INSURANCE ROAD MAP
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In the state of Pennsylvania, autism related services can be covered by private insurance, Medical Assistance and the new Community Health Choices Program. The following button will help you better navigate the insurance process. Click on here to view a health insurance road map. Click on link to access Act 62: Autism Insurance Act FAQs. More FAQ's about the Pennsylvania's Autism Insurance Act: Download A Fact Sheet Why should you care about Act 62 Information for Families?
​​If you have private insurance, you may want to call the Human Resources Department and ask what is covered. The Department of Human Services, Pennsylvania Insurance Department and the Department of State are working together to implement the Autism Insurance Act (ACT 62) which requires private health insurance companies to cover the cost of diagnostic assessment and treatments of ASD for children under 21 years of age. If you suspect insurance discrimination from your private insurance, call 877-888-4877 to clarify or go to https://www.attorneygeneral.gov/taking-action/ to submit a complaint.
Even though your child may be under your primary insurance, consider applying for MA. How to apply for medical assistance.
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Medical versus Behavioral Health: Which one is right for you?
NEW DHS is committed to increasing opportunities for older Pennsylvanians and individuals with physical disabilities to remain in their homes. If you’re 21 or older and have both Medicare and Medicaid, or receive long-term supports through Medicaid because you need help with everyday personal tasks, you’ll be covered by Community HealthChoices. (See the informative video on the link.)
Community HealthChoices will coordinate your health care coverage to improve the quality of your health care experience — serving more people in communities rather than in facilities, giving them the opportunity to work, spend more time with their families, and experience an overall better quality of life.
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​​In the meantime, you may want to apply for Medical Assistance. If you apply while you wait for a diagnosis, this can save you some time by being able to apply for services as soon as you receive a diagnosis. Some services that are covered by MA include BHRS, in-home personal care, diapers for 3 yr old children/older, prescriptions, PT, OT, and speech therapy. There are three ways to apply: online, in-person, or print a hard copy application.
​​Denied? Download the following doc to help you through the appeal process.
http://docs.wixstatic.com/ugd/e866aa_c255c1b27291486692029647936e7bcb.pdf
PA Health Choices Managed Care Physical Health Plan-Special Needs Unit Contact Info for Lehigh and Northampton Counties. These departments within the managed care plan that can work with you to resolve issues and get results:
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Managed Care Plan Special Needs Unit #
Aetna Better Health 215-282-3589
AmeriHealth Caritas PA 1-888-991-7200
​Gateway 1-800-392-1146
United Health Care 1-877-844-8844
UPMC for You 1-877-521-7433
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**Keep in mind some agencies and providers won't accept medical assistance. The reason is that the reimbursement rate is lower compared to private insurance.
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Health Insurance Premium Payment (HIPP) Program
The Health Insurance Premium Payment (HIPP) Program is a program developed to help families, who have at least one person enrolled in Medical Assistance (MA), pay for private health insurance through an employer.
​State Launches New Tool & Process to Determine Clinical Eligibility for Medicaid LTSS
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On April 1st Pennsylvania began a new method to determine clinical eligibility for Medical Assistance (MA) long-term services and supports (LTSS), which includes all nursing facility services as well as all home and community based services.
To receive MA-funded LTSS, an individual must meet both clinical and financial eligibility standards. To be clinically eligible, an individual must meet the need for the level of care provided in a nursing facility (Nursing Facility Clincially Eligible or NFCE).
1. The individual has an illness, injury, disability, or medicla condition diagnosed by a physician AND
2. As a result of it, the individual needs care and services that are above the level of norm and board AND
3. A physician certifies that the individual is NFCE AND
4. The needed care and services are either:
a. Skilled nursing or rehabilitation services are specified by the Medicare program in 42 C.F.R. 409.31 (a), 409.31 (b) (1) and (three), 409.32-409.35 OR
b. Health related care and services that are not as complex as killed nursing or rehabilitation services but are needed and provided on a regular basis in the context of planned program of healthcare and management and were previously available only through institutional facilities.
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Behavioral Insurance
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Magellan Healthcare
A 20+ track record of improving the health of individuals with complex needs through managing specialized services including pharmacy, specialty solutions and behavioral health. Available Services include: Beh. Health Rehabilitation services for kids/adults, Case Mgt Services, Certified Peer Support, Certified Recovery Services, Clozaril Monitoring and Support, Community Treatment Team, Dual Diagnosis Treatment Team, Electroconvulsive Therapy, Extended Acute Care, Family Based Mental Health Services for kids/adults, Methadone Maintenance, Mobile Mental Health Treatment, Multi-Systemic therapy, Non-Hosp, Residental Detoxification Rehabilitation and Halfway House, Partial Hospital Services Mental Health, Psychiatric Inpatient Services, Psychological Testing, and Residential Treatment for Children and Adults. Services no covered: Medical Services, Prescription Drugs, and Physical Heath Managed Care.
