Pennsylvania Medicaid Autism Coverage
Pennsylvania is unique in having two autism-specific adult Medicaid waivers (Adult Autism Waiver and ACAP) plus three IDD waivers. PH-95 (the "loophole") gives disabled children Medicaid coverage regardless of family income, and Act 62 requires commercial insurance to cover ABA through age 21.
Quick Answer
Pennsylvania is unique in having two autism-specific adult Medicaid waivers (Adult Autism Waiver and ACAP) plus three IDD waivers. PH-95 (the "loophole") gives disabled children Medicaid coverage regardless of family income, and Act 62 requires commercial insurance to cover ABA through age 21.
- ABA benefit: covered under EPSDT for under 21 (via epsdt).
- HCBS waivers: 5 relevant waiver options listed on this page.
- Commercial insurance: Pennsylvania has a state autism insurance mandate.
Medicaid ABA Coverage
Yes — EPSDT
Under 21 (via EPSDT)
Insurance Mandate
Yes
$36,000/year (original; adjusted annually for inflation)
HCBS Waivers
5 available
Waitlist: Limited slots; interest list
About this information
This page summarizes public Medicaid, waiver, and insurance-mandate information for general reference.
Medicaid benefits, managed-care rules, and waiver waitlists can change quickly, so families should verify eligibility, prior authorization, and enrollment steps with the administering agency before relying on this page.
Last reviewed 2026-04-21 by Autism Hearts Editorial Team
Pennsylvania Commercial Insurance Mandate
- Statute
- Act 62 of 2008 (40 P.S. § 764h)
- Year enacted
- 2008
- Age limit
- Through age 21
- Annual cap
- $36,000/year (original; adjusted annually for inflation)
Covered services
Self-funded employer plans (often from large employers) are regulated by federal ERISA law, not state mandates, and may be exempt. Always confirm your plan type on your Summary of Benefits and Coverage.
Medicaid ABA Therapy Benefit
- Covers ABA
- Yes
- Age limit
- Under 21 (via EPSDT)
- Prior auth required
- Yes
PA Medical Assistance covers Behavioral Health Rehabilitation Services (BHRS) and Applied Behavior Analysis. Delivered through HealthChoices managed care.
Pennsylvania HCBS Waivers
Adult Autism Waiver (AAW)
Covers autismAdults 21+ with autism diagnosis
- Waitlist:
- Limited slots; interest list
- Apply via:
- ODP Bureau of Autism Services
Adult Community Autism Program (ACAP)
Covers autismAdults 21+ with autism — managed care model
- Apply via:
- Bureau of Autism Services
Consolidated Waiver
Covers autismIndividuals with IDD, ages 3+
- Waitlist:
- Emergency/priority-of-urgent-need based
- Apply via:
- County Administrative Entity
Community Living Waiver (CLW)
Covers autismIndividuals with IDD living in community
- Apply via:
- County Administrative Entity
Person/Family-Directed Support (P/FDS) Waiver
Covers autismIndividuals with IDD needing lower levels of support
- Apply via:
- County Administrative Entity
Katie Beckett / TEFRA Option
Available — PH-95 Category (Medical Assistance for Children with Disabilities — "Loophole")
PA uses the PH-95 category of Medical Assistance to provide Medicaid to children with significant disabilities regardless of family income. Commonly called the "loophole" — essentially a Katie Beckett program.
Early Intervention (Birth–3)
PA Early Intervention (administered through county ELRCs and MHIDD programs) — Pennsylvania's IDEA Part C program. Children under 3 with developmental delays can access services without a formal autism diagnosis.
Official Sources
Use these primary sources when you need to confirm current Medicaid rules, waiver access, or state-agency guidance in Pennsylvania.
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Find providers in Pennsylvania
Browse informational listings for therapists, diagnostic centers, and support groups. Confirm details directly.
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Evaluation costs in Pennsylvania
Private-pay, insurance, and low-cost options.
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Compare waitlists across 50 states
Sortable table of every state's HCBS waiver waits.