{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3418.17.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3418.17.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3418.17.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3418.17.html"}],"law_id":81144,"edition_id":1,"section_id":81144,"structure_id":14324,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","history":"2011, cc. 876, 878; 2015, cc. 649, 650; 2019, cc. 451, 452; 2020, cc. 305, 613; 2022, cc. 101, 102.","full_text":"A\n\nNotwithstanding the provisions of § 38.2-3419 and any other provision of law, each insurer proposing to issue accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall, as provided in this section, provide coverage for the diagnosis of autism spectrum disorder and the treatment of autism spectrum disorder, in individuals (i) from January 1, 2012, until January 1, 2016, from age two years through age six years; (ii) from January 1, 2016, until January 1, 2020, from age two years through age 10 years; and (iii) from and after January 1, 2020, of any age, subject to the annual maximum benefit limitation set forth in subsection K and to the provisions of subsection G. If an individual who is being treated for autism spectrum disorder becomes older than the applicable maximum age set forth in the preceding sentence and continues to need treatment, this section does not preclude coverage of treatment and services. In addition to the requirements imposed on health insurance issuers by § 38.2-3436, an insurer shall not terminate coverage or refuse to deliver, issue, amend, adjust, or renew coverage of an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder.B\n\nFor purposes of this section:\n\t\t\t“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.\n\t\t\t“Autism spectrum disorder” means any pervasive developmental disorder or autism spectrum disorder, as defined in the most recent edition or the most recent edition at the time of diagnosis of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.\n\t\t\t“Behavioral health treatment” means professional, counseling, and guidance services and treatment programs that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.\n\t\t\t“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.\n\t\t\t“Medically necessary” means in accordance with the generally accepted standards of mental disorder or condition care and clinically appropriate in terms of type, frequency, site, and duration, based upon evidence and reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, or disability; (ii) reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or (iii) assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.\n\t\t\t“Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.\n\t\t\t“Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.\n\t\t\t“Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.\n\t\t\t“Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists, or clinical social workers.\n\t\t\t“Treatment for autism spectrum disorder” shall be identified in a treatment plan and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. The prescribing practitioner shall be independent of the provider of applied behavior analysis.\n\t\t\t“Treatment plan” means a plan for the treatment of autism spectrum disorder developed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendation of the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry.C\n\nExcept for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, an insurer, corporation, or health maintenance organization shall have the right to request a review of that treatment, including an independent review, not more than once every 12 months unless the insurer, corporation, or health maintenance organization and the individual’s licensed physician or licensed psychologist agree that a more frequent review is necessary. The cost of obtaining any review, including an independent review, shall be covered under the policy, contract, or plan.D\n\nCoverage under this section will not be subject to any visit limits, and shall be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, lifetime dollar limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.E\n\nNothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of autism spectrum disorder under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract, or plan.F\n\nThe provisions of this section shall not apply to (i) short-term travel, accident only, limited, or specified disease policies; (ii) short-term nonrenewable policies of not more than six months’ duration; or (iii) policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.G\n\nThe requirements of this section requiring that coverage be provided with regard to individuals from age two years through age six years shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2012, but prior to January 1, 2016; the requirements of this section requiring that coverage be provided with regard to individuals from age two years through age 10 years shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2016, but prior to January 1, 2020; the requirements of this section requiring that coverage be provided with regard to individuals of any age shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2020, and to all such policies, contracts, or plans to which a term is changed or any premium adjustment is made on or after such date; and the requirements of this section requiring that coverage be provided by policies, contracts, or plans issued in the individual market or small group markets shall apply to all insurance policies, subscription contracts, and health care plans in the individual and small group markets delivered, issued for delivery, reissued, or extended on or after January 1, 2021, and to all such policies, contracts, or plans to which a term is changed or any premium adjustment is made on or after such date.H\n\nAny coverage required pursuant to this section shall be in addition to the coverage required by § 38.2-3418.5 and other provisions of law. This section shall not be construed as diminishing any coverage required by § 38.2-3412.1. This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.I\n\nPursuant to the provisions of § 2.2-2818.2, this section shall apply to health coverage offered to state employees pursuant to § 2.2-2818 and to health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, teachers, and retirees pursuant to § 2.2-1204.J\n\nNotwithstanding any provision of this section to the contrary:1\n\nAn insurer, corporation, or health maintenance organization, or a governmental entity providing coverage for such treatment pursuant to subsection I, is exempt from providing coverage for behavioral health treatment required under this section and not covered by the insurer, corporation, health maintenance organization, or governmental entity providing coverage for such treatment pursuant to subsection I as of December 31, 2011, if:\n\t\t\t\ta. An actuary, affiliated with the insurer, corporation, or health maintenance organization, who is a member of the American Academy of Actuaries and meets the American Academy of Actuaries’ professional qualification standards for rendering an actuarial opinion related to health insurance rate making, certifies in writing to the Commissioner of Insurance