West Virginia Won't Cover ABA If the Diagnosis Came After the Eighth Birthday.

Most state Medicaid programs set an upper age for ABA. West Virginia sets one at the other end, and it is not an age of service — it is an age of diagnosis.

“ABA services are available to Medicaid members ages 18 months through age 20 with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday.”

That is Section 519.23.1 of Chapter 519.23 of the BMS Provider Manual, effective April 1, 2020. Read the clause carefully: the diagnosis has to have been made before the eighth birthday. A West Virginia child diagnosed at nine does not become eligible later, and does not age into eligibility. They are outside the benefit permanently.

Why that clause is the one to check first

Late diagnosis is common, and it is not evenly distributed. A child whose autism was identified at nine — after a school referral, after a move, after a misdiagnosis — arrives at an intake looking exactly like an eligible referral. Every other box can be ticked. The diagnosis is current, the severity level is documented, the EPSDT encounter happened, the treatment plan is sound.

The eligibility test is a date in the past that nobody in the room controls, and it is the only clause in the chapter that no amount of clinical justification can satisfy.

The diagnostic assessment itself also has a shelf life. It must have been made within the previous 24 months by a qualified diagnostic provider — the manual's list is a licensed physician such as a neurologist, pediatric neurologist, developmental pediatrician or psychiatrist, a supervising or licensed psychologist, a licensed independent social worker, or a licensed independent counselor — and must document the current ICD or DSM diagnosis, the diagnostic severity level including communication and restricted repetitive behaviors, and the specifiers.

Forty hours a week, eight in a day, across the whole code set

The caps are combined rather than per-code. Under each of 97151 through 97158, the manual repeats the same limit: the code “may be used in combination with” the others “up to a maximum of 40 hours per week and/or eight hours within a 24-hour period.”

And it defines the week, which many states do not: “The service week is defined as Sunday 12:00 am through Saturday 11:59 pm.” A schedule that runs Monday to Sunday is measuring against a different week from the one the payer measures.

Who may deliver, and who may bill

Three tiers, all defined by BACB certification “current and in good standing” rather than a state license:

• BCBA, master's and doctoral levels both.
• BCaBA, working under the supervision of a BCBA or someone meeting BACB supervisor requirements.
• RBT, working under the supervision of a BCBA or BCaBA meeting those requirements. The manual's definition adds that “the RBT does not design intervention or assessment plans,” and that it is the supervisor's responsibility “to determine which tasks an RBT may perform as a function of his or her training, experience, and competence.”

On 97153, delivery and billing are separated explicitly: “Direct contact with member is made by an RBT under supervision of the BCBA or BCaBA … The BCBA or BCaBA may bill for this service.”

Four things the manual says are not allowed

Section 519.23.6 ends with a list, and it is unusually blunt:

• No balance billing. If a provider fails to obtain prior authorization, or the request is denied for medical necessity, the provider “cannot hold (or balance bill) the member and/or guardian responsible for private payment of services rendered during that time period.” The cost of a missed authorization stays with the practice.
• No back-dating. “Back-dating of authorizations is NOT allowed and ‘retrospective review requests' will be denied.” Not reviewed unfavorably — denied.
• No self-referral by families. “Requests for services received from parents/guardians are not accepted.”
• No family delivery. “Family members or any other non-credentialed individual providing ABA services to the member is NOT a covered benefit.”

The documentation rules carry the same tone. Illegible documentation “will result in dis-allowment.” Records requested for a retrospective review must be produced “within one business day of the request.” Discharge reports must be filed on case closure.

The limits

This chapter carries an effective date of April 1, 2020 and it is the version currently published by the Bureau for Medical Services. It is the standing requirement, not a change arriving, and nothing here has a future deadline attached.

Two things it does not settle on its face. The manual routes coverage, prior authorization and service-limit detail to the BMS fiscal agent and to utilization management guidelines issued by BMS contracted agents — and it states that those approved guidelines “function as policy,” so the operative numbers for a given member can sit outside the chapter. And it says enrollment and service provision are subject to review by BMS and its contracted agents, without describing the review cycle.

What you must know or do

• Add the date of diagnosis to your West Virginia intake screen, before anything clinical. Not the date of the current assessment — the date of the original ASD diagnosis. If it falls on or after the eighth birthday, the member is not eligible and no treatment plan changes that.
• Audit your current West Virginia caseload against the same question. If anyone was accepted without that date being checked, the exposure is retrospective, and there is no retrospective review to fix it with.
• Confirm your diagnostic assessments are inside 24 months and were made by someone on the manual's list. A diagnosis from a provider type not named there does not qualify, however competent.
• Set your utilization week to Sunday through Saturday. If your system counts Monday to Sunday, a member at 40 hours in your week can be over 40 in theirs, and the combined cap runs across 97151 to 97158 together rather than per code.
• Check that nothing is being delivered before the authorization lands. There is no back-dating and no retrospective review, and you cannot bill the family for the gap. Every hour delivered ahead of approval is an hour nobody pays for.