Getting Autism Therapy Covered by Insurance in Tennessee

Tennessee’s mandate

Tenn. Code Ann. § 56-7-2360 (mental health parity), superseding the 2006 autism mandate at § 56-7-2367, enacted 2006, requires state-regulated health plans in Tennessee to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Do not stop at the 2006 statute, which reads as covering only people under twelve. The Department of Commerce and Insurance stated in its August 2019 bulletin that autism is a condition listed in both the ICD and the DSM, so treatment must be covered at parity under § 56-7-2360 and federal MHPAEA — the age-twelve ceiling in the older mandate is not the operative rule.

Dollar cap: No autism-specific cap. Coverage is at parity, so deductibles, copayments and benefit limits may be no more stringent than those applied to other neurological disorders.

The parity argument is the strong one in Tennessee, and the 2019 bulletin is the document to cite: it says in terms that medically necessary, non-experimental treatment such as applied behavior analysis must be covered at parity. Carriers also have to certify their parity compliance to the Department each year by 1 March, which is useful leverage when a denial looks like a blanket autism exclusion.

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, Tenn. Code Ann. § 56-7-2360 (mental health parity), superseding the 2006 autism mandate at § 56-7-2367 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

TennCare covers ABA for members under 21 through EPSDT, separately from the parity route above.

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 Tennessee Department of Commerce and Insurance on 615-741-1670 if you believe Tenn. Code Ann. § 56-7-2360 (mental health parity), superseding the 2006 autism mandate at § 56-7-2367 is being violated. Their consumer pages are here.