Policy 519.23 prints an April 1, 2020 effective date on every page (BMS Provider Manual Chapter 519, Policy 519.23). The ABA fee schedule is a one-page table with per-code effective dates from 08/01/2019 to 04/01/2021 and no schedule-level date, so the rates' overall currency is not confirmed. The commercial mandate was read from the 2012 enrolled bill, because the code site was blocked.
The BMS fee schedule lists effective dates for each code (2019 to 2021) but no overall year. Confirm the current schedule before modeling revenue. The commercial limits shown are the 2012 enacted figures, and the live code text was not read.
The reimbursement criteria at a glance
- Is ABA covered by West Virginia Medicaid
- Who is eligible
- Rates
- Place of service and telehealth
- Prior authorization and hour cap
- Provider qualifications
- The commercial mandate
- Practices with in-house diagnostics versus ABA-only practices
- How this connects to the rest of your compliance stack
- What this guide could not verify
- West Virginia reimbursement variables at a glance
- Frequently asked questions
- Where professional advice is essential
Is ABA covered by West Virginia Medicaid
Yes. Policy 519.23 serves members "who are referred for necessary diagnostic and treatment services identified during an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) encounter with a health professional practicing within the scope of his or her practice" (BMS Policy 519.23, effective April 1, 2020).
Who is eligible
"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." The prior authorization must include "the qualifying diagnostic assessment establishing the ASD diagnosis prior to age eight and completed within the previous 24 months" and "the annual physician's order for ABA Services" (BMS Policy 519.23).
Rates
The BMS fee schedule, titled "Contracts and Codes for: ABA - Medicaid," lists the standard fee per unit. Codes 97151 to 97158 are 15-minute units, and H0031 is one assessment event, "maximum of one per year per member" (BMS ABA fee schedule; Policy 519.23).
| Code | Rate | Code effective |
|---|---|---|
| 97151 | $29.14 | 04/01/2020 |
| 97152 | $9.90 | 04/01/2021 |
| 97153 | $9.90 | 04/01/2021 |
| 97154 | $4.50 | 04/01/2021 |
| 97155 | $29.14 | 04/01/2020 |
| 97156 | $17.43 | 04/01/2020 |
| 97158 | $11.79 | 04/01/2020 |
| H0031 | $120.00 | 04/01/2020 |
| H0032, H2012, H2019 | $29.14 each | 08/01/2019 |
| H2014 | $11.79 (U4 $5.50; U5 $2.50) | 08/01/2019 |
No line appears for 97157.
Place of service and telehealth
"Therapeutic activities may be provided to a member in his/her natural environment through a structured program as identified in the goals and objectives described in the ABA service plan," and group services "must be limited to four members to each staff person." Telehealth "must align with requirements in Chapter 519 Practitioner's Services' Policy 519.17, Telehealth Services" (BMS Policy 519.23). School, clinic, and community setting rules and the telehealth details were not verified.
Prior authorization and hour cap
"PA for all ABA services requests must be made prior to any service being rendered," and "back-dating of authorizations is NOT allowed and 'retrospective review requests' will be denied." The assessment code "may be used in combination with 97152, 97153, 97154, 97155, 97156, and 97158 of up to a maximum of 40 hours per week and/or eight hours within a 24-hour period." A utilization management contractor or managed care organization may request additional documents (BMS Policy 519.23). The BMS annual report for State Fiscal Year 2025 says it "contracts with four MCOs" for Mountain Health Trust but does not say whether ABA is an MCO benefit (BMS Mountain Health Trust annual report, September 30, 2025), so whether ABA is carved out to fee-for-service was not verified.
Provider qualifications
West Virginia recognizes providers "when their certification by the Behavior Analyst Certification Board is current and in good standing, and they have met participation enrollment requirements": a BCBA (including BCBA-D), a BCaBA working under a supervising BCBA, and an RBT working under a supervising BCBA or BCaBA. For 97153, "direct contact with member is made by an RBT under supervision of the BCBA or BCaBA," and the BCBA or BCaBA may bill. "Family members or any other non-credentialed individual providing ABA services to the member is NOT a covered benefit." Enrollment follows Chapter 300 of the BMS Provider Manual (BMS Policy 519.23). See the West Virginia Licensing page.
The commercial mandate
HB 4260 (2012) amended sections 5-16-7, 5-16B-6e, 33-16-3v, 33-24-7k, and 33-25A-8j of the West Virginia Code. As enacted it required "coverage for diagnosis and treatment of autism spectrum disorder in individuals ages eighteen months to eighteen years" in an amount "not to exceed $30,000 per individual, for three consecutive years from the date treatment commences." ABA "shall be provided or supervised by a certified behavior analyst" (West Virginia HB 4260, 2012 enrolled). A legislative listing shows no Regular Session amendment to section 33-24-7k from 2013 through 2026, but the live codified text was not read, so whether the 2012 limits remain in force is unconfirmed.
Practices with in-house diagnostics versus ABA-only practices
Prior authorization requires a diagnostic assessment completed within 24 months and an annual physician's order. A practice with an in-house psychologist or physician can complete both from within, while an ABA-only practice relies on outside providers for the assessment and the order each year.
How this connects to the rest of your compliance stack
See the West Virginia Licensing page for the credential posture and the West Virginia entity page for the structure analysis.
What this guide could not verify
- A rate for 97157, and the schedule's overall effective year.
- School, clinic, and community setting rules, and the telehealth details of Policy 519.17.
- Whether ABA is covered by the Mountain Health Trust managed care organizations or carved out, and which contractor reviews fee-for-service authorizations.
- The live codified text of the commercial mandate and whether the 2012 limits remain.
West Virginia reimbursement variables at a glance
| Variable | West Virginia value |
|---|---|
| ABA covered by Medicaid? | Yes, Policy 519.23, effective April 1, 2020 |
| Eligibility | 18 months through 20; ASD diagnosed before age 8 |
| Hour cap | 40 hours per week and eight hours in 24 |
| 97153 rate | $9.90 per 15 minutes |
| Commercial mandate | HB 4260 (2012): ages 18 months to 18; $30,000 per individual for three years |
Frequently asked questions
What is the weekly limit on ABA?
Can prior authorization be back-dated?
Are family members covered providers?
Where professional advice is essential, not optional
West Virginia's rates are low relative to its neighbors and its policy has not changed since 2020, so the economics depend on technician volume under the 40 hour cap. Confirm the current schedule before you model revenue.
The governing authorities to know are BMS Policy 519.23 and HB 4260 (2012).
This page describes rules read from the Bureau for Medical Services provider manual, its fee schedule, and the 2012 enrolled bill. The Bureau for Medical Services, the Offices of the Insurance Commissioner, and each payor provide current requirements. Do not rely on this page or any secondary source in place of direct verification.