that:1\n\nBased on an analysis to be completed no more frequently than one time per year by each insurer, corporation, or health maintenance organization, or such governmental entity, for the most recent experience period of at least one year’s duration, the costs associated with coverage of behavioral health treatment required under this section, and not covered as of December 31, 2011, exceeded one percent of the premiums charged over the experience period by the insurer, corporation, or health maintenance organization; and2\n\nThose costs solely would lead to an increase in average premiums charged of more than one percent for all insurance policies, subscription contracts, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation, or health maintenance organization, or such governmental entity, employs; and\n\t\t\t\t\tb. The Commissioner approves the certification of the actuary;2\n\nAn exemption allowed under subdivision 1 shall apply for a one-year coverage period following inception or next renewal date of all insurance policies, subscription contracts, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment required under this section;3\n\nAn insurer, corporation, or health maintenance organization, or such governmental entity, may claim an exemption for a subsequent year, but only if the conditions specified in subdivision 1 again are met; and4\n\nNotwithstanding the exemption allowed under subdivision 1, an insurer, corporation, or health maintenance organization, or such a governmental entity, may elect to continue to provide coverage for behavioral health treatment required under this section.K\n\nCoverage for applied behavior analysis under this section will be subject to an annual maximum benefit of $35,000, unless the insurer, corporation, or health maintenance organization elects to provide coverage in a greater amount.L\n\nAs of January 1, 2014, to the extent that this section requires benefits that exceed the essential health benefits specified under § 1302(b) of the federal Patient Protection and Affordable Care Act (H.R. 3590), as amended (the ACA), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in the Commonwealth by a health carrier through a health benefit exchange established under § 1311 of the ACA. Nothing in this subsection shall nullify application of this section to plans offered outside such an exchange.","order_by":null,"text":{"0":{"id":290825,"text":"Notwithstanding the provisions of § 38.2-3419 and any other provision of law, each insurer proposing to issue accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall, as provided in this section, provide coverage for the diagnosis of autism spectrum disorder and the treatment of autism spectrum disorder, in individuals (i) from January 1, 2012, until January 1, 2016, from age two years through age six years; (ii) from January 1, 2016, until January 1, 2020, from age two years through age 10 years; and (iii) from and after January 1, 2020, of any age, subject to the annual maximum benefit limitation set forth in subsection K and to the provisions of subsection G. If an individual who is being treated for autism spectrum disorder becomes older than the applicable maximum age set forth in the preceding sentence and continues to need treatment, this section does not preclude coverage of treatment and services. In addition to the requirements imposed on health insurance issuers by § 38.2-3436, an insurer shall not terminate coverage or refuse to deliver, issue, amend, adjust, or renew coverage of an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":290826,"text":"For purposes of this section:\n\t\t\t“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.\n\t\t\t“Autism spectrum disorder” means any pervasive developmental disorder or autism spectrum disorder, as defined in the most recent edition or the most recent edition at the time of diagnosis of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.\n\t\t\t“Behavioral health treatment” means professional, counseling, and guidance services and treatment programs that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.\n\t\t\t“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.\n\t\t\t“Medically necessary” means in accordance with the generally accepted standards of mental disorder or condition care and clinically appropriate in terms of type, frequency, site, and duration, based upon evidence and reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, or disability; (ii) reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or (iii) assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.\n\t\t\t“Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.\n\t\t\t“Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.\n\t\t\t“Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.\n\t\t\t“Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists, or clinical social workers.\n\t\t\t“Treatment for autism spectrum disorder” shall be identified in a treatment plan and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. The prescribing practitioner shall be independent of the provider of applied behavior analysis.\n\t\t\t“Treatment plan” means a plan for the treatment of autism spectrum disorder developed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendation of the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":290827,"text":"Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, an insurer, corporation, or health maintenance organization shall have the right to request a review of that treatment, including an independent review, not more than once every 12 months unless the insurer, corporation, or health maintenance organization and the individual’s licensed physician or licensed psychologist agree that a more frequent review is necessary. The cost of obtaining any review, including an independent review, shall be covered under the policy, contract, or plan.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":290828,"text":"Coverage under this section will not be subject to any visit limits, and shall be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, lifetime dollar limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":290829,"text":"Nothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of autism spectrum disorder under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract, or plan.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":290830,"text":"The provisions of this section shall not apply to (i) short-term travel, accident only, limited, or specified disease policies; (ii) short-term nonrenewable policies of not more than six months’ duration; or (iii) policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":290831,"text":"The requirements of this section requiring that coverage be provided with regard to individuals from age two years through age six years shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2012, but prior to January 1, 2016; the requirements of this section requiring that coverage be provided with regard to individuals from age two years through age 10 years shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2016, but prior to January 1, 2020; the requirements of this section requiring that coverage be provided with regard to individuals of any age shall apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2020, and to all such policies, contracts, or plans to which a term is changed or any premium adjustment is made on or after such date; and the requirements of this section requiring that coverage be provided by policies, contracts, or plans issued in the individual market or small group markets shall apply to all insurance policies, subscription contracts, and health care plans in the individual and small group markets delivered, issued for delivery, reissued, or extended on or after January 1, 2021, and to all such policies, contracts, or plans to which a term is changed or any premium adjustment is made on or after such date.