Getting Autism Therapy Covered by Insurance in Colorado

Colorado’s mandate

C.R.S. § 10-16-104(1.4), enacted 2009, requires state-regulated health plans in Colorado to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: No age limit in the current law. Colorado originally covered children under 19; Senate Bill 15-015 folded autism into the state's mental health parity requirements effective January 2017, and the age ceiling went with it.

Dollar cap: None. Coverage cannot carry dollar limits, deductibles or coinsurance less favorable than the plan applies to physical illness generally.

Two clauses worth quoting back at an insurer. Speech, occupational and physical therapy MAY exceed 20 visits where medically necessary — the 20-visit ceiling that applies to other conditions is not a hard stop here. And early intervention services are required to supplement ASD services, not replace them, which answers the argument that a child already receiving EI does not need covered therapy.

Whether the mandate applies to your plan

This is the question to settle first, because the answer decides whether anything above is enforceable for you. State insurance mandates bind fully insured plans. Self-funded employer plans — where the employer pays claims itself and an insurer only administers them — are generally exempt under federal ERISA, and they cover roughly six in ten people with employer coverage.

Ask your HR department, in writing, which type your plan is. If it is self-funded, C.R.S. § 10-16-104(1.4) does not compel coverage — but federal parity law may still help, and many large self-funded employers cover ABA voluntarily. Ask what the plan actually covers rather than assuming the answer is no.

The Medicaid route

Health First Colorado covers ABA for members under 21 through EPSDT, separately from this mandate.

How Medicaid waivers work covers the route for families who do not qualify on income alone.

When you are denied

1. Get the denial reason in writing. Insurers must give a specific reason, and the appeal has to answer that reason rather than restate the diagnosis.
2. File the internal appeal within the deadline on the denial letter, with a letter of medical necessity that addresses the stated reason directly.
3. Request external review if the internal appeal fails. Fully insured plans carry external review rights, and an independent reviewer overturns denials more often than families expect.
4. Complain to the Colorado Division of Insurance on 303-894-7490 if you believe C.R.S. § 10-16-104(1.4) is being violated. Their consumer pages are here.