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The new draft definition of medical necessity for Medical Assistance
could affect the number of hours of wraparound service (TSS) for which
children with autism would be authorized in the following ways:
1) The intervention must be "medical" in nature. It's not clear
whether most therapies for children with autism would be considered "medical".
2) The intervention must be "consistent with an existing national standard
of care." It's not clear that there is an "existing national standard
of care" when it comes to therapies for children with autism.
3) The intervention must be: "the most economic and quality alternative
among two (2) or more equally effective interventions." This criteria
could be used to cut hours for parents using intensive programs that use
lots of hours until there is agreement among clinicians that one modality
is more effective than another.
People who are concerned about this draft definition of medical necessity for Medical Assistance, should write to Suzanne Love, Director, Bureau of Program & Policy Development. She can be reached
You should make sure to give personal examples as to how the draft definition of medical necessity would affect the services your children receives through MA.
David Gates, PA Health Law Project
Below is the full draft definition of medical necessity.
An intervention will be considered medically necessary if it meets ALL FOUR of the following conditions:
1. The intervention is medical in nature. Medical interventions are those that are rendered, ordered or prescribed by a licensed health care professional
2. The intervention is effective. Effective interventions are those that a reasonable practitioner would conclude that:
a. A sufficient body of scientific literature exists to demonstrate that a substantial benefit would be expected from using the intervention for the condition for which it is being prescribed, or
b. Use of the intervention for the condition for which it is being prescribed is consistent with an existing national standard of care.
3. The intervention is individualized. Individualized interventions are those that a reasonable practitioner would predict would provide demonstrable benefit to the individual for whom the intervention is being prescribed, given the current status of that individual.
4. The intervention is consistent with efficiency economy and quality of care as demonstrated by:
a. It is the only effective intervention for the condition for which it is being prescribed; or
b. It is the alternative among two (2) or more effective quality interventions that a reasonable practitioner would predict would produce a substantially more beneficial outcome, given the condition for which it is being prescribed and the individual's current status; or
c. It is the most economic and quality alternative among two (2)
or more equally effective interventions that a reasonable practitioner
would predict would produce similar beneficial outcomes, given the condition
for which it is being prescribed and the individual's current status.
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