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":290832,"text":"Any coverage required pursuant to this section shall be in addition to the coverage required by § 38.2-3418.5 and other provisions of law. This section shall not be construed as diminishing any coverage required by § 38.2-3412.1. This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"8":{"id":290833,"text":"Pursuant to the provisions of § 2.2-2818.2, this section shall apply to health coverage offered to state employees pursuant to § 2.2-2818 and to health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, teachers, and retirees pursuant to § 2.2-1204.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"9":{"id":290834,"text":"Notwithstanding any provision of this section to the contrary:","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"J1"},"10":{"id":290835,"text":"An insurer, corporation, or health maintenance organization, or a governmental entity providing coverage for such treatment pursuant to subsection I, is exempt from providing coverage for behavioral health treatment required under this section and not covered by the insurer, corporation, health maintenance organization, or governmental entity providing coverage for such treatment pursuant to subsection I as of December 31, 2011, if:\n\t\t\t\ta. An actuary, affiliated with the insurer, corporation, or health maintenance organization, who is a member of the American Academy of Actuaries and meets the American Academy of Actuaries’ professional qualification standards for rendering an actuarial opinion related to health insurance rate making, certifies in writing to the Commissioner of Insurance that:","type":"section","prefixes":["J","1"],"prefix":"1","entire_prefix":"J1","prefix_anchor":"J1","level":2,"prior_prefix":"J","next_prefix":"J11"},"11":{"id":290836,"text":"Based on an analysis to be completed no more frequently than one time per year by each insurer, corporation, or health maintenance organization, or such governmental entity, for the most recent experience period of at least one year’s duration, the costs associated with coverage of behavioral health treatment required under this section, and not covered as of December 31, 2011, exceeded one percent of the premiums charged over the experience period by the insurer, corporation, or health maintenance organization; and","type":"section","prefixes":["J","1","1"],"prefix":"1","entire_prefix":"J11","prefix_anchor":"J11","level":3,"prior_prefix":"J1","next_prefix":"J12"},"12":{"id":290837,"text":"Those costs solely would lead to an increase in average premiums charged of more than one percent for all insurance policies, subscription contracts, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation, or health maintenance organization, or such governmental entity, employs; and\n\t\t\t\t\tb. The Commissioner approves the certification of the actuary;","type":"section","prefixes":["J","1","2"],"prefix":"2","entire_prefix":"J12","prefix_anchor":"J12","level":3,"prior_prefix":"J11","next_prefix":"J2"},"13":{"id":290838,"text":"An exemption allowed under subdivision 1 shall apply for a one-year coverage period following inception or next renewal date of all insurance policies, subscription contracts, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment required under this section;","type":"section","prefixes":["J","2"],"prefix":"2","entire_prefix":"J2","prefix_anchor":"J2","level":2,"prior_prefix":"J12","next_prefix":"J3"},"14":{"id":290839,"text":"An insurer, corporation, or health maintenance organization, or such governmental entity, may claim an exemption for a subsequent year, but only if the conditions specified in subdivision 1 again are met; and","type":"section","prefixes":["J","3"],"prefix":"3","entire_prefix":"J3","prefix_anchor":"J3","level":2,"prior_prefix":"J2","next_prefix":"J4"},"15":{"id":290840,"text":"Notwithstanding the exemption allowed under subdivision 1, an insurer, corporation, or health maintenance organization, or such a governmental entity, may elect to continue to provide coverage for behavioral health treatment required under this section.","type":"section","prefixes":["J","4"],"prefix":"4","entire_prefix":"J4","prefix_anchor":"J4","level":2,"prior_prefix":"J3","next_prefix":"K"},"16":{"id":290841,"text":"Coverage for applied behavior analysis under this section will be subject to an annual maximum benefit of $35,000, unless the insurer, corporation, or health maintenance organization elects to provide coverage in a greater amount.","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J4","next_prefix":"L"},"17":{"id":290842,"text":"As of January 1, 2014, to the extent that this section requires benefits that exceed the essential health benefits specified under § 1302(b) of the federal Patient Protection and Affordable Care Act (H.R. 3590), as amended (the ACA), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in the Commonwealth by a health carrier through a health benefit exchange established under § 1311 of the ACA. Nothing in this subsection shall nullify application of this section to plans offered outside such an exchange.","type":"section","prefixes":["L"],"prefix":"L","entire_prefix":"L","prefix_anchor":"L","level":1,"prior_prefix":"K"}},"ancestry":[{"id":14324,"edition_id":1,"name":"Mandated Benefits","identifier":"2","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:47:45","date_modified":"2026-06-26 03:47:45","permalink":{"id":215143,"object_type":"structure","relational_id":14324,"identifier":"2","token":"38.2\/34\/2","url":"\/38.2\/34\/2\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":87046,"structure_id":14324,"section_number":"38.2-3408","catch_line":"Policy providing for reimbursement for services that may be performed by certain practitioners other than physicians","url":"\/38.2-3408\/","token":"38.2\/34\/2\/38.2-3408","metadata":false},{"id":55621,"structure_id":14324,"section_number":"38.2-3409","catch_line":"Coverage of dependent children","url":"\/38.2-3409\/","token":"38.2\/34\/2\/38.2-3409","metadata":false},{"id":68501,"structure_id":14324,"section_number":"38.2-3410","catch_line":"Construction of policy generally; words \"physician\" and \"doctor\" to include dentist","url":"\/38.2-3410\/","token":"38.2\/34\/2\/38.2-3410","metadata":false},{"id":76551,"structure_id":14324,"section_number":"38.2-3411","catch_line":"Coverage of newborn children required","url":"\/38.2-3411\/","token":"38.2\/34\/2\/38.2-3411","metadata":false},{"id":71629,"structure_id":14324,"section_number":"38.2-3411.1","catch_line":"Coverage for child health supervision