Payment (HIPP) Program
- If your child is covered by a commercial insurance plan through an employer and becomes eligible for MA, you may become enrolled in the HIPP Program.
- The state determines who is enrolled based on cost-effectiveness.
- If you are chosen to be enrolled in HIPP, the state will pay your monthly health insurance premiums for commercial insurance. MA stays in effect; however, if your child was enrolled in a Managed Care plan through MA, he/she will be disenrolled and placed into the Medical Assistance fee-for-service program. The fee-for-service plan may not be accepted by all of your child’s medical or therapy providers.
- This usually does not impact ABA, but it may be an issue with other providers.
- You can appeal your enrollment in HIPP if you can demonstrate that enrollment is detrimental to your child’s care.
Private Insurance Information/Act 62
- The Pennsylvania Autism Insurance Act (PA Act 62) requires private health insurance companies to pay for diagnostic and treatment up to a certain amount. This amount of “cap” is adjusted annually.
- Insurance plans that are self-funded, out of state, or through a company with less than 51 employees are exempt.
- All deductibles and co-pays are still the responsibility of the family unless the child is also eligible for Medical Assistance and the service is covered.
- Some plans that are exempt under Act 62 will still cover ABA therapy as part of their benefits package.
- Contact your insurance company for coverage details. If your insurance company does not cover services, you can also appeal to your Human Resources department to request that your employer cover services.
Applying for Medical Assistance for Your Child
Children with a medical and/or behavioral diagnosis (including Autism) are eligible for Medical Assistance (MA), regardless of income. MA can be either a primary or a secondary insurance for children. Facilities that participate with MA generally cover the full cost of visits.
There are several ways to enroll in PA Medicaid.https://www.enrollnow.net/enroll
How to Enroll in Medical Assistance
Apply using a Mobile App
- Apply online
- Apply using a mobile app on an Android or iPhone
- By phone Toll-free number 800-440-3989
- By mail to PA Enrollment Services, P.O. Box 61077, Harrisburg, PA 17106
This is an annual process. After your child is approved for Medical Assistance, you will receive renewal paperwork that you must complete and submit each year by the date indicated in the packet in order to maintain coverage.
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