1. 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.

2. Which Plans are Effected?
PEIA
CHIP
Group accident and sickness insurance
No small businesses (25 employees or fewer)
No self-funded plans (ERISA - federal law)
Medicaid “medical card” is NOT effected

3. 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 ABA
June 9, 2012

4. What is Covered?
Treatments that are medically necessary
and ordered or prescribed by a
licensed physician or a licensed
psychologist

5. 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

6. 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.

7. 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.

8. 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

9. 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.

10. 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.