services","url":"\/38.2-3411.1\/","token":"38.2\/34\/2\/38.2-3411.1","metadata":false},{"id":70694,"structure_id":14324,"section_number":"38.2-3411.2","catch_line":"Coverage of adopted children required","url":"\/38.2-3411.2\/","token":"38.2\/34\/2\/38.2-3411.2","metadata":false},{"id":77817,"structure_id":14324,"section_number":"38.2-3411.3","catch_line":"Coverage for childhood immunizations","url":"\/38.2-3411.3\/","token":"38.2\/34\/2\/38.2-3411.3","metadata":false},{"id":86598,"structure_id":14324,"section_number":"38.2-3411.4","catch_line":"Coverage for infant hearing screening and related diagnostics","url":"\/38.2-3411.4\/","token":"38.2\/34\/2\/38.2-3411.4","metadata":false},{"id":63024,"structure_id":14324,"section_number":"38.2-3412","catch_line":"Repealed","url":"\/38.2-3412\/","token":"38.2\/34\/2\/38.2-3412","metadata":false},{"id":84153,"structure_id":14324,"section_number":"38.2-3412.1","catch_line":"Coverage for mental health and substance use disorders","url":"\/38.2-3412.1\/","token":"38.2\/34\/2\/38.2-3412.1","metadata":false},{"id":75255,"structure_id":14324,"section_number":"38.2-3412.1:01","catch_line":"Repealed","url":"\/38.2-3412.1_01\/","token":"38.2\/34\/2\/38.2-3412.1_01","metadata":false},{"id":67892,"structure_id":14324,"section_number":"38.2-3413","catch_line":"Repealed","url":"\/38.2-3413\/","token":"38.2\/34\/2\/38.2-3413","metadata":false},{"id":81885,"structure_id":14324,"section_number":"38.2-3414","catch_line":"Optional coverage for obstetrical services","url":"\/38.2-3414\/","token":"38.2\/34\/2\/38.2-3414","metadata":false},{"id":74497,"structure_id":14324,"section_number":"38.2-3414.1","catch_line":"Obstetrical benefits; coverage for postpartum services","url":"\/38.2-3414.1\/","token":"38.2\/34\/2\/38.2-3414.1","metadata":false},{"id":58957,"structure_id":14324,"section_number":"38.2-3415","catch_line":"Exclusion or reduction of benefits for certain causes prohibited","url":"\/38.2-3415\/","token":"38.2\/34\/2\/38.2-3415","metadata":false},{"id":69898,"structure_id":14324,"section_number":"38.2-3416","catch_line":"Repealed","url":"\/38.2-3416\/","token":"38.2\/34\/2\/38.2-3416","metadata":false},{"id":59007,"structure_id":14324,"section_number":"38.2-3417","catch_line":"Deductibles and coinsurance options required","url":"\/38.2-3417\/","token":"38.2\/34\/2\/38.2-3417","metadata":false},{"id":81514,"structure_id":14324,"section_number":"38.2-3418","catch_line":"Coverage for victims of rape or incest","url":"\/38.2-3418\/","token":"38.2\/34\/2\/38.2-3418","metadata":false},{"id":85746,"structure_id":14324,"section_number":"38.2-3418.1","catch_line":"Coverage for mammograms","url":"\/38.2-3418.1\/","token":"38.2\/34\/2\/38.2-3418.1","metadata":false},{"id":86304,"structure_id":14324,"section_number":"38.2-3418.10","catch_line":"Coverage for diabetes","url":"\/38.2-3418.10\/","token":"38.2\/34\/2\/38.2-3418.10","metadata":false},{"id":87414,"structure_id":14324,"section_number":"38.2-3418.11","catch_line":"Coverage for hospice care","url":"\/38.2-3418.11\/","token":"38.2\/34\/2\/38.2-3418.11","metadata":false},{"id":81464,"structure_id":14324,"section_number":"38.2-3418.12","catch_line":"Coverage for hospitalization and anesthesia for dental procedures","url":"\/38.2-3418.12\/","token":"38.2\/34\/2\/38.2-3418.12","metadata":false},{"id":82972,"structure_id":14324,"section_number":"38.2-3418.13","catch_line":"Coverage for the treatment of morbid obesity","url":"\/38.2-3418.13\/","token":"38.2\/34\/2\/38.2-3418.13","metadata":false},{"id":85731,"structure_id":14324,"section_number":"38.2-3418.14","catch_line":"Coverage for lymphedema","url":"\/38.2-3418.14\/","token":"38.2\/34\/2\/38.2-3418.14","metadata":false},{"id":71964,"structure_id":14324,"section_number":"38.2-3418.15","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15\/","token":"38.2\/34\/2\/38.2-3418.15","metadata":false},{"id":57543,"structure_id":14324,"section_number":"38.2-3418.15:1","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15_1\/","token":"38.2\/34\/2\/38.2-3418.15_1","metadata":false},{"id":61286,"structure_id":14324,"section_number":"38.2-3418.16","catch_line":"Coverage for telemedicine services","url":"\/38.2-3418.16\/","token":"38.2\/34\/2\/38.2-3418.16","metadata":false},{"id":81144,"structure_id":14324,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","url":"\/38.2-3418.17\/","token":"38.2\/34\/2\/38.2-3418.17","metadata":false},{"id":60567,"structure_id":14324,"section_number":"38.2-3418.18","catch_line":"Coverage for formula and enteral nutrition products as medicine","url":"\/38.2-3418.18\/","token":"38.2\/34\/2\/38.2-3418.18","metadata":false},{"id":79176,"structure_id":14324,"section_number":"38.2-3418.19","catch_line":"Coverage for organ, eye or tissue transplant","url":"\/38.2-3418.19\/","token":"38.2\/34\/2\/38.2-3418.19","metadata":false},{"id":69963,"structure_id":14324,"section_number":"38.2-3418.1:1","catch_line":"Repealed","url":"\/38.2-3418.1_1\/","token":"38.2\/34\/2\/38.2-3418.1_1","metadata":false},{"id":72277,"structure_id":14324,"section_number":"38.2-3418.1:2","catch_line":"Coverage for pap smears","url":"\/38.2-3418.1_2\/","token":"38.2\/34\/2\/38.2-3418.1_2","metadata":false},{"id":64216,"structure_id":14324,"section_number":"38.2-3418.1:3","catch_line":"Cost sharing for breast examinations","url":"\/38.2-3418.1_3\/","token":"38.2\/34\/2\/38.2-3418.1_3","metadata":false},{"id":80233,"structure_id":14324,"section_number":"38.2-3418.2","catch_line":"Coverage of procedures involving bones and joints","url":"\/38.2-3418.2\/","token":"38.2\/34\/2\/38.2-3418.2","metadata":false},{"id":73658,"structure_id":14324,"section_number":"38.2-3418.20","catch_line":"Coverage for hearing aids and related services [Not in effect]","url":"\/38.2-3418.20\/","token":"38.2\/34\/2\/38.2-3418.20","metadata":false},{"id":76455,"structure_id":14324,"section_number":"38.2-3418.21","catch_line":"Coverage for hearing aids and related services","url":"\/38.2-3418.21\/","token":"38.2\/34\/2\/38.2-3418.21","metadata":false},{"id":67690,"structure_id":14324,"section_number":"38.2-3418.22","catch_line":"Coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome","url":"\/38.2-3418.22\/","token":"38.2\/34\/2\/38.2-3418.22","metadata":false},{"id":79724,"structure_id":14324,"section_number":"38.2-3418.3","catch_line":"Coverage for hemophilia and congenital bleeding disorders","url":"\/38.2-3418.3\/","token":"38.2\/34\/2\/38.2-3418.3","metadata":false},{"id":86337,"structure_id":14324,"section_number":"38.2-3418.4","catch_line":"Coverage for reconstructive breast surgery; notice; eligibility","url":"\/38.2-3418.4\/","token":"38.2\/34\/2\/38.2-3418.4","metadata":false},{"id":87401,"structure_id":14324,"section_number":"38.2-3418.5","catch_line":"Coverage for early intervention services","url":"\/38.2-3418.5\/","token":"38.2\/34\/2\/38.2-3418.5","metadata":false},{"id":61674,"structure_id":14324,"section_number":"38.2-3418.6","catch_line":"Minimum hospital stay for mastectomy and certain lymph node dissection patients","url":"\/38.2-3418.6\/","token":"38.2\/34\/2\/38.2-3418.6","metadata":false},{"id":71759,"structure_id":14324,"section_number":"38.2-3418.7","catch_line":"Coverage for prostate cancer screening","url":"\/38.2-3418.7\/","token":"38.2\/34\/2\/38.2-3418.7","metadata":false},{"id":62197,"structure_id":14324,"section_number":"38.2-3418.7:1","catch_line":"Coverage