ABA insurance and Medicaid coverage in South Carolina

Autism insurance mandate

State mandate for autism coverage

Yes, the research found a state autism coverage law.

Statute

S.C. Code Ann. § 38-71-280 (added by 2007 Act No. 65, R.85, S.20). Effective July 1, 2008, for health insurance plans issued, renewed, delivered, or entered into on or after that date. The current Code history lists no later amendment.

Age limits

Diagnosis of autistic spectrum disorder at age eight or younger is required. Benefits must be provided to any eligible person under sixteen years of age (S.C. Code Ann. § 38-71-280(E)).

Annual cap

Behavioral therapy only: statutory base of $50,000 per year, adjusted each January 1 to the CPI-U (All Urban Consumers) beginning one year after the July 1, 2008 effective date. SC Department of Insurance Bulletin 2025-09 (October 1, 2025) sets the maximum at $73,400 for the calendar year beginning January 1, 2026. Other covered autism treatment is outside that dollar cap and may not have dollar limits, deductibles, or coinsurance less favorable than those that apply to physical illness generally (§ 38-71-280(C), (E)). The statute sets no hour cap.

Excludes self-funded employer plans

Yes, self-funded employer plans are generally outside state mandates.

Notes

The mandate applies to a health insurance plan, defined as a group health insurance policy or group health benefit plan offered by an insurer, and it expressly includes the State Health Plan (employee and retiree insurance under Article 5, Chapter 11, Title 1). An insurer is an insurance company, HMO, or other entity providing health insurance coverage as defined in § 38-71-670(6) that is licensed to engage in the business of insurance in South Carolina and subject to state insurance regulation (§ 38-71-280(A)(2), (A)(4)). A private self-funded ERISA plan is outside that definition. The same subsection also excludes individual-market plans as defined in § 38-71-670(11), individually underwritten plans, and any plan provided to a small employer. The current Code still says small employer as defined by § 38-71-1330(17). As codified today, § 38-71-1330(17) is Risk-assuming insurer, and Small employer is § 38-71-1330(18): an employer that on at least 50 percent of its working days during the preceding calendar year employed no more than 50 eligible employees, or an average of not more than 50 employees, and that employs at least one employee on the first day of the plan year. § 38-71-1340 applies the small-group article to groups of two to fifty. The 2007 enrolled act cited § 38-71-1330(17) when that subsection was the small-employer definition; 2013 Act No. 48 (eff. June 7, 2013) renumbered § 38-71-1330, and § 38-71-280's history shows no conforming amendment. Coverage is limited to treatment prescribed by the insured's treating medical doctor under a treatment plan that includes diagnosis, proposed treatment by type, frequency, and duration, anticipated outcomes stated as goals, the update frequency, and the treating medical doctor's signature. The plan may request an updated treatment plan only once every six months unless the plan and the doctor agree that emerging clinical circumstances require more frequent review (§ 38-71-280(B), (D)). Autism spectrum disorder means Autistic Disorder, Asperger's Syndrome, or Pervasive Developmental Disorder—Not Otherwise Specified, as defined in the most recent edition of the DSM (§ 38-71-280(A)(1)). The statute does not define behavioral therapy and does not name applied behavior analysis. An insurer may not deny or refuse to issue coverage, refuse to contract, refuse to renew or reissue, or otherwise terminate or restrict coverage solely because the person is diagnosed with autism spectrum disorder. General exclusions still apply, including coordination of benefits, participating-provider requirements, restrictions on services by family or household members, medical-necessity review, case management, and other managed care provisions (§ 38-71-280(B), (C)). The act has no statutory short title. Bulletin 2025-09 is addressed to all insurers and HMOs writing accident and health coverage in South Carolina, including the State Health Plan.

Medicaid ABA coverage

Medicaid covers ABA

Yes, per the sources below.

Program

Healthy Connections Medicaid Autism Spectrum Disorder (ASD) Services (Title XIX State Plan; FFS and MCO). Added effective for dates of service on or after July 1, 2017. Current ASD Services Provider Manual effective July 1, 2026 (MB# 26-015 and MB# 26-021). Medically necessary ABA for members age 0 through the last day of the month of the 21st birthday with a DSM ASD diagnosis valid at assessment, an IDEA ASD designation confirmed by a physician, or a BHDD-OIDD autism-category determination confirmed by a physician. EPSDT presumptive ABA eligibility for members at risk (IDEA Part C and/or medical-care-home physician documentation): child must be 18–36 months at assessment; eligibility lasts until the 6th birthday and lapses without a DSM-supported ASD diagnosis before that birthday. Telehealth ASD diagnoses are not valid. No annual dollar cap is stated. Unit limits (15-minute units): 97151 up to 32 units per 12 months and 8 units per date of service (no prior authorization; in person only); 97152 up to 16 units per date of service; 0362T up to 16 units per date of service; 97153 up to 160 units per week and 32 units per date of service; 97154, 2–6 patients, up to 18 units per date of service; 97155 up to 10% of rendered 97153 hours, up to 64 units per month and 16 units per week; 0373T up to 24 units per date of service; 97156 up to 96 units per 12 months, minimum 4 units (1 hour) each month of authorized direct treatment, max 16 units per date of service; 97157 up to 16 units per date of service (1 provider, up to 8 caregivers / 2–6 patients); 97158, 2–6 patients, up to 16 units per date of service. All ASD treatment requires prior authorization from the QIO (Acentra, https://scdhhs.acentra.com); six-month renewals, submitable up to 30 days before and no later than 10 days before expiration. ASD Services Fee Schedule effective 8/13/2026: 97153 $14.88, 97155 $21.25, 97154 $9.10, 97156 $21.25 (BCBA/BCBA-D and BCaBA staff levels; 15-minute units).

Agency

South Carolina Department of Health and Human Services (SCDHHS)

Provider enrollment

https://providerservices.scdhhs.gov/ProviderEnrollmentWeb/

Payers named in our research

Names come from the research behind this page. Appearing here does not mean a payer is accepting new providers or that networks are open. Always confirm directly with the payer.