Getting Autism Therapy Covered by Insurance in Georgia

Georgia's SB 169 mandate

Georgia Senate Bill 169, enacted in 2015 and later expanded, requires all Georgia-regulated health insurance plans to cover ABA therapy for autism spectrum disorder. There is no age cap on coverage and no dollar cap on covered services.

BCBA license requirement:the BCBA providing ABA services must hold a current Georgia state license. Before beginning any prior auth process, confirm your provider's Georgia licensure — coverage can be denied for a BCBA who lacks a Georgia license even if they hold BACB certification.

Who qualifies: individuals with an autism diagnosis, with ABA therapy prescribed as medically necessary by a licensed physician or psychologist.

ERISA exemption:self-funded employer plans are generally exempt from SB 169 under federal ERISA law. Confirm your plan type — if you're on a self-funded employer plan, the mandate may not apply.

Prior authorization in Georgia

Prior authorization is required for ABA therapy in Georgia. Your BCBA or treating physician will submit the request. Documents to prepare:

• Autism diagnosis report with DSM-5 criteria documentation
• Letter of medical necessity from the diagnosing physician
• BCBA's treatment plan with recommended weekly hours
• BCBA's NPI number and Georgia license number
• Any specific prior auth forms required by your insurer

Confirm the authorization in writing before the first therapy session. Track the expiration date and submit renewal requests at least 30 days in advance to avoid coverage gaps.

Appeals

If your Georgia insurer denies ABA coverage or prior authorization:

1. Request the denial reason in writing — insurers are legally required to provide a specific reason.
2. File a written internal appealwithin 30 days. Ask your child's physician for a letter of medical necessity specifically addressing the denial reason.
3. Request external review if the internal appeal fails — Georgia law provides external review rights for fully insured plans.
4. Contact the Georgia Department of Insurance at 1-800-656-2298 if you believe SB 169 is being violated.

Georgia Families Medicaid

Georgia's Medicaid managed care program, Georgia Families, covers ABA therapy for children under 21. Coverage is administered through managed care organizations (MCOs) — the specific prior auth process depends on which MCO your child is enrolled with.

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

Medicaid and private insurance: if your child has both private insurance and Medicaid, private insurance is billed first. Georgia Families Medicaid covers remaining costs.