ABA insurance and Medicaid coverage in Pennsylvania

Autism insurance mandate

State mandate for autism coverage

Yes, the research found a state autism coverage law.

Statute

Act 62 of 2008, adding Section 635.2 to The Insurance Company Law of 1921 (40 P.S. 764h)

Age limits

Coverage for diagnostic assessment and treatment of autism spectrum disorders for covered individuals under 21 years of age.

Annual cap

The statute's original maximum benefit is $36,000 per year, with no limit on the number of visits. After Dec 30, 2011 the Insurance Commissioner publishes an annual CPI-U adjustment in the Pennsylvania Bulletin. As of 2026-10-21, the published adjusted figure is $51,908 for policies issued or renewed in 2026, and $53,310 has been announced for 2027. Neither adjusted figure should be treated as a universally enforceable payment ceiling: PID Notices 2023-16, 2025-02 and 2026-06 require consideration of mental health parity requirements and say the adjustment is not expected to affect coverage. The statutory cap language and the parity requirements may conflict, so the cap that applies to a given plan should be confirmed with the insurer or the Pennsylvania Insurance Department.

Excludes self-funded employer plans

Yes, self-funded employer plans are generally outside state mandates.

Notes

Applies to health insurance policies offered, issued or renewed on or after July 1, 2009 to groups of 51 or more employees. Act 62 specifically excludes small-group (fewer than 51 employees) coverage. It also applies to the government programs defined in the section, which include the Commonwealth's medical assistance program, the adult basic coverage program and the Children's Health Care Program. The adult basic coverage program is a statutory listing and is not evidence of a currently operating program. 'Health insurance policy' is defined by reference to entities subject to the Insurance Company Law, HMO Act and 40 Pa.C.S. Ch. 61/63. As a state mandate, it does not apply to self-funded plans; that exclusion does not establish an absence of coverage under other requirements. Treatment must be medically necessary and must satisfy the prescribing and provider conditions in subsection (f)(14). It includes rehabilitative care such as applied behavioral analysis, provided by an autism service provider or someone working under their direction, pursuant to a treatment plan developed by a licensed physician or licensed psychologist. The insurer may review the treatment plan every 6 months, subject to utilization review, and another frequency may be agreed upon with the physician or psychologist. Insurers must contract with autism service providers enrolled in the Commonwealth's medical assistance program who are within the insurer's service area and accept the insurer's applicable payment levels, terms and conditions.

Medicaid ABA coverage

Medicaid covers ABA

Yes, per the sources below.

Program

Medical Assistance (MA) Intensive Behavioral Health Services (IBHS), including ABA services, for children, youth and young adults under 21

Agency

Pennsylvania Department of Human Services (Office of Mental Health and Substance Abuse Services)

Provider enrollment

We could not verify this yet - check with Pennsylvania Department of Human Services (Office of Mental Health and Substance Abuse Services).

Payers named in our research

We could not verify named payers for Pennsylvania yet - check with the state Medicaid agency.