for colorectal cancer screening","url":"\/38.2-3418.7_1\/","token":"38.2\/34\/2\/38.2-3418.7_1","metadata":false},{"id":63576,"structure_id":14324,"section_number":"38.2-3418.8","catch_line":"Coverage for clinical trials for treatment studies on cancer","url":"\/38.2-3418.8\/","token":"38.2\/34\/2\/38.2-3418.8","metadata":false},{"id":72556,"structure_id":14324,"section_number":"38.2-3418.9","catch_line":"Minimum hospital stay for hysterectomy","url":"\/38.2-3418.9\/","token":"38.2\/34\/2\/38.2-3418.9","metadata":false},{"id":66144,"structure_id":14324,"section_number":"38.2-3419","catch_line":"Additional mandated coverage made optional to group policy or contract holder","url":"\/38.2-3419\/","token":"38.2\/34\/2\/38.2-3419","metadata":false},{"id":57559,"structure_id":14324,"section_number":"38.2-3419.1","catch_line":"Report of costs and utilization of mandated benefits","url":"\/38.2-3419.1\/","token":"38.2\/34\/2\/38.2-3419.1","metadata":false}],"previous_section":{"id":61286,"structure_id":14324,"section_number":"38.2-3418.16","catch_line":"Coverage for telemedicine services","url":"\/38.2-3418.16\/","token":"38.2\/34\/2\/38.2-3418.16","metadata":false},"next_section":{"id":60567,"structure_id":14324,"section_number":"38.2-3418.18","catch_line":"Coverage for formula and enteral nutrition products as medicine","url":"\/38.2-3418.18\/","token":"38.2\/34\/2\/38.2-3418.18","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3418.17\/","history_text":"

This law was first created in 2011. The record of its establishment is cataloged in chapters 876<\/a> and 878<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 4 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 2015, chapters 649<\/a> and 650<\/a>; in 2019, chapters 451<\/a> and 452<\/a>; in 2020, chapters 305<\/a> and 613<\/a>; in 2022, chapters 101<\/a> and 102<\/a>.<\/p>","references":[{"id":54577,"section_number":"46.2-203.3","catch_line":"Driver communication improvement program","order_by":null,"url":"\/46.2-203.3\/"},{"id":79681,"section_number":"46.2-342","catch_line":"What license to contain; organ donor information; Uniform Donor Document","order_by":null,"url":"\/46.2-342\/"},{"id":64770,"section_number":"46.2-600.1","catch_line":"Indication of special communication needs","order_by":null,"url":"\/46.2-600.1\/"},{"id":72830,"section_number":"52-34.13","catch_line":"Definitions","order_by":null,"url":"\/52-34.13\/"}],"refers_to":[{"id":68317,"section_number":"2.2-2818","catch_line":"Health and related insurance for state employees","order_by":null,"url":"\/2.2-2818\/"},{"id":64235,"section_number":"2.2-2818.2","catch_line":"Application of mandates to the state employee health insurance plan","order_by":null,"url":"\/2.2-2818.2\/"},{"id":84153,"section_number":"38.2-3412.1","catch_line":"Coverage for mental health and substance use disorders","order_by":null,"url":"\/38.2-3412.1\/"},{"id":87401,"section_number":"38.2-3418.5","catch_line":"Coverage for early intervention services","order_by":null,"url":"\/38.2-3418.5\/"},{"id":66144,"section_number":"38.2-3419","catch_line":"Additional mandated coverage made optional to group policy or contract holder","order_by":null,"url":"\/38.2-3419\/"},{"id":77749,"section_number":"38.2-3436","catch_line":"Eligibility to enroll","order_by":null,"url":"\/38.2-3436\/"}],"permalink":{"id":215253,"object_type":"law","relational_id":81144,"identifier":"38.2-3418.17","token":"38.2\/34\/2\/38.2-3418.17","url":"\/38.2-3418.17\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3418.17\/","token":"38.2\/34\/2\/38.2-3418.17","dublin_core":{"Title":"Coverage for autism spectrum disorder","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3418.17","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Notwithstanding the provisions of § 38.2-3419<\/a> and any other provision of law<\/span>, each insurer<\/span> proposing to issue<\/span> accident and sickness insurance policies<\/span> providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing accident and sickness subscription contracts<\/span>; and each health maintenance organization providing a health care plan for health care services shall, as provided in this section, provide coverage for the diagnosis of autism spectrum disorder<\/span><\/span> and the treatment of autism spectrum disorder<\/span>, in individuals (i) from January 1, 2012, until January 1, 2016, from age two years through age six years; (ii) from January 1, 2016, until January 1, 2020, from age two years through age 10 years; and (iii) from and after January 1, 2020, of any age, subject to the annual maximum benefit limitation set forth in subsection K and to the provisions of subsection G. If an individual who is being treated for autism spectrum disorder<\/span> becomes older than the applicable maximum age set forth in the preceding sentence and continues to need treatment, this section does not preclude coverage of treatment and services. In addition to the requirements imposed on health insurance issuers by § 38.2-3436<\/a>, an insurer<\/span> shall not terminate coverage or refuse to deliver, issue<\/span>, amend<\/span>, adjust, or renew coverage of an individual solely because the individual is diagnosed with autism spectrum disorder<\/span> or has received treatment for autism spectrum disorder<\/span><\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> For purposes of this section:\n\t\t\t“Applied behavior analysis<\/span>” 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.\n\t\t\t“Autism spectrum disorder<\/span>” means any pervasive developmental disorder or autism spectrum disorder<\/span>, as defined in the most recent edition or the most recent edition at the time of diagnosis of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.\n\t\t\t“Behavioral health treatment<\/span>” means professional, counseling, and guidance services and treatment programs that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.\n\t\t\t“Diagnosis of autism spectrum disorder<\/span><\/span>” means medically necessary<\/span> assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder<\/span>.\n\t\t\t“Medically necessary<\/span>” means in accordance with the generally accepted standards of mental disorder or condition care and clinically appropriate in terms of type, frequency, site, and duration, based upon evidence<\/span> and reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, or disability; (ii) reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or (iii) assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.\n\t\t\t“Pharmacy care<\/span>” means medications prescribed by a licensed physician and any health-related services deemed medically necessary<\/span> to determine the need or effectiveness of the medications.\n\t\t\t“Psychiatric care<\/span>” means direct or consultative services provided by a psychiatrist licensed in the state<\/span> in which the psychiatrist practices.\n\t\t\t“Psychological care<\/span>” means direct or consultative services provided by a psychologist licensed in the state<\/span> in which the psychologist practices.\n\t\t\t“Therapeutic care<\/span>” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists, or clinical social workers.