SETTING UP INSURANCE
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Does private insurance cover Autism services?
Jan 11, 2024-Pennsylvania Governor Josh Shapiro and Insurance Commissioner Michael Humphreys recently announced a directive requiring all state-regulated commercial insurers to treat autism spectrum disorder (ASD) as a mental health condition and cover autism treatment and services in compliance with federal and state mental health.
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When should I set up Medicaid insurance?
You should apply for Medicaid for your loved one following their Autism diagnosis.
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Where can I apply for my child to get Medicaid?
Click here for an overview of Medicaid in PA and follow the prompts to read about eligibility and links to apply.
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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?
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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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You might be eligible 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 medical 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.
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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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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)
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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
Where: 520 Christopher Columbus Blvd, Suite 602, Philadelphia, PA 19123
Call: 215-567-6143
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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
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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
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
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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
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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.
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