Getting Autism Therapy Covered by Insurance in Utah

Utah's HB 323 mandate

Utah House Bill 323, signed in 2016, requires all Utah-regulated health insurance plans to cover ABA therapy for autism spectrum disorder through age 18. There is no dollar cap on covered services — plans must cover all medically necessary therapy hours until the individual's 18th birthday.

The age 18 cap:HB 323 coverage ends on the 18th birthday. Families should begin planning the adult transition before that date. Utah's DSPD waiver can provide ongoing support after insurance coverage ends, but the waitlist is long — apply before age 18 if possible.

Who qualifies: individuals under 18 with an autism diagnosis, with ABA therapy prescribed as medically necessary by a licensed physician or psychologist.

ERISA exemption: self-funded employer plans are generally exempt from HB 323 under federal ERISA law. Confirm your plan type with your HR department.

Prior authorization in Utah

Prior authorization is required for ABA therapy in Utah. Your BCBA or treating physician will submit the request. Documents to prepare:

• Autism diagnosis report with DSM-5 criteria documentation
• Letter of medical necessity from the diagnosing physician
• BCBA's treatment plan with recommended weekly hours
• BCBA's NPI number and credentials
• Any specific prior auth forms required by your insurer

Confirm the prior auth approval in writing before the first session. Set a calendar reminder for renewal — typically 6 months to 1 year. A lapse in authorization can result in claim denials for services that did take place.

Appeals

If your Utah insurer denies ABA coverage or prior authorization:

1. Request the denial reason in writing — insurers are required to provide a specific reason.
2. File a written internal appealwithin 30 days of the denial. Include a letter of medical necessity from your child's physician that directly addresses the stated denial reason.
3. Request external review if the internal appeal fails — Utah law provides external review rights for fully insured plans.
4. Contact the Utah Insurance Department at 1-800-439-3805 if you believe HB 323 is being violated.

Medicaid, CHIP, and the DSPD waiver

Utah Medicaid:Utah Medicaid covers ABA therapy for children under 21 who meet income eligibility requirements. Apply at health.utah.gov/medicaid or through the state's myCase portal.

Utah CHIP:the Children's Health Insurance Program covers children in families who earn too much to qualify for Medicaid but can't afford private coverage. CHIP covers ABA therapy for children through age 18 in Utah. Check eligibility at healthinsurance.utah.gov.

DSPD waiver for adults:Utah's Division of Services for People with Disabilities (DSPD) administers Medicaid waiver programs that can fund ongoing support services for adults with autism — including residential support, employment services, and some behavioral support. Waitlists are long. Families should apply before the child's 18th birthday. Contact DSPD at dspd.utah.gov or call 1-800-837-6811.

The DSPD waiver does not directly replace ABA therapy, but it can fund behavioral support services that help adults with autism maintain quality of life after they age out of private insurance coverage.