Getting Autism Therapy Covered by Insurance in California

California's SB 946 mandate

California Senate Bill 946, signed in 2011, requires all California-regulated health insurance plans to cover ABA therapy for autism spectrum disorder. There is no age cap — coverage applies to children and adults alike. There is no dollar cap on covered services.

Who qualifies: the individual must have an autism diagnosis, and ABA therapy must be prescribed by a licensed physician or psychologist. The BCBA delivering services must hold a current California state license.

What's covered: ABA therapy, including assessment, treatment planning, and direct intervention. Coverage is required for all medically necessary hours — insurers cannot cap hours arbitrarily.

ERISA exemption:if your employer is self-funded (pays claims directly rather than buying coverage from an insurer), SB 946 may not apply. Look for language like “self-funded,” “self-insured,” or “administered by” in your plan documents. If you're unsure, ask your HR department directly.

Prior authorization in California

Even with SB 946 protections, California insurers almost always require prior authorization before ABA therapy begins. Your BCBA or treating physician will submit the authorization request, but you can prepare by gathering:

• The autism diagnosis report (DSM-5 criteria documentation)
• The BCBA's treatment plan with recommended hours per week
• The BCBA's NPI number and California license number
• Any specific prior auth forms your insurer requires

California law requires insurers to process standard prior auth requests within 5 business days and urgent requests within 72 hours. Get the approval in writing and confirm the authorized dates and hours before your child's first session.

Appeals and California's IMR process

California has one of the strongest external review processes in the country. If your insurer denies ABA coverage or prior authorization, you have two paths:

1. Internal appeal: file a written appeal within 30–180 days of the denial (your plan documents will specify the deadline). Ask your provider for a letter of medical necessity that addresses the denial reason specifically.
2. Independent Medical Review (IMR):if your internal appeal is denied — or if waiting for an internal appeal would seriously jeopardize your child's health — you can request an IMR from the DMHC. A third-party medical reviewer evaluates the case independently. This process is free and the reviewer's decision is binding on the insurer. Contact DMHC at 1-888-466-2219 or file online at dmhc.ca.gov.

Keep copies of every denial letter, appeal submission, authorization approval, and correspondence with your insurer. These records are essential if the dispute escalates.

Medi-Cal coverage for ABA

California's Medicaid program, Medi-Cal, covers ABA therapy for individuals under 21 as a required service. If your family qualifies for Medi-Cal, it can cover ABA therapy independently or alongside private insurance.

Income-based eligibility: Medi-Cal uses Modified Adjusted Gross Income (MAGI) rules for most families. Children in many households qualify even if parents do not.

Regional Centers:California's 21 Regional Centers provide additional services funded through the Lanterman Act, separate from Medi-Cal. Regional Center services can complement insurance-covered ABA and fill gaps in coverage. Contact your local Regional Center to open a case if you haven't already.

For Medi-Cal enrollment, visit your county social services office or apply at coveredca.com. If you already have Medi-Cal, contact your managed care plan to confirm ABA coverage and how to request authorization.