Getting Autism Therapy Covered by Insurance in Georgia

What Georgia law requires

Georgia's autism insurance mandate is Code section 33-24-59.10, “Coverage for autism”, known as Ava's Law. It arrived in 2015 covering children through age six, and was substantially widened effective 1 January 2019. Accident and sickness policies must cover autism spectrum disorder for a person who is 20 years of age or under.

Visits cannot be limited. Dollars can. These two rules sit in adjacent subsections and are the most commonly garbled part of Georgia's law. A policy shall not include any limits on the number of visits. But a policy may limit coverage for applied behavior analysis to $35,000 a year. So an insurer telling you that you have used up your sessions is on the wrong side of the statute; one telling you that you have reached the annual ABA maximum may not be. One useful protection here: the insurer may not apply payments for care unrelated to autism toward that maximum.

The credential is national, not state. To be covered, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts, or performed under the supervision of such a person. That is Behavior Analyst Certification Board certification. Georgia does not license behavior analysts for this purpose, so if you have been told to produce your provider's Georgia license number, that requirement is not in the law.

Small employers are exempt. Subsection (g) says the section does not apply to any plan offered by an employer with ten or fewer employees. Self-funded employer plans are separately pre-empted by federal ERISA law, and limited-benefit policies — accident only, dental, vision, disability income, long-term care, Medicare supplement and similar — are outside the definition entirely.

Two further limits worth knowing. A qualified health plan sold through the exchange is not required to provide benefits that exceed the federal essential health benefits, though the mandate still applies to plans sold outside the exchange. And an insurer can claim a one-year exemption if its actuary certifies to the Commissioner that the coverage raised premiums by more than 1 percent, though it must resume coverage afterwards and re-qualify each time.

School services are separate. The statute says explicitly that it does not affect any obligation to provide services under an individualized family service plan, an IEP under the federal Individuals with Disabilities Education Act, or an individualized service plan.

Prior authorization in Georgia

The statute does not itself impose prior authorization, but it does let the covering entity determine medical necessity against established criteria, and it allows an insurer to require a licensed physician or licensed psychologist to demonstrate ongoing medical necessity at least annually. In practice most plans require authorization. Documents to prepare:

• The autism diagnosis report, with DSM criteria documented
• Assessments, evaluations or tests by a licensed physician or licensed psychologist — the statute names these specifically for diagnosis
• A letter of medical necessity addressing the plan's established criteria
• The treatment plan with recommended weekly hours
• The provider's NPI and national board certification details

Confirm any authorization in writing before the first session, track the expiry date, and start the annual medical-necessity renewal well before it lapses.

Appeals

If your Georgia insurer denies autism coverage or prior authorization:

1. Request the denial reason in writing. You need the specific stated reason before you can answer it.
2. Check the reason against the statute. A denial based on the number of visits contradicts subsection (b)(3) outright. A denial based on your child's age is only valid above 20. A demand for a Georgia behavior analyst license has no statutory basis.
3. File a written internal appeal with a letter of medical necessity that addresses the stated reason. Federal rules give you at least 180 days from the denial notice — Georgia's autism statute sets no 30-day deadline, despite what you may read.
4. Request external review if the internal appeal fails, then contact the Office of Commissioner of Insurance and Safety Fire at 1-800-656-2298.

Georgia Families Medicaid

Georgia Families, the state's Medicaid managed care program, covers ABA for children under 21 through federal EPSDT rules. That is a separate and often more generous route than the private mandate, with no $35,000 ceiling. The prior authorization process depends on which managed care organization your child is enrolled with.

Enrollment: apply through gateway.ga.gov or the Department of Community Health. Children with disabilities may qualify through SSI-linked Medicaid regardless of household income.

Holding both: if your child has private insurance and Medicaid, the private plan is billed first and Medicaid covers what remains. In Georgia this pairing matters more than in most states, because Medicaid is what picks up the therapy after a private plan hits its annual ABA cap.