\n\t\t\t“Treatment for autism spectrum disorder<\/span><\/span>” shall be identified in a treatment plan<\/span> and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder<\/span> by a licensed physician or a licensed psychologist who determines the care to be medically necessary<\/span>: (i) behavioral health treatment<\/span>, (ii) pharmacy care<\/span>, (iii) psychiatric care<\/span>, (iv) psychological care<\/span>, (v) therapeutic care<\/span>, and (vi) applied behavior analysis<\/span> when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. The prescribing practitioner shall be independent of the provider of applied behavior analysis<\/span>.\n\t\t\t“Treatment plan<\/span>” means a plan for the treatment of autism spectrum disorder<\/span> developed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendation of the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder<\/span>, an insurer<\/span>, corporation, or health maintenance organization shall have the right to request a review of that treatment, including an independent review, not more than once every 12 months unless the insurer<\/span>, corporation, or health maintenance organization and the individual’s licensed physician or licensed psychologist agree that a more frequent review is necessary. The cost of obtaining any review, including an independent review, shall be covered under the policy, contract<\/span>, or plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Coverage under this section will not be subject to any visit limits, and shall be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, lifetime dollar limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Nothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of autism spectrum disorder<\/span> under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract<\/span>, or plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The provisions of this section shall not apply to (i) short-term travel, accident only, limited, or specified disease policies; (ii) short-term nonrenewable policies of not more than six months’ duration; or (iii) policies or contracts<\/span> designed for issuance to persons<\/span> eligible for coverage under Title XVIII of the Social Security Act, known as Medicare<\/span>, or any other similar coverage under state<\/span> or federal governmental plans. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> The requirements of this section requiring that coverage be provided with regard to individuals from age two years through age six years shall apply to all insurance policies<\/span>, subscription contracts<\/span>, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2012, but prior to January 1, 2016; the requirements of this section requiring that coverage be provided with regard to individuals from age two years through age 10 years shall apply to all insurance policies<\/span>, subscription contracts<\/span>, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2016, but prior to January 1, 2020; the requirements of this section requiring that coverage be provided with regard to individuals of any age shall apply to all insurance policies<\/span>, subscription contracts<\/span>, and health care plans delivered, issued for delivery, reissued, or extended on or after January 1, 2020, and to all such policies, contracts<\/span>, or plans to which a term is changed or any premium adjustment is made on or after such date; and the requirements of this section requiring that coverage be provided by policies, contracts<\/span>, or plans issued in the individual market or small group markets shall apply to all insurance policies<\/span>, subscription contracts<\/span>, and health care plans in the individual and small group markets delivered, issued for delivery, reissued, or extended on or after January 1, 2021, and to all such policies, contracts<\/span>, or plans to which a term is changed or any premium adjustment is made on or after such date. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Any coverage required pursuant to this section shall be in addition to the coverage required by § 38.2-3418.5<\/a> and other provisions of law<\/span>. This section shall not be construed as diminishing any coverage required by § 38.2-3412.1<\/a>. This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> Pursuant to the provisions of § 2.2-2818.2<\/a>, this section shall apply to health coverage offered to state<\/span> employees pursuant to § 2.2-2818<\/a> and to health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, teachers, and retirees pursuant to § 2.2-1204<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> Notwithstanding any provision of this section to the contrary: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> An insurer<\/span>, corporation, or health maintenance organization, or a governmental entity providing coverage for such treatment pursuant to subsection I, is exempt from providing coverage for behavioral health treatment<\/span> required under this section and not covered by the insurer<\/span>, corporation, health maintenance organization, or governmental entity providing coverage for such treatment pursuant to subsection I as of December 31, 2011, if:\n\t\t\t\ta. An actuary, affiliated with the insurer<\/span>, corporation, or health maintenance organization, who is a member of the American Academy of Actuaries and meets the American Academy of Actuaries’ professional qualification standards for rendering an actuarial opinion<\/span> related to health insurance rate<\/span> making, certifies in writing to the Commissioner of Insurance<\/span> that: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Based on an analysis to be completed no more frequently than one time per year by each insurer<\/span>, corporation, or health maintenance organization, or such governmental entity, for the most recent experience period of at least one year’s duration, the costs associated with coverage of behavioral health treatment<\/span> required under this section, and not covered as of December 31, 2011, exceeded one percent of the premiums charged over the experience period by the insurer<\/span>, corporation, or health maintenance organization; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Those costs solely would lead to an increase in average premiums charged of more than one percent for all insurance policies<\/span>, subscription contracts<\/span>, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer<\/span>, corporation, or health maintenance organization, or such governmental entity, employs; and\n\t\t\t\t\tb. The Commissioner approves the certification of the actuary; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> An exemption allowed under subdivision 1 shall apply for a one-year coverage period following inception or next renewal date of all insurance policies<\/span>, subscription contracts<\/span>, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer<\/span>, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment<\/span> required under this section; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> An insurer<\/span>, corporation, or health maintenance organization, or such governmental entity, may claim an exemption for a subsequent year, but only if the conditions specified in subdivision 1 again are met; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Notwithstanding the exemption allowed under subdivision 1, an insurer<\/span>, corporation, or health maintenance organization, or such a governmental entity, may elect to continue to provide coverage for behavioral health treatment<\/span> required under this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

