§5-16B-6e. Coverage for treatment of autism spectrum disorders


Published: 2015

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WVC 5 - 16 B- 6 E

§5-16B-6e. Coverage for treatment of autism spectrum disorders.

     (a) To the extent that the diagnosis, evaluation and treatment

of autism spectrum disorders are not already covered by this

agency, on or after January 1, 2012, a policy, plan or contract

subject to this section shall provide coverage for such diagnosis,

evaluation and treatment, for individuals ages eighteen months to

eighteen years. To be eligible for coverage and benefits under

this section, the individual must be diagnosed with autism spectrum

disorder at age eight or younger. Such policy shall provide

coverage for treatments that are medically necessary and ordered or

prescribed by a licensed physician or licensed psychologist and in

accordance with a treatment plan developed from a comprehensive

evaluation by a certified behavior analyst for an individual

diagnosed with autism spectrum disorder.

     (b) The coverage shall include, but not be limited to, applied

behavior analysis. Applied behavior analysis shall be provided or

supervised by a certified behavior analyst. The annual maximum

benefit for applied behavior analysis required by this subsection

shall be in an amount not to exceed $30,000 per individual, for

three consecutive years from the date treatment commences. At the

conclusion of the third year, coverage for applied behavior

analysis required by this subsection shall be in an amount not to

exceed $2,000 per month, until the individual reaches eighteen

years of age, as long as the treatment is medically necessary and

in accordance with a treatment plan developed by a certified

behavior analyst pursuant to a comprehensive evaluation or

reevaluation of the individual. This section shall not be construed as limiting, replacing or affecting any obligation to provide

services to an individual under the Individuals with Disabilities

Education Act, 20 U.S.C. 1400 et seq., as amended from time to

time, or other publicly funded programs. Nothing in this section

shall be construed as requiring reimbursement for services provided

by public school personnel.

     (c) The certified behavior analyst shall file progress reports

with the agency semiannually. In order for treatment to continue,

the agency must receive objective evidence or a clinically

supportable statement of expectation that:

     (1) The individual's condition is improving in response to

treatment; and

     (2) A maximum improvement is yet to be attained; and

     (3) There is an expectation that the anticipated improvement

is attainable in a reasonable and generally predictable period of

time.

     (d) On or before January 1 each year, the agency shall file an

annual report with the Joint Committee on Government and Finance

describing its implementation of the coverage provided pursuant to

this section. The report shall include, but shall not be limited

to, the number of individuals in the plan utilizing the coverage

required by this section, the fiscal and administrative impact of

the implementation, and any recommendations the agency may have as

to changes in law or policy related to the coverage provided under

this section. In addition, the agency shall provide such other

information as may be requested by the Joint Committee on

Government and Finance as it may from time to time request.

     (e) For purposes of this section, the term:

     (1) "Applied Behavior Analysis" means the design,

implementation, and evaluation of environmental modifications using

behavioral stimuli and consequences, to produce socially

significant improvement in human behavior, including the use of

direct observation, measurement, and functional analysis of the

relationship between environment and behavior.

     (2) "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.

     (3) "Certified behavior analyst" means an individual who is

certified by the Behavior Analyst Certification Board or certified

by a similar nationally recognized organization.

     (4) "Objective evidence" means standardized patient assessment

instruments, outcome measurements tools or measurable assessments

of functional outcome. Use of objective measures at the beginning

of treatment, during and after treatment is recommended to quantify

progress and support justifications for continued treatment. The

tools are not required, but their use will enhance the

justification for continued treatment.

     (f) To the extent that the application of this section for

autism spectrum disorder causes an increase of at least one percent

of actual total costs of coverage for the plan year the agency may

apply additional cost containment measures.

     (g) To the extent that the provisions of this section require

benefits that exceed the essential health benefits specified under

section 1302(b) of the Patient Protection and Affordable Care Act,

Pub. L. No. 111-148, as amended, the specific benefits that exceed

the specified essential health benefits shall not be required of

the West Virginia Children's Health Insurance Program.



