What we know about the recently enacted autism insurance legislation – H4935
ARICA (An Act Relative to Insurance Coverage for Autism), is a law passed in 2010, requiring private health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder.
The legislation affects only certain types of health care policies, so coverage under ARICA depends on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs are all required to comply with the mandate. Many employers have “self-funded” plans, which are regulated under a federal law and not subject to ARICA. However, a majority of “self-funded” plans in Massachusetts are covering autism treatments.
Contact your employer or insurer to ask if your policy is self-funded or not. Even if your plan is self-funded, your company may provide coverage under ARICA, and/or cover autism therapies.
If your plan doesn’t provide coverage for therapies, there are options for obtaining insurance through MassHealth and/or the Health Connector to access coverage. Important: If a child is transitioning out of Early Intervention and will need alternate coverage, it’s important to plan this well before the child turns 3, as some of the alternatives can be accessed only during specific enrollment periods.
If your employer doesn’t provide coverage for autism treatment, our Center can help you advocate with your employer and advise you on alternative ways to access coverage.
ARICA applies only to state regulated private insurance, but MassHealth covers many of the same treatments:
- MassHealth covers Applied Behavior Analysis (ABA) therapy for children under age 21 with MassHealth Standard and MassHealth CommonHealth; and under age 19 with MassHealth Family Assistance. Read more about MassHealth ABA Coverage.
- MassHealth may cover co-pays and deductibles for ARICA mandated treatments covered by private insurance.
- The Premium Assistance Program can help subsidize purchase of private insurance policies and policies through the Connector that will cover ARICA.
- Families covered by MassHealth with children under age 9 can also apply for the Massachusetts Children’s Autism Medicaid Waiver through the Massachusetts Department of Developmental Services (DDS). Note – this is a limited program with specific application windows, check with DDS for more information.
- Consumers can access other services for emotional and behavioral issues through the Children’s Behavioral Health Initiative (CBHI) program.
No. There are no age limits. Per ARICA “The diagnosis and treatment of Autism Spectrum Disorders is not subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.”
The law covers the following care prescribed, provided, or ordered for an individual diagnosed with one of the Autism Spectrum Disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary:
- Habilitative or Rehabilitative Care – this includes professional, counseling and guidance services and treatment programs, including but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
- Pharmacy care – medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.
- Psychiatric care – direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
- Psychological care – direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
- Therapeutic care – services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.
Yes, subject to medical necessity criteria.
ARICA does not affect educational services provided under an IFSP, IEP or ISP. Insurers are not required to pay for in-school services. Conversely, schools may not require parents to access private insurance for services that a child is entitled to receive through school. Additional information can be found at the Massachusetts Department of Elementary and Secondary Education website.