K.<\/span> Coverage for applied behavior analysis<\/span> under this section will be subject to an annual maximum benefit of $35,000, unless the insurer<\/span>, corporation, or health maintenance organization elects to provide coverage in a greater amount. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

L.<\/span> As of January 1, 2014, to the extent that this section requires benefits that exceed the essential health benefits specified under § 1302(b) of the federal Patient Protection and Affordable Care Act (H.R. 3590), as amended (the ACA), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in the Commonwealth by a health carrier through a health benefit exchange established under § 1311 of the ACA. Nothing in this subsection shall nullify application of this section to plans offered outside such an exchange. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCOVERAGE FOR AUTISM SPECTRUM DISORDER (\u00a7 38.2-3418.17)\n\nA. Notwithstanding the provisions of § 38.2-3419 and any other provision of\nlaw, each insurer proposing to issue accident and sickness insurance policies\nproviding hospital, medical and surgical, or major medical coverage on an\nexpense-incurred basis; each corporation providing accident and sickness\nsubscription contracts; and each health maintenance organization providing a\nhealth care plan for health care services shall, as provided in this section,\nprovide coverage for the diagnosis of autism spectrum disorder and the treatment\nof autism spectrum disorder, in individuals (i) from January 1, 2012, until\nJanuary 1, 2016, from age two years through age six years; (ii) from January 1,\n2016, until January 1, 2020, from age two years through age 10 years; and (iii)\nfrom and after January 1, 2020, of any age, subject to the annual maximum\nbenefit limitation set forth in subsection K and to the provisions of subsection\nG. If an individual who is being treated for autism spectrum disorder becomes\nolder than the applicable maximum age set forth in the preceding sentence and\ncontinues to need treatment, this section does not preclude coverage of\ntreatment and services. In addition to the requirements imposed on health\ninsurance issuers by § 38.2-3436, an insurer shall not terminate coverage\nor refuse to deliver, issue, amend, adjust, or renew coverage of an individual\nsolely because the individual is diagnosed with autism spectrum disorder or has\nreceived treatment for autism spectrum disorder.\n\nB. For purposes of this section:\n\t\t\t“Applied behavior analysis” means the design, implementation, and\nevaluation of environmental modifications, using behavioral stimuli and\nconsequences, to produce socially significant improvement in human behavior,\nincluding the use of direct observation, measurement, and functional analysis of\nthe relationship between environment and behavior.\n\t\t\t“Autism spectrum disorder” means any pervasive developmental\ndisorder or autism spectrum disorder, as defined in the most recent edition or\nthe most recent edition at the time of diagnosis of the Diagnostic and\nStatistical Manual of Mental Disorders of the American Psychiatric Association.\n\t\t\t“Behavioral health treatment” means professional, counseling, and\nguidance services and treatment programs that are necessary to develop,\nmaintain, or restore, to the maximum extent practicable, the functioning of an\nindividual.\n\t\t\t“Diagnosis of autism spectrum disorder” means medically necessary\nassessments, evaluations, or tests to diagnose whether an individual has an\nautism spectrum disorder.\n\t\t\t“Medically necessary” means in accordance with the generally\naccepted standards of mental disorder or condition care and clinically\nappropriate in terms of type, frequency, site, and duration, based upon evidence\nand reasonably expected to do any of the following: (i) prevent the onset of an\nillness, condition, injury, or disability; (ii) reduce or ameliorate the\nphysical, mental, or developmental effects of an illness, condition, injury, or\ndisability; or (iii) assist to achieve or maintain maximum functional capacity\nin performing daily activities, taking into account both the functional capacity\nof the individual and the functional capacities that are appropriate for\nindividuals of the same age.\n\t\t\t“Pharmacy care” means medications prescribed by a licensed\nphysician and any health-related services deemed medically necessary to\ndetermine the need or effectiveness of the medications.\n\t\t\t“Psychiatric care” means direct or consultative services provided\nby a psychiatrist licensed in the state in which the psychiatrist practices.\n\t\t\t“Psychological care” means direct or consultative services\nprovided by a psychologist licensed in the state in which the psychologist\npractices.\n\t\t\t“Therapeutic care” means services provided by licensed or\ncertified speech therapists, occupational therapists, physical therapists, or\nclinical social workers.\n\t\t\t“Treatment for autism spectrum disorder” shall be identified in a\ntreatment plan and includes the following care prescribed or ordered for an\nindividual diagnosed with autism spectrum disorder by a licensed physician or a\nlicensed psychologist who determines the care to be medically necessary: (i)\nbehavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv)\npsychological care, (v) therapeutic care, and (vi) applied behavior analysis\nwhen provided or supervised by a board certified behavior analyst who shall be\nlicensed by the Board of Medicine. The prescribing practitioner shall be\nindependent of the provider of applied behavior analysis.\n\t\t\t“Treatment plan” means a plan for the treatment of autism\nspectrum disorder developed by a licensed physician or a licensed psychologist\npursuant to a comprehensive evaluation or reevaluation performed in a manner\nconsistent with the most recent clinical report or recommendation of the\nAmerican Academy of Pediatrics or the American Academy of Child and Adolescent\nPsychiatry.\n\nC. Except for inpatient services, if an individual is receiving treatment for an\nautism spectrum disorder, an insurer, corporation, or health maintenance\norganization shall have the right to request a review of that treatment,\nincluding an independent review, not more than once every 12 months unless the\ninsurer, corporation, or health maintenance organization and the\nindividual’s licensed physician or licensed psychologist agree that a more\nfrequent review is necessary. The cost of obtaining any review, including an\nindependent review, shall be covered under the policy, contract, or plan.\n\nD. Coverage under this section will not be subject to any visit limits, and\nshall be neither different nor separate from coverage for any other illness,\ncondition, or disorder for purposes of determining deductibles, lifetime dollar\nlimits, copayment and coinsurance factors, and benefit year maximum for\ndeductibles and copayment and coinsurance factors.