Getting Autism Therapy Covered by Insurance in Virginia

Virginia’s mandate

Va. Code § 38.2-3418.17, enacted 2011, requires state-regulated health plans in Virginia to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Any age. Virginia removed its age cap effective 1 January 2020 — before that, coverage ran only from age 2 through 10.

Dollar cap: $35,000 a year for ABA specifically. The cap is a floor, not a ceiling: an insurer may choose to cover more, and some do — ask yours directly rather than assuming.

The age cap and the dollar cap moved separately, and it is commonly reported that the 2020 amendment removed both. It did not. Age is unlimited; the annual ABA maximum remains. ABA must be provided or supervised by a behavior analyst licensed by the Virginia Board of Medicine.

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, Va. Code § 38.2-3418.17 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

Virginia Medicaid covers ABA for members under 21 through EPSDT, which is a federal entitlement and is not subject to the $35,000 ABA cap in the private mandate.

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 Virginia State Corporation Commission, Bureau of Insurance on 1-877-310-6560 if you believe Va. Code § 38.2-3418.17 is being violated. Their consumer pages are here.