Getting Autism Therapy Covered by Insurance in Massachusetts

Massachusetts’s mandate

M.G.L. c. 175 § 47AA (ARICA), enacted 2010, requires state-regulated health plans in Massachusetts to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: No age limit. ARICA sets none, which makes Massachusetts one of the better states for an autistic adult still needing therapy.

Dollar cap: No autism-specific cap, and no visit cap. The statute bars a plan from putting any annual or lifetime dollar or service limit on autism care that is lower than the limit it applies to physical conditions — parity rather than unlimited benefit.

The statute explicitly forbids limiting the number of visits to an autism services provider. One caveat worth knowing: it allows a three-year exemption for an insurer whose autism costs would exceed 1 percent of premiums — a business exception, not a coverage limit, but ask whether your carrier has claimed it.

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, M.G.L. c. 175 § 47AA (ARICA) 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

MassHealth covers ABA to age 21, so the state Medicaid route is narrower on age than ARICA is. If your child is over 21, the private mandate is the stronger argument.

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 Massachusetts Division of Insurance on 617-521-7794 if you believe M.G.L. c. 175 § 47AA (ARICA) is being violated. Their consumer pages are here.