Getting Autism Therapy Covered by Insurance in Mississippi

Mississippi’s mandate

Miss. Code Ann. § 83-9-26, enacted 2015, requires state-regulated health plans in Mississippi to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: This is the most restrictive ABA rule we have found in any state: the Insurance Department states that ABA therapy is only REQUIRED for individuals under the age of 8. Ask anyway — several major Mississippi insurers have voluntarily waived that limit, so being over eight does not necessarily mean being refused.

Dollar cap: No dollar cap stated. Hours are limited instead: ABA is capped at 25 hours a week, of which no more than 10 hours a week may be services from a licensed behavior analyst. Cost sharing may not exceed what the plan applies to other physical health services.

One protection here is broader than the therapy benefit and worth knowing on its own: no insurer may terminate coverage, or refuse to issue, amend or renew it, solely because someone has been diagnosed with or treated for an autism spectrum disorder. Preauthorization may still be required.

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, Miss. Code Ann. § 83-9-26 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

Mississippi Medicaid covers ABA for members under 21 through EPSDT, which carries no age-8 cut-off. For a Mississippi child over eight whose insurer has not waived the limit, this is the route that still exists.

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 Mississippi Insurance Department on 1-800-562-2957 if you believe Miss. Code Ann. § 83-9-26 is being violated. Their consumer pages are here.