\n\nE. Nothing shall preclude the undertaking of usual and customary procedures,\nincluding prior authorization, to determine the appropriateness of, and medical\nnecessity for, treatment of autism spectrum disorder under this section,\nprovided that all such appropriateness and medical necessity determinations are\nmade in the same manner as those determinations are made for the treatment of\nany other illness, condition, or disorder covered by such policy, contract, or\nplan.\n\nF. The provisions of this section shall not apply to (i) short-term travel,\naccident only, limited, or specified disease policies; (ii) short-term\nnonrenewable policies of not more than six months’ duration; or (iii)\npolicies or contracts designed for issuance to persons eligible for coverage\nunder Title XVIII of the Social Security Act, known as Medicare, or any other\nsimilar coverage under state or federal governmental plans.\n\nG. The requirements of this section requiring that coverage be provided with\nregard to individuals from age two years through age six years shall apply to\nall insurance policies, subscription contracts, and health care plans delivered,\nissued for delivery, reissued, or extended on or after January 1, 2012, but\nprior to January 1, 2016; the requirements of this section requiring that\ncoverage be provided with regard to individuals from age two years through age\n10 years shall apply to all insurance policies, subscription contracts, and\nhealth care plans delivered, issued for delivery, reissued, or extended on or\nafter January 1, 2016, but prior to January 1, 2020; the requirements of this\nsection requiring that coverage be provided with regard to individuals of any\nage shall apply to all insurance policies, subscription contracts, and health\ncare plans delivered, issued for delivery, reissued, or extended on or after\nJanuary 1, 2020, and to all such policies, contracts, or plans to which a term\nis changed or any premium adjustment is made on or after such date; and the\nrequirements of this section requiring that coverage be provided by policies,\ncontracts, or plans issued in the individual market or small group markets shall\napply to all insurance policies, subscription contracts, and health care plans\nin the individual and small group markets delivered, issued for delivery,\nreissued, or extended on or after January 1, 2021, and to all such policies,\ncontracts, or plans to which a term is changed or any premium adjustment is made\non or after such date.\n\nH. Any coverage required pursuant to this section shall be in addition to the\ncoverage required by § 38.2-3418.5 and other provisions of law. This\nsection shall not be construed as diminishing any coverage required by §\n38.2-3412.1. This section shall not be construed as affecting any obligation to\nprovide services to an individual under an individualized family service plan,\nan individualized education program, or an individualized service plan.\n\nI. Pursuant to the provisions of § 2.2-2818.2, this section shall apply to\nhealth coverage offered to state employees pursuant to § 2.2-2818 and to\nhealth insurance coverage offered to employees of local governments, local\nofficers, teachers, and retirees, and the dependents of such employees,\nteachers, and retirees pursuant to § 2.2-1204.\n\nJ. Notwithstanding any provision of this section to the contrary:\n\n 1. An insurer, corporation, or health maintenance organization, or a\n governmental entity providing coverage for such treatment pursuant to\n subsection I, is exempt from providing coverage for behavioral health\n treatment required under this section and not covered by the insurer,\n corporation, health maintenance organization, or governmental entity providing\n coverage for such treatment pursuant to subsection I as of December 31, 2011,\n if:\n \t\t\t\ta. An actuary, affiliated with the insurer, corporation, or health\n maintenance organization, who is a member of the American Academy of Actuaries\n and meets the American Academy of Actuaries’ professional qualification\n standards for rendering an actuarial opinion related to health insurance rate\n making, certifies in writing to the Commissioner of Insurance that:\n\n 1. Based on an analysis to be completed no more frequently than one time per\n year by each insurer, corporation, or health maintenance organization, or\n such governmental entity, for the most recent experience period of at least\n one year’s duration, the costs associated with coverage of behavioral\n health treatment required under this section, and not covered as of December\n 31, 2011, exceeded one percent of the premiums charged over the experience\n period by the insurer, corporation, or health maintenance organization; and\n\n 2. Those costs solely would lead to an increase in average premiums charged\n of more than one percent for all insurance policies, subscription contracts,\n or health care plans commencing on inception or the next renewal date, based\n on the premium rating methodology and practices the insurer, corporation, or\n health maintenance organization, or such governmental entity, employs; and\n \t\t\t\t\tb. The Commissioner approves the certification of the actuary;\n\n 2. An exemption allowed under subdivision 1 shall apply for a one-year\n coverage period following inception or next renewal date of all insurance\n policies, subscription contracts, or health care plans issued or renewed\n during the one-year period following the date of the exemption, after which\n the insurer, corporation, or health maintenance organization, or such\n governmental entity, shall again provide coverage for behavioral health\n treatment required under this section;\n\n 3. An insurer, corporation, or health maintenance organization, or such\n governmental entity, may claim an exemption for a subsequent year, but only if\n the conditions specified in subdivision 1 again are met; and\n\n 4. Notwithstanding the exemption allowed under subdivision 1, an insurer,\n corporation, or health maintenance organization, or such a governmental\n entity, may elect to continue to provide coverage for behavioral health\n treatment required under this section.\n\nK. Coverage for applied behavior analysis under this section will be subject to\nan annual maximum benefit of $35,000, unless the insurer, corporation, or health\nmaintenance organization elects to provide coverage in a greater amount.\n\nL. As of January 1, 2014, to the extent that this section requires benefits that\nexceed the essential health benefits specified under § 1302(b) of the\nfederal Patient Protection and Affordable Care Act (H.R. 3590), as amended (the\nACA), the specific benefits that exceed the specified essential health benefits\nshall not be required of a qualified health plan when the plan is offered in the\nCommonwealth by a health carrier through a health benefit exchange established\nunder § 1311 of the ACA. Nothing in this subsection shall nullify\napplication of this section to plans offered outside such an exchange.\n\nHISTORY: 2011, cc. 876, 878; 2015, cc. 649, 650; 2019, cc. 451, 452; 2020, cc.\n305, 613; 2022, cc. 101, 102.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}