ABA insurance and Medicaid coverage in West Virginia

Autism insurance mandate

State mandate for autism coverage

Yes, the research found a state autism coverage law.

Statute

W. Va. Code §33-16-3v (group accident and sickness insurers), §33-24-7k (hospital, medical, dental, and health service corporations), and §33-25A-8j (HMOs). Same subject for public programs: §5-16-7(a)(8) (Public Employees Insurance Agency) and §5-16B-6a (WVCHIP, incorporating the PEIA autism benefit). §5-16B-6e is repealed. Code pages list signed bills as enrolled committee substitute for H.B. 2693 (2011 Regular Session) and enrolled committee substitute for H.B. 4260 (2012 Regular Session). The insurance sections apply to policies delivered, renewed, or issued on or after January 1, 2012.

Age limits

Insurance sections (§33-16-3v, §33-24-7k, §33-25A-8j): diagnosis, evaluation, and treatment for individuals ages 18 months to 18 years, and only if diagnosed with autism spectrum disorder at age eight or younger. Required ABA coverage after year three runs until the individual reaches 18 years of age. PEIA §5-16-7(a)(8) and WVCHIP §5-16B-6a use the same 18-months-to-18-years window and the same diagnosis-at-age-eight-or-younger rule. Separate Medicaid rule (BMS Provider Manual Ch. 519.23, policy effective April 1, 2020): ABA for members ages 18 months through age 20 whose primary ASD diagnosis was made prior to the eighth birthday.

Annual cap

On the three insurance sections, the ABA benefit the statute requires is capped at $30,000 per individual for three consecutive years from the date treatment commences, then $2,000 per month until age 18. Those dollar figures apply to applied behavior analysis only. The sections set no separate dollar cap on other medically necessary autism treatment and no lifetime dollar cap. PEIA §5-16-7(a)(8) states no $30,000 or $2,000 cap. Medicaid Ch. 519.23 states no annual dollar cap; prior authorization is required, and ABA codes 97151/97152/97153/97154/97155/97156/97158 combined are limited to 40 hours per week and/or 8 hours in a 24-hour period (service week Sunday 12:00 a.m. through Saturday 11:59 p.m.).

Excludes self-funded employer plans

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

Notes

Coverage must include diagnosis, evaluation, and treatment that is medically necessary and ordered or prescribed by a licensed physician or licensed psychologist, under a treatment plan from a comprehensive evaluation by a certified behavior analyst (Behavior Analyst Certification Board or a similar nationally recognized organization). ABA must be provided or supervised by a certified behavior analyst. ASD is defined as any pervasive developmental disorder, including autistic disorder, Asperger's Syndrome, Rett syndrome, childhood disintegrative disorder, or pervasive developmental disorder, as defined in the most recent DSM. To continue ABA, the analyst must file progress reports semiannually with objective evidence or a clinically supportable statement that the condition is improving, maximum improvement is not yet attained, and anticipated improvement is attainable in a reasonable and generally predictable period of time. Each insurance section excludes small employers: a person, firm, corporation, partnership, or association actively engaged in business in West Virginia that, in the preceding calendar year, employed an average of no more than 25 eligible employees. If applying the section raises actual total costs of coverage by at least 1 percent for the plan year, the carrier may apply additional cost containment measures. Benefits that exceed essential health benefits under ACA §1302(b) are not required of a health benefit plan offered by the insurer, corporation, or HMO, and the same EHB-excess carve-out applies to PEIA. The sections do not require reimbursement of public school personnel and do not limit IDEA or other public programs. S.B. 383 (2024 Regular Session), which would have amended these sections to increase autism coverage, died after introduction; last action was referral to Senate Health and Human Resources on January 12, 2024. §9-5-21 requires the Bureau for Medical Services to file an annual autism-treatment report by January 1; it is not itself a coverage mandate. The CMS West Virginia EHB benchmark summary for plan years 2025-2027 (Highmark Blue Cross Blue Shield West Virginia, Gold Shared Cost PPO $1000, small-group market) lists mental/behavioral health outpatient services and habilitation services as covered and does not restate an ABA dollar limit.

Medicaid ABA coverage

Medicaid covers ABA

We could not verify this yet - check with West Virginia Department of Human Services, Bureau for Medical Services (BMS). Fiscal agent for provider enrollment is Gainwell Technologies..

Program

West Virginia Medicaid Applied Behavior Analysis (BMS Provider Manual, Chapter 519 Practitioner Services, Policy 519.23)

Agency

West Virginia Department of Human Services, Bureau for Medical Services (BMS). Fiscal agent for provider enrollment is Gainwell Technologies.

Provider enrollment

https://bms.wv.gov/providers/gainwell-technology

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.