Getting Autism Therapy Covered by Insurance in Maryland

Maryland’s mandate

Md. Code, Insurance § 15-835 (habilitative services), enacted 2013, requires state-regulated health plans in Maryland to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Coverage runs until at least the end of the month in which the child turns 19. Maryland reaches autism through its habilitative services mandate rather than a standalone autism law, which is why the wording looks different from other states.

Dollar cap: The statute sets no dollar cap and no hour cap on habilitative services.

Ask for habilitative services by name. Maryland covers autism treatment under that heading, and a request framed as 'autism therapy' can be handled by staff looking for an autism-specific benefit that does not exist here. Medical necessity determinations follow regulations set by the Insurance Commissioner rather than the insurer's own definition.

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, Md. Code, Insurance § 15-835 (habilitative services) 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

Maryland Medicaid covers ABA for members under 21 through EPSDT. Because the private mandate stops at 19, Medicaid is the longer-running route for families who qualify.

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 Maryland Insurance Administration on 1-800-492-6116 if you believe Md. Code, Insurance § 15-835 (habilitative services) is being violated. Their consumer pages are here.