Section 38-71-280, Autism Spectrum Disorder Maximum Benefit for Coverage for Behavioral Therapy
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Bulletin establishing the annual Consumer Price Index adjustment to the statutory $50,000 per‑year maximum benefit for coverage of behavioral therapy for Autism Spectrum Disorder for insurers and HMOs writing accident and health coverage in South Carolina.
The maximum benefit for coverage for behavioral therapy is increased to $73,400 for the calendar year beginning January 1, 2026.
Coverage Criteria
Coverage for behavioral therapy for Autism Spectrum Disorder is governed by S.C. Code Ann. § 38-71-280 and is subject to a statutory annual maximum benefit that is adjusted each January 1 to reflect the prior year change in the Consumer Price Index (All Urban Consumers). Amounts billed in excess of the statutorily adjusted annual maximum are not covered under the statute. For the calendar year beginning January 1, 2026, the Department has determined the adjusted maximum benefit to be $73,400.
Coding and Limits
Provider Actions and Authorization
Use CPI‑adjusted annual maximum when authorizing services
The bulletin directs insurers to use the CPI‑adjusted annual maximum when determining coverage limits; prior authorization requirements must operate within the statutory annual maximum.
Reference the updated annual maximum in authorizations and member communications
Ensure all prior authorization and claims adjudication use the CPI‑adjusted annual maximum (e.g., $73,400 for calendar year 2026) when calculating remaining benefit availability and communicating coverage limits to members.
- Adjustment occurs each January 1 to reflect the prior year change in the Consumer Price Index, All Urban Consumers.
- Prior authorization rules remain subject to each insurer’s policies but must operate within the statutory annual maximum.
Apply annual CPI‑adjusted maximum to claims
Insurers must apply the annually adjusted maximum benefit when adjudicating behavioral therapy coverage claims for Autism Spectrum Disorder.
- The Department determined the maximum benefit is increased to $73,400 for the calendar year beginning January 1, 2026.
Limit claims to the statutorily adjusted annual maximum
Claims for behavioral therapy are limited to the statutorily adjusted dollar amount for the year; amounts in excess of that annual maximum are not covered by the statute and may be denied or limited accordingly.
- The maximum benefit is increased to $73,400 for the calendar year beginning January 1, 2026.
- Coverage for behavioral therapy is subject to a fifty‑thousand‑dollar maximum benefit per year, adjusted annually by CPI.
Definitions
Background
This bulletin implements the statutory requirement in S.C. Code Ann. § 38-71-280(E) that the $50,000 per-year maximum benefit for behavioral therapy be adjusted annually on January 1 to reflect changes in the Consumer Price Index, All Urban Consumers (CPI‑U). The Department reviewed the current CPI‑U and increased the maximum benefit to $73,400 for the calendar year beginning January 1, 2026. The bulletin provides the Department’s determination of the CPI‑adjusted dollar limit; it does not alter clinical indications, therapy modalities, or insurers’ other routine utilization management requirements.
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