Getting Autism Therapy Covered by Insurance in Minnesota

Minnesota’s mandate

Minn. Stat. § 62A.3094, enacted 2013, requires state-regulated health plans in Minnesota to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Children under 18.

Dollar cap: None in the statute. Minnesota sets no dollar maximum and no hour cap — coverage follows the individualized treatment plan instead.

Coverage follows an individualized treatment plan written by the treating physician or mental health professional. The statute limits treatment plan reviews to once every six months unless circumstances warrant more — useful to know if an insurer is demanding reauthorisation more often than that.

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, Minn. Stat. § 62A.3094 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

Minnesota Medical Assistance covers autism treatment through its Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit, which is a separate route from the private mandate and is worth asking about on its own.

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 Minnesota Department of Commerce on 651-539-1600 if you believe Minn. Stat. § 62A.3094 is being violated. Their consumer pages are here.