WV Autism Insurance Law West Virginia Autism Insurance Stakeholders Roundtable July 13, 2012 Stonewall Resort Jill Scarbro-McLaury M.S., BCBA Bright Futures Learning Services Inc.
Which Plans are Effected?PEIACHIPGroup accident and sickness insurance No 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 policies2012 Legislation:Specifies monetary caps exclusively for ABA June 9, 2012
What is Covered?Treatments that are medically necessary and ordered or prescribed by a licensed physician or a licensed psychologist
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, Aspergers 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 TreatmentIn 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 CapsAnnual treatment cap can not exceed $30,000 per individual for three consecutive years from the date TREATMENT commencesAt the conclusion of the third year, required coverage should not exceed $2,000 per month.
Impact on Public ProgramsNothing 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.
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