Getting Autism Therapy Covered by Insurance in Connecticut

Connecticut’s mandate

C.G.S. § 38a-514b (group) and § 38a-488b (individual), enacted 2009, requires state-regulated health plans in Connecticut to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Behavioral therapy is covered for children under 21.

Dollar cap: None in the current statute. Connecticut originally set age-banded caps — $50,000 a year under 9, $35,000 for 9 to 12, $25,000 for 13 to 14 — and those are gone from the operative text. The statute also bars an insurer from putting any limit on the number of visits except where the visits are not medically necessary.

Connecticut writes the supervision ratio into law: behavioral therapy must be provided or supervised by a licensed behavior analyst, physician or psychologist, with at least one hour of face-to-face supervision for every ten hours of therapy delivered. If a provider is billing supervised hours without that ratio, the plan is not getting what the statute requires.

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.G.S. § 38a-514b (group) and § 38a-488b (individual) 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

HUSKY Health covers ABA for members under 21 through EPSDT, separately from the private 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 Connecticut Insurance Department on 1-800-203-3447 if you believe C.G.S. § 38a-514b (group) and § 38a-488b (individual) is being violated. Their consumer pages are here.