Click to access the 2018 Report to the Community
Click How to file a complaint about services to Magellan to download instructions.
​Contacts:
John Lees, MSW, LSW-Member and Family Advocate for Lehigh & Northampton Counties
Email: JGLees@MagellanHealth.com or call 610-814-8025
For more info on Magellan in Lehigh County, click here.
For more info on Magellan in Northampton County, click here.
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For Lehigh & Northampton County Children's Services:
Kristen Scalise, Clinical Single Point of Contact Children's Services
Call: 1-866-238-2311 x60851
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For Lehigh County Adult Services:
Melodie Higgins, Clinical Single Point of Contact
Call: 1-866-238-2311 x68043
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For Northampton County Adult Services:
Maria LaMonica, Clinical Single Point of Contact
Call: 1-866-238-2312 x68013
Website: http://www.magellanofpa.com/
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Neighborhood Health Centers​ of the Lehigh Valley
Provides primary and preventative health and wellness services in the Lehigh Valley. regardless of a person's ability to pay. Partnerships with other organizations allow them to create a primary health care home for an under served community. Mental health counseling and social services are also available. Social services can include Rx assistance and help with areas such as health insurance, public benefits and social security.
Where: 218 N. 2nd Street, Allentown, PA 18102 (610-841-8400)
1210 East 4th Street, Bethlehem, PA 18015 (484-408-0755)
1101 Northampton St, Easton, PA 18042 (484-544-3113)
Website: http://www.nhclv.org/
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​​HEALTHCARE RELATED ADVOCACY SERVICES:
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Pennsylvania Health Law Project
​We use our legal expertise and our experience working with clients to train advocates, health care providers, social workers, and consumers throughout the state on a wide range of health care related topics. These trainings include both in-person and webinar events, and range in topic from Medicaid 101 to more in-depth topics like successful appeal strategies, writing letters of medical necessity, and more.
123 Chestnut Street, Suite 400, Philadelphia, PA 19106
Call: 215-625-3990
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The PEAL Center (Parent Education & Advocacy Leadership Center)
The mission of the PEAL Center is to ensure that children, youth, and adults with disabilities and special health care needs lead rich, active lives and participate as full members of their schools and communities by providing training, information, parent leadership, and technical assistance based on best practices to individuals and families and all people who support them. (taken from website)
Services: Parent and professional trainings, advising parents about IEP meetings, and health related issues.
Where: 2325 E Carson St., Suite 100A, Pittsburgh, PA 15203
Call: 866-950-1040
Website: http://www.pealcenter.org
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Our Family to Family (F2F) Health Information Center Coordinator, Kelly King, assists families across the entire state with health-related issues. Kelly provides support, information, and resources to families and professionals. She helps families with access to healthcare, health insurance, and community services.
Contact: Kelly King, Family to Family Coordinator specializing in Health Care & Community Svs.
Call: 412-281-4404 ext. 207 or email kking@pealcenter.org
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Pennsylvania Health Law Project-Follow healthcare activity through Congress too.
Services: Offers information, advice and direct representation to individuals accessing health care benefits under Medical Assistance.
Call: 1-800-688-4226
Website: www.phlp.org
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When you need an attorney for Medicaid Waiver Appeals or any other insurance related issue:
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Batchis Nestle & Reimann LLC
Leah Batchis
Where: 116 Bala Avenue, Bala Cynwyd, PA 19004
Call: 215-550-1760
Website: http://specialedlawgroup.com/
Facebook: https://www.facebook.com/SpecialEdLawGroup/
Murphy & Murphy, P.C.
Angela J. Uliana Murphy
Where: 106 North Franklin Street, Suite 2, PO Box 97, Pen Argyl, PA 18072
Call: 610-863-8502
Website: http://www.murphy2.com/Attorneys/Angela-J-Uliana-murphy.shtml
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The Law Offices of Frankel and Kershenbaum, LLC
Where: 1230 County Line Rd, Bryn Mawr, PA 19010
Call: 610-922-4200
Website: http://www.mykidslawyer.com/
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Autistic Self Advocacy Network
It is a 501(c)(3) nonprofit organization run by and for autistic people. ASAN was created to serve as a national grassroots disability rights organization for the autistic community run by and for autistic Americans, advocating for systems change and ensuring that the voices of autistic people are heard in policy debates and the halls of power. There is a lot of info about self-advocacy for Medicaid.
Website: http://autisticadvocacy.org/
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