ABA insurance and Medicaid coverage in Kentucky

Autism insurance mandate

State mandate for autism coverage

Yes, the research found a state autism coverage law.

Statute

KRS 304.17A-142 (coverage for diagnosis and treatment of autism spectrum disorders), created by 2010 Ky. Acts ch. 150, sec. 17, effective January 1, 2011, and amended by 2018 Ky. Acts ch. 86, sec. 1 (HB 218), effective January 1, 2019. Related: KRS 304.17A-144 (autism-benefits liaison; 2016 Ky. Acts ch. 102, effective July 15, 2016); KRS 18A.225(15) (state-employee plans). KRS 304.17A-141 and KRS 304.17A-143 were repealed by 2018 Ky. Acts ch. 86, sec. 2, effective January 1, 2019.

Age limits

None. KRS 304.17A-142 applies to an individual and states no minimum or maximum age. HB 218 (2018 Ky. Acts ch. 86), signed April 2, 2018 and effective January 1, 2019, deleted the prior limit of ages 1 through 21.

Annual cap

None. KRS 304.17A-142(3) states coverage shall not be subject to any maximum annual benefit limit, including any limits on the number of visits to an autism services provider. Effective January 1, 2019, HB 218 repealed the former large-group caps of $50,000 per year from age 1 through the seventh birthday and $1,000 per month from age 7 through 21, and repealed KRS 304.17A-143, which had capped individual and small-group coverage at $1,000 per month for ages 1 through 21.

Excludes self-funded employer plans

We could not verify this yet - check with your state insurance department.

Notes

Applies to health benefit plans issued or renewed on or after January 1, 2019. Treatment includes medical care by a licensed physician, APRN, or other licensed provider; habilitative or rehabilitative care, including applied behavior analysis necessary to develop, maintain, and restore functioning; pharmacy care only if the plan covers pharmacy; psychiatric care; psychological care by a Kentucky Board of Examiners of Psychology licensee or the equivalent out-of-state licensee; speech, occupational, and physical therapy; and ABA prescribed or ordered by a licensed health or allied health professional. Autism spectrum disorder is defined by the most recent DSM, including pervasive developmental disorders. An insurer may not terminate or refuse to issue or renew coverage solely because of an autism diagnosis or treatment. Copayment, deductible, and coinsurance may apply if no less favorable than for other medical services. For non-inpatient treatment, utilization review may be requested no more than once every 12 months unless the insurer and the individual's licensed physician, licensed psychologist, or licensed psychological practitioner agree to more frequent review; the insurer pays for the review and may require a treatment plan with measurable goals. KRS 304.17A-144 requires a member liaison who explains benefits, prior authorization, ABA coding, adjudication, and appeals. No reimbursement is required for services the insured has no legal obligation to pay, services provided by a publicly funded program, services by a relative for which no charge would be made, or services by a person not licensed as required by law. The mandate does not require the plan to cover services already included in an IFSP, IEP, individualized service plan, or other publicly funded program, and mandated coverage is in addition to those programs. Medicaid is outside the mandate: KRS 304.17A-005(22)(a)6 excludes HMO contracts to provide Medicaid benefits under KRS Chapter 205, and (22)(b)12 excludes coverage provided under KRS Chapter 205. Also excluded from "health benefit plan" are short-term limited-duration coverage, student health insurance, and the listed excepted and limited-benefit policies. Under KRS 304.17A-096(3), effective January 1, 2025 for policies issued or renewed on or after that date, an insurer in the individual, small-group, or employer-organized association market that offers a basic health benefit plan may exclude any state-mandated benefit; the benefits that still must be included are diabetes (KRS 304.17A-148), hospice (KRS 304.17A-250(6)), chiropractic (KRS 304.17A-171), breast examinations (KRS 304.17A-133), and federally mandated benefits. Autism is not on that required list. The Department of Insurance July 2017 consumer PDF still describes the repealed dollar and age caps and is superseded on those points by KRS 304.17A-142 as amended effective January 1, 2019.

Medicaid ABA coverage

Medicaid covers ABA

Yes, per the sources below.

Program

Kentucky Medicaid behavioral health services (licensed behavioral analyst services)

Agency

Cabinet for Health and Family Services, Department for Medicaid Services (DMS)

Provider enrollment

https://chfs.ky.gov/agencies/dms/provider/Pages/providerenroll.aspx

Payers named in our research

Names come from the research behind this page. Appearing here does not mean a payer is accepting new providers or that networks are open. Always confirm directly with the payer.