WV Autism Insurance FAQ

Which insurance plans are effected by the state mandate?

The autism insurance mandate effect approximately 23% of children diagnosed with autism. The mandate applies to PEIA, CHIP, group health plans, and individual plans purchased through the WV exchange market.

Are any insurance companies exempt from the mandate?

This mandate does not apply to Medicaid/medical cards, self-funded plans, federal employees, insurance plans that originate outside of WV, or companies with 25 or fewer employees.

Many policies, such as those for coalmines and medical facilities are self-funded. Asking if a policy is self-funded should be one of the first questions families ask when calling to access the autism benefit.

If your primary policy does not cover autism treatment, you may consider purchasing an individual policy for your child through the WV health exchange. For information visit: http://bewv.wvinsurance.gov/.

To what diagnoses does the mandate apply?

The mandate applies to all individuals diagnosed with an autism spectrum disorder by age eight or younger who are currently 18 months to 18years of age. According to the mandate, autism spectrum disorder includes "any pervasive developmental disorder, including autistic disorder, Asperger's Syndrome, Rett syndrome, childhood disintegrative disorder, or Pervasive Development Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association".

Who must prescribe my child's treatment?

All treatments must be prescribed by a licensed physician or licensed psychologist. Preauthorization is commonly required.

Which treatments are covered?

Any treatment that is medically necessary and prescribed by a licensed physician or licensed psychologist. Applied Behavioral Analysis (ABA) services are expressly covered by the mandate.

What are the stipulations for Applied Behavior Analysis (ABA) services?

A Board Certified Behavior Analyst (BCBA) must develop a treatment plan, which includes:

  1. A comprehensive evaluation or reevaluation of the individual, subject to review by the insurance agency every six months.
  2. Progress reports are required to be filed with the insurance agency semi-annually.
  3. In order for treatment to continue, the agency must receive objective evidence or a clinically supportable statement of expectation that:
    1. The individual's condition is improving in response to treatment, and
    2. A maximum improvement is yet to be attained, and
    3. There is an expectation that the anticipated improvement is attainable

Are there coverage limits?

Yes, the annual budget for ABA is $30,000 for the first three years of treatment. At the end of the third year, the service budget is reduced to $2,000 per month and remains at this level until they are 18.

Although the law stipulates this cap is only for ABA treatment, some plans may apply the cap to all autism related treatment. If you suspect your plan is over-applying the treatment cap, please contact MAP for assistance.

Have reimbursement rates and co-pay amounts been established?

Reimbursement rates and co-pays are determined by your employer's agreement with the insurance company. Call the number listed on your insurance card to find the co-pay and coverage specifications for your policy.

Can publicly funded programs such as schools bill insurance for autism-specific services?

No. These services in no way replace those provided by the school system or other publicly funded programs. Services reimbursed through insurance shall not be construed as limiting, replacing, or affecting any obligation to provide services to an individual under the Individuals with Disabilities Education Act, 20 U.S.C. 1400 et seq., or other publicly funded programs. Services provided by school personnel are not eligible for insurance reimbursement.

Barriers to implementation:

Each insurance company defines "medically necessary" differently. Treatment providers should make certain their recommendations meet the definition set forth by the insurance company.

ABA is a newly recognized medical treatment. Standardized provider and treatment codes have not been established. Families and treatment providers will need to work closely with insurance providers to assure the correct codes are utilized.