Shapiro Administration Directs Insurers to Meet Obligations for Autism Coverage Under Mental Health Parity Laws, Removing Barriers to Care and Expanding Access to Services for Pennsylvanians

The Shapiro Administration has directed health insurers to provide coverage for autism benefits starting on January 1, 2024 in compliance with mental health parity laws, taking action to ensure that parity for autism benefits is a reality for tens of thousands of Pennsylvanians with autism.  

Harrisburg, PA – Today, Governor Josh Shapiro and Pennsylvania Insurance Department (PID) Commissioner Michael Humphreys announced that starting on January 1, 2024, the Shapiro Administration will require all commercial insurers to meet their obligations under Pennsylvania law to provide coverage for autism benefits.

The PID published a Notice in the Pennsylvania Bulletin on November 4, 2023 announcing that by no later than January 1, 2024, PID will require insurers offering commercial health insurance policies that include coverage for autism services to handle claims for those services in a manner that complies with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Pennsylvania’s mental health parity requirements.

“Today, my Administration is making clear that autism services are mental health services with full parity protections, and under our mental health parity laws, we expect insurers to cover treatment consistently and fairly,” said Governor Josh Shapiro. “With today’s announcement, we are removing unnecessary barriers to care for over 55,000  Pennsylvanians with autism, and helping them secure the treatment they need to live happy, productive lives. My Administration is deeply committed to improving access to care for Pennsylvanians – and it is my hope that we continue to make real progress and come together to deliver commonsense solutions that give families peace of mind.”

The Shapiro Administration is working to make mental health parity a true reality in Pennsylvania – and part of making this a reality includes requiring that commercial insurers comply with all mental health parity laws to cover autism services fairly and consistently. With this action, the Shapiro Administration will require those insurers to fully comply with parity requirements in administering autism coverage, which means recognizing that autism services are mental health benefits.

Some commercial insurers have historically categorized autism services as a physical health benefit while other insurers categorize all services for autism as mental health benefits. Most of the major health insurers offering comprehensive health insurance in Pennsylvania already treat autism as a mental health condition, subject to parity requirements. PID’s Notice directs the remaining insurers to do the same.

In his first budget address, Governor Shapiro called for stronger mental health parity and directed Commissioner Humphreys and the PID to hold insurers accountable to ensure that mental health benefits are covered fairly. As a result, PID announced that it has strengthened its review of mental health and substance use disorder coverage in 2024 health plans and will enhance its compliance review of mental health and substance use disorder parity requirements to prevent potential violations before they have a chance to harm Pennsylvania consumers.

“We expect insurers to promptly adjust health insurance policy form language and claims handling processes, if necessary, to provide Pennsylvania consumers with autism with the protections afforded by the mental health parity provisions,” said Pennsylvania Insurance Commissioner Michael Humphreys. “We share this message with the entire autism community – if you are getting denials for services or running up against unfair coverage limitations, we encourage you to reach out to us. The Shapiro Administration wants to support you and work with you and your insurer to avoid mental health parity violations and to help you live healthy and productive lives.”

Categorizing autism as a mental health benefit will make a positive impact on the approximately 55,000 Pennsylvanians with autism by requiring health insurers to adjust their insurance policy form language and claims handling processes to provide Pennsylvanians with autism the protections afforded by the mental health parity provisions. As a result, health insurers may not: charge higher copays or deductibles for autism services than for physical health services, cover fewer autism service visits than they would for other health conditions, impose an annual limit for autism services, as well as other safeguards afforded by state and federal parity laws.

“Parity between coverage for autism-related care and other services has long been a goal of the disability community,” said Rep. Jessica Benham. “I am grateful to Governor Shapiro and his Administration for prioritizing this change, which is a step in the right direction toward ensuring greater access to care for individuals with developmental disabilities.”

Drexel University’s A.J. Drexel Autism Institute is a partner of the Commonwealth’s ASERT (Autism Services, Education, Resources & Training) Collaborative, which is funded by the Pennsylvania Department of Human Services’ Bureau of Supports for Autism and Special Populations. The mission of the ASERT Collaborative is to innovate, collaborate, and lead to improve access to quality services, data, and information; to provide support, training and education in best practices; and to facilitate the connection between individuals with autism, developmental disabilities, and special populations, families and key stakeholders at local, state, and national levels.

“Today, we are all here together to celebrate a significant milestone in Pennsylvania mental health parity for autistic individuals. Mental health parity means that insurance plans should provide fair coverage and financial support for mental health and substance use disorder services, including autism services” said Dr. Diana Robins, Director and Professor at the A.J. Drexel Autism Institute. “I would like to thank Governor Shapiro and his Administration – the Department of Human Services and the Insurance Department – for their continued support and action for Pennsylvanians with Autism and Intellectual/Developmental Disabilities.”

Eagles Autism Foundation Executive Director Ryan Hammond joined the Shapiro Administration and the A.J. Drexel Autism Institute for the announcement. The Eagles Autism Foundation helps to fund innovative research, drive scientific breakthroughs, and provide critical resources to create a major shift from awareness to action in the autism community.

“The Eagles Autism Foundation is proud to support the work of Governor Shapiro and key stakeholders whose efforts will result in much needed access to services for individuals diagnosed with autism,” said Ryan Hammond, Executive Director of the Eagles Autism Foundation. “We know intervention and support is critical in changing the trajectory and outcomes in a person’s life and we believe through this policy, families’ needs will be better served, and lives will be changed as a result. We recognize it takes all of us to advance our collective mission of helping people live their best life and today is a wonderful example that we can continue to build upon in the future.”

PID believes that treating autism as a mental health condition is consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, which was in effect at the time of enactment of Act 62 of 2008, state and federal MHPAEA laws, as well as generally recognized independent standards of current medical practice, including both the current edition of the DSM and the current edition of the International Classification of Diseases, as recognized in the federal mental health parity regulatory definition of “mental health benefit.” The DSM is the authoritative source under Pennsylvania’s autism law, Act 62.

Pennsylvania law requires coverage of the diagnostic assessment and treatment of autism spectrum disorders by certain group insurance policies or contracts. Through the Affordable Care Act, that law also applies to individual and small group policies. The Department has monitored the coverage of autism services, including whether they have been covered as a mental health condition subject to the federal MHPAEA law that was adopted into state law in 2010.

For support with insurers, Pennsylvanians can contact PID’s Consumer Services Bureau online or at 1-877-881-6388. For more information on the Shapiro Administration’s commitment to supporting Pennsylvanians with autism, visit pa.gov/autism.

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