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New West Virginia law helps children with autism get health insurance coverage

Crawford Frazer

Autism has been in the news quite a bit in recent years. And as increased publicity and research bring greater public awareness, state governments are grappling with the question of whether health insurance companies should be required to cover it.

In April 2011, Gov. Earl Ray Tomblin signed a law that makes West Virginia the 25th state to enact autism insurance reform. The state law takes effect July 1, 2011.

The cost of autism

According to a 2009 report from the federal Centers for Disease Control and Prevention, about one in 110 children in the United States has an autism spectrum disorder. For these children’s families, the medical and financial consequences are daunting; the Autism Society estimates that it costs between $3.5 million and $5 million over a child’s lifetime to cover the condition. Early diagnosis is critical.

The new law

The law requires private insurance companies doing business in the state as well as the West Virginia Public Employee Insurance Plan to provide coverage of evidence-based, medically necessary autism therapies, such as applied behavior analysis. It affects West Virginia insurance plans issued or renewed as of Jan. 1, 2012. More specifically, the law does the following:

  • Amends a current law regarding treatment of mental disorders to include autism.
  • Prevents a health care plan from discriminating between medical-surgical benefits and mental health benefits — the latter of which would include autism — when setting limits on things like annual or lifetime coverage, health care visits, co-payments, deductibles and co-insurance.
  • Requires health insurance companies to provide coverage of applied behavior analysis.

It’s important to note, however, that this law does not apply to self-funded insurance plans (offered by many larger companies), which fall under the federal Employee Retirement Income Security Act (ERISA), according to the Autism Society.

According to the West Virginia law, health insurance companies now are required to cover autism treatment costs by:

  • Providing a maximum benefit for applied behavior analysis therapy of $30,000 annually for the first three consecutive years after diagnosis.
  • Providing a maximum benefit of $2,000 a month after those first three years until the patient reaches age 18.

To receive this coverage, the child must have been diagnosed by age 8. For treatment to continue, the child’s doctor or specialists must file progress reports with the health insurance company every six months.

These reports, according to the law, must show that the child’s condition is improving, that the maximum improvement has yet to be reached and that maximum improvement is possible “in a reasonable and generally predictable period of time.”

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