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Obtaining Wrap Around Services For Your Child
Wrap Around is for children in Pennsylvania who have serious emotional or behavioral problems and are between 2 and 21 years of age. It is used by many families with children on the autism spectrum.
Wrap Around is also known as BHRS, which stands for Behavioral Health Rehabilitation Services. It is a behavioral health support service provided by a team that may consist of the following individuals:
- Behavior Specialist Consultant (BSC), who writes and implements a treatment plan and then monitors the child's progress towards meeting the goals set in the treatment plan;
- Case Manger, who manages and coordinates the services provided to a family;
- Therapeutic Support Staff (TSS) worker, who provides most of the behavior services by working to redirect the child to learn more appropriate behaviors or responses, working on behavioral modification, or whatever else is called for in the treatment plan; and
- Mobile Therapist (MT), who provides individual therapy to the child and family, including discussing emotions and problems the child is having.
What do Wrap Around services look like?
A team of trained people work to help your child to improve his or her behavior.
- A BSC writes the plan about how to change your child's behavior. The plan states what the child is learning to do, describes how to teach the child to do it, and says how the child will be rewarded for learning.
- A MT may meet with your child or with other members of the family for individual or family mental health counseling at home, in the community, or at school. This is like going to therapy, but the therapist comes to you.
- A TSS will work individually with your child at home, in school, or in the community, to help your child learn to change his or her behavior. The TSS may work with your child every day or several days each week, possibly including weekends. (Though Wrap Around services may occur at school, Wrap Around is not an educational service and is not provided by the Department of Education.)
A responsible adult must be present when Wrap Around services are provided. Wrap Around staff are not childcare staff. Additionally, they do not participate in personal hygiene care such as changing diapers. (If your disabled child needs 1:1 assistance with personal hygiene he or she may qualify for Home Health Aide services.)
How can I get Wrap Around services for my child?
There are two ways to obtain Wrap Around services: through your private health insurance or through Medical Assistance. If your private health insurance is subject to the Autism Insurance Act 62, the private insurer must provide medically necessary psychological, rehabilitative, and therapeutic care to children on the autism spectrum – in other words, Wrap Around services. (In general, Act 62 applies to employer provided health insurance issued in Pennsylvania where the employer has more than 50 employees and the plan is not self-funded by the employer.) If Act 62 does not apply, your child may be eligible for Wrap Around services through Medical Assistance, regardless of your family's income, if services are "medically necessary." Wrap Around services may take as long as 2-6 months to put into place. If your child is covered by a private health insurance plan subject to Act 62 and by Medical Assistance, you must apply for Wrap Around through the private insurance plan first.
Applying for Wrap Around services through private insurance:
If Act 62 applies, call your insurance company and obtain a list of in-network autism providers. Choose a provider, and request an intake evaluation to see if Wrap Around services are appropriate. After talking with you and spending time with your child, a doctor or psychologist will determine whether or not services are medically necessary. Make sure you clearly explain your child's difficulties at home, school, and in the community, focusing particularly on any behavioral and social challenges. You may also provide documentation from your own medical doctor or other professionals who have evaluated your child. The insurance company will review all materials and make the final determination of eligibility. Eligibility may be periodically reviewed; check with your insurance company for how frequently these reviews occur and make sure you follow all required procedures and timelines.
If your child is denied Wrap Around services by the private insurer based on medical necessity, the decision may be appealed under the expedited review process detailed in Act 62. If the decision to deny services is overturned, the private insurer must cover the services. If the decision is upheld, you may apply for Wrap Around services through Medical Assistance. Medical Assistance may use a different definition of medical necessity, through which your child may qualify for services.
Applying for Wrap Around services through Medical Assistance:
If you are applying for Wrap Around services thorough Medical Assistance, your child must first be approved to receive Medical Assistance. (Instructions for applying for Medical Assistance appear in a separate article in the CAR Autism Roadmap™.) Call the Behavioral Health Managed Care Organization (MCO) for your county and ask for an evaluation for Wrap Around services. Some of the Behavioral Health MCOs in Pennsylvania are:
- Community Behavioral Health, serving Philadelphia
- Magellan Behavioral Health, serving Bucks, Delaware, Lehigh, Montgomery, and Northampton Counties
- Community Behavioral Healthcare Network Of PA (Choose Mental Health/Behavioral Health And PA), serving Bedford, Blair, Clinton, Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon, Lycoming, Perry, and Somerset Counties
- Value Behavioral Health, serving Armstrong, Beaver, Butler, Cambria, Crawford, Fayette, Greene, Indiana, Lawrence, Mercer, Venango, Washington, and Westmoreland Counties
- Community Care Behavioral Health Organization, serving all other counties
The MCO will give you a list of doctors near your home who can do the evaluation. You can bring any reports from other evaluations with you to the appointment. Talk to the doctor about what your child needs help with and what he is good at. After the Wrap Around evaluation, you will get a report or a letter saying if your child qualifies. If your child qualifies, call the Behavioral MCO for another appointment. You will need to schedule an Interagency Service Planning Team (ISPT) meeting, which will set up the services your child is eligible to receive. Wrap Around services should start within 60 days.
If nothing happens in 60 days, call your MCO to fix the problem. If nothing happens after you call the MCO, call 412-565-5226 (Western PA) or 717-214-9076 (Eastern PA) to fix the problem. If the problem is still not fixed, call 1-800-274-3258.
In order to keep Wrap Around services, you will need to reapply periodically. Check with your MCO about when you will need to reapply, and don't put it off. Your child will need to have an evaluation each time you reapply, and the evaluation and determination must occur before your child's Wrap Around services expire.
If your child is denied services based on medical necessity, you may ask to have another doctor perform an evaluation. Be sure to bring any supplemental materials (reports from others who have evaluated your child) to help support the need for services.
Is Wrap Around the same, regardless of who pays for it?
There are a few differences in the Wrap Around services your child may receive, depending on whether Medical Assistance or your private health insurance is paying for it.
- Private insurers use their own medical necessity criteria. Though the child's doctor must state that the specific services in the treatment plan are medically necessary, the insurance company will review the plan and make the ultimate determination. Medical necessity will be reviewed periodically by the insurance company as long as your child receives services. If your child receives services through Medical Assistance, medical necessity will be determined by your MCO and will be reviewed periodically as well.
- There may be different service providers for Wrap Around Services, depending on who is covering the cost. If your child receives Wrap Around services through your private insurer, the service providers must be part of your insurance company's network. Similarly, if you receive Wrap Around through Medical Assistance, you will need to use a provider contracted by Medical Assistance.
- Case management services are usually not covered by private health insurers.