What is ARICA and what does it do?
ARICA (An Act Relative to Insurance Coverage for Autism) is a law requiring private health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder (ASD).
What types of policies does ARICA cover?
This law applies only to certain types of health care policies, so it is important to know the type of policy you have. Private insurers (including fully funded plans obtained through an employer), the state plan that covers state employees and retirees, hospital service plans, and HMOs are all required to comply with the ARICA mandate. Some employers have “self-funded” plans, which are not subject to ARICA, but instead are regulated under federal law. However, a majority of “self-funded” plans in Massachusetts have elected to cover autism treatments. For more information, refer to our Fact Sheet “Accessing ABA through Insurance.”
How can I find out if I have coverage for autism therapies?
If you have insurance through your employer, ask Human Resources whether your policy is self-funded. If you have a self-funded plan, ask who you should contact to get specific information about the coverage for autism therapies.
What if my employer’s self-funded plan won’t cover the autism therapies I need?
You can advocate for expanding coverage of autism therapies under the employer’s self-funded plan. If the employer’s self-funded plan will not provide coverage for therapies, there are options for obtaining coverage through insurance available from MassHealth and/or the Health Connector. Our Center can help you to advocate with your employer to expand its coverage for autism therapies and, if necessary, advise you on alternative ways to access coverage. Important: If a child is transitioning out
of Early Intervention and will need coverage for services, such as ABA, under insurance, it’s important to plan for this change well before the child turns 3, as
some of insurance options can only be accessed during specific enrollment periods.
Is MassHealth subject to ARICA?
ARICA applies only to state-regulated private insurance, but MassHealth covers many of the same treatments:
- MassHealth Standard and MassHealth CommonHealth cover Applied Behavior Analysis (ABA) therapy for children under age 21, while MassHealth Family Assistance provides coverage until the child turns 19. Prior authorization is required.
- MassHealth may cover co-pays and deductibles for ARICA-mandated treatments covered by private insurance.
- The Premium Assistance Program can help subsidize the 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).
Are there age, service, or dollar limitations to the amount of the coverage under ARICA?
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.”
What treatments are covered under ARICA?
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.
Are Social Skills Groups covered?
Yes, so long as they are deemed to be “medically necessary.”
How are education services affected?
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.
Have a question about ARICA? E-mail us at AIRC@umassmed.edu.