WVC 5 - 16 B- 6 E

§5-16B-6e. Coverage for treatment of autism spectrum disorders.

     (a) To the extent that the diagnosis and treatment of autism

spectrum disorders are not already covered by this agency, after

January 1, 2012, a policy, plan or contract subject to this section

shall provide coverage for such diagnosis and treatment, for

individuals ages eighteen months through eighteen years. To be

eligible for coverage and benefits under this section, the

individual must be diagnosed with autism spectrum disorder at age

eight or younger. Such policy shall provide coverage for

treatments that are medically necessary and ordered or prescribed

by a licensed physician or licensed psychologist for an individual

diagnosed with autism spectrum disorder, in accordance with a

treatment plan developed by a certified behavior analyst pursuant

to a comprehensive evaluation or reevaluation of the individual

subject to review by the agency every six months. Progress reports

are required to be filed with the agency semi-annually. In order

for treatment to continue, objective evidence or a clinically

supportable statement of expectation that:

     (1) the individual's condition is improving in response to

treatment, and

     (2) maximum improvement is yet to be attained, and

     (3) there is an expectation that the anticipated improvement

is attainable in a reasonable and generally predictable period of

time.

     (b) Such coverage shall include, but not be limited to, applied behavioral analysis provided or supervised by a certified

behavior analyst: Provided, That the annual maximum benefit for

treatment required by this section shall be in amount not to exceed

$30,000 per individual, for three consecutive years from the date

treatment commences. At the conclusion of the third year, required

coverage shall be in an amount not to exceed $2000 per month, until

the individual reaches eighteen years of age, as long as the

treatment is medically necessary and in accordance with a treatment

plan developed by a certified behavior analyst pursuant to a

comprehensive evaluation or reevaluation of the individual. This

section shall not be construed as limiting, replacing or affecting

any obligation to provide services to an individual under the

Individuals with Disabilities Education Act, 20 U.S.C. 1400 et

seq., as amended from time to time or other publicly funded

programs. Nothing in this section shall be construed as requiring

reimbursement for services provided by public school personnel.

     (c) On or before January 1 each year, the agency shall file an

annual report with the joint committee on government and finance

describing its implementation of the coverage provided pursuant to

this section. The report shall include, but shall not be limited to

the number of individuals in the plan utilizing the coverage

required by this section, the fiscal and administrative impact of

the implementation, and any recommendations the agency may have as

to changes in law or policy related to the coverage provided under

this section. In addition, the agency shall provide such other information as may be requested by the joint committee on

government and finance as it may from time to time request.

     (d) For purposes of this section, the term:

     (1) "Applied Behavior Analysis" means the design,

implementation, and evaluation of environmental modifications using

behavioral stimuli and consequences, to produce socially

significant improvement in human behavior, including the use of

direct observation, measurement, and functional analysis of the

relationship between environment and behavior.

     (2) "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.

     (3) "Certified behavior analyst" means an individual who is

certified by the Behavior Analyst Certification Board or certified

by a similar nationally recognized organization.

     (4) "Objective evidence" means standardized patient assessment

instruments, outcome measurements tools or measurable assessments

of functional outcome. Use of objective measures at the beginning

of treatment, during and/or after treatment is recommended to

quantify progress and support justifications for continued

treatment. Such tools are not required, but their use will enhance

the justification for continued treatment.

     (e) To the extent that the application of this section for

autism spectrum disorder causes an increase of at least one percent

of actual total costs of coverage for the plan year the agency may

apply additional cost containment measures.

     (f) To the extent that the provisions of this section requires

benefits that exceed the essential health benefits specified under

section 1302(b) of the Patient Protection and Affordable Care Act,

Pub. L. No. 111-148, as amended, the specific benefits that exceed

the specified essential health benefits shall not be required of

the West Virginia Children's Health Insurance Program.





Note: WV Code updated with legislation passed through the 2015 Regular Session

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