§ 1805. Exclusions
This subchapter does not apply to short-term travel, accident-only or limited or specified disease policies.
§ 1728. Preferred Provider Organization
(a) Notwithstanding the provisions of this chapter, any physician who is a member of a Preferred Provider Organization (“PPO”) which meets, the requirements set forth below, shall not be subject to the requirements of section 1724 of this title: (1) The PPO physician shall require no more than a reasonable co- payment by the patient […]
§ 1731. Definiitons
As used in this subchapter: (a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior. (b) “Autism services provider” means any person, […]
§ 1732. Coverage for autism spectrum disorders
(a) After the effective date of this subchapter, a health care insurer that offers, issues for delivery, delivers, executes, adjusts, uses, or renews a health care insurance plan shall provide coverage for the costs of the diagnosis and treatment of autism spectrum disorders that are medically necessary and evidence-based. (b) Coverage required in health care […]
§ 1733. Prohibitions
A healthcare insurance plan must not impose: (1) any limits on the number of visits an insured may make to an autism services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage which places a […]
§ 1734. Limitations; review of treatment plan; diagnosis period
(a) The insurer may limit the coverage in the insurance health care plan for behavioral therapy to a yearly benefit of $50,000 for a child who is younger than nine years of age, $35,000 for a child who is at least nine years of age but younger than thirteen years of age and $25,000 for […]
§ 1735. Obligation to pay
(a) This subchapter does not limit benefits that are otherwise available to an individual under a health benefit plan. (b) Nothing in this subchapter relieves an insurer from an otherwise valid obligation to provide or to pay for services provided to an individual with a disability.
§ 1724. Initial billing
(a) If a patient, at the time of requesting health care services, presents to the health care provider evidence of coverage by a recognized health insurer, then the health care provider shall apply the following procedure when requiring payment for any services rendered: (1) The health care provider may require payment at or before the […]
§ 1725. Prompt payment by insurer
(a) Any insurer providing health insurance coverage shall be required to process and pay any uncontested claim, within thirty (30) calendar days from the date of receiving the claim. (b) If there is a contested claim, the insurer shall, within the same thirty (30) day calendar period notify the health care provider of its decision […]
§ 1726. Information and dispute resolution requirements
(a) Each insurer providing coverage under a health insurance plan shall establish and maintain an accessible information service which health care providers may contact telephonically and electronically to ascertain immediately whether a patient, service or procedure is covered under the plan, and whether a patient has satisfied any deductible amounts under the plan. The health […]