WV Autism Insurance Law

West Virginia Autism Insurance Stakeholders RoundtableJuly 13, 2012

Stonewall Resort

Jill Scarbro-McLaury M.S., BCBABright Futures Learning Services Inc.

Which Plans are Effected?

PEIA

CHIP

Group accident and sickness insuranceNo small businesses (25 employees or

fewer)No self-funded plans (ERISA - federal law)

Medicaid “medical card” is NOT effected

When Does Coverage Begin?2011 Legislation:

Requires coverage for autism spectrum disorders: As policies renew starting January 1,

2012. July 1, 2012 for most policies

2012 Legislation:

Specifies monetary caps exclusively for ABAJune 9, 2012

Treatments that are medically necessary and ordered or prescribed by a licensed physician or a licensed psychologist

What is Covered?

Who is Covered?Any person 18 months to 18 years

diagnosed with an autism spectrum disorder before age 8.

Autism spectrum disorder means 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

What about ABA Services?

Coverage includes but is NOT LIMITED to ABA provided or supervised by Certified Behavior Analyst (BCBA)

Certified behavior analyst means an individual who is certified by the Behavior Analyst Certification Board or certified by a similar nationally recognized organization.

BCBA Treatment Plan must include:

A comprehensive evaluation or reevaluation of the individual, subject to review by the insurance agency every six months.

Progress reports are required to be filed with the insurance agency semi-annually.

Continuation of Treatment

In order for treatment to continue, the agency must receive objective evidence or a clinically supportable statement of expectation that: The individual’s condition is improving in

response to treatment, and A maximum improvement is yet to be

attained, and There is an expectation that the anticipated

improvement is attainable

ABA Treatment Caps

Annual treatment cap can not exceed $30,000 per individual for three consecutive years from the date TREATMENT commences

At the conclusion of the third year, required coverage should not exceed $2,000 per month.

Impact on Public Programs

Nothing in the law should be construed as limiting, replacing or affecting any obligation to provide services to an individual under the Individuals with Disabilities Education Act or other publicly funded programs.

Nothing in the law shall be construed as requiring reimbursement for services provided by public school personnel.