The passage of two laws in Massachusetts over the last decade has expanded access to insurance coverage for autism treatment. ARICA (An Act Relative to Insurance Coverage for Autism), a law passed in 2010, requires private health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder. The Autism Omnibus Bill, passed in 2014, expanded coverage for autism treatment under MassHealth.
People have many different types of health insurance. The autism treatment coverage under your plan depends on the type of insurance you have. It is important to understand the type of insurance you have, what autism treatment coverage your insurance is required to have under Massachusetts (or federal) law, and what options you may have for expanding your current coverage.
Below is an overview of the various types of health insurance you may have:
- Public – This is insurance coverage through MassHealth (Massachusetts Medicaid Program), or Medicare. There are many different types of MassHealth coverage. Eligibility for MassHealth, and the type of MassHealth, is determined by several factors, including income, age, and special circumstances (including having a disability). A person must be a Massachusetts resident to be eligible for MassHealth. U.S. citizenship is not required, but immigration status is a factor in determining what type of MassHealth a person is assigned. People with disabilities are usually eligible for MassHealth regardless of income, but they may be charged a premium if the household income is above a certain level. A person can be eligible for MassHealth, even if they have other insurance.
- Private – Most private employers offer health insurance to their employees, but there are important differences between the 2 most common types of employer-sponsored plans:
- An employer may purchase health insurance from an insurance company on behalf of its employees. Under this arrangement, the insurance company is directly responsible for covering the health care costs of the employee (and the employee’s family, in the case of family coverage). This is referred to as a “fully funded” plan (sometimes called a “fully insured” plan). Fully funded plans from Massachusetts insurers are regulated under Massachusetts law and are subject to ARICA.
- An employer (usually a large employer) may pay directly for its employees’ health care costs, rather than buying policies from an insurance company. This is referred a
“self-funded” plan. Self-funded plans are subject to federal laws, but not to state laws like ARICA. Although these plans are not required to follow the mandates in ARICA, a majority of them do include some coverage for autism treatments. Employers that set up self-funded plans often hire an insurance company to handle administrative functions (such as claims processing).
Which type of plan you have may not be immediately obvious. For example, employees with fully funded and self-funded plans can have identical looking insurance cards (i.e., a United Healthcare card, with the same co-pays, deductibles, etc.).
- Other types of private plans:
- Massachusetts state employees, and some municipal employees, receive their private insurance through the Group Insurance Commission (GIC). All GIC plans are subject to ARICA.
- The Massachusetts Health Connector sells many types of plans. Only some of these plans, Unsubsidized Qualified Health Plans (QHP’s), are subject to ARICA.
Autism Treatment coverage, (including ABA therapy) under different plans
|Type of Plan||Coverage||Notes:|
|MassHealth||YES||ABA is covered under MassHealth Standard, CommonHealth, and Family Assistance. Age limits apply.|
|Private Fully funded||YES||Out of State plans may have different coverage.|
|Private Self-funded||Maybe||Contact your plan, or your HR Department|
|State employees (GIC)||YES|
Where do I start?
- Determine what type of coverage you have. The Autism Insurance Resource Center’s “Am I Covered” is an online tool that can help.
- Make a list of the autism treatments you need. Insurance only covers treatments considered to be “medically necessary.” A person with autism may need additional services and supports that are not covered by insurance.
- Figure out if your insurance covers the treatment you need.
- If the treatment is covered, determine what your out-of-pocket costs are (deductibles, co-pays, etc.). These can vary a great deal, from zero out-of-pocket cost, to thousands of dollars. Note that most policies also have an “out of pocket maximum” cost. (Usually about 2x the deductible). Once this cost is met, there are no additional co-pays, etc. for the rest of the year.
- If you have private insurance, and it either doesn’t cover the treatments you need or you want assistance with the out-of-pocket costs, you may want to consider applying for MassHealth CommonHealth as secondary insurance.
Frequently Asked Questions
Can a person have both private insurance and MassHealth? If so, which plan will be primary?
Yes, people can have private insurance and MassHealth. Private insurance will always be primary.
My child has private insurance through my employer and MassHealth as a secondary insurance. But my providers have difficulty dealing with the private insurance company. Can I drop this and just keep my child on MassHealth?
No. MassHealth is always the “payer of last resort.” A family CANNOT choose to drop their child from private insurance and rely solely on MassHealth.
Can I purchase a policy from the Health Connector that will provide access to ARICA benefits?
Yes, but it has to be an UNSUBSIDIZED plan (referred to as a “Qualified Health Plan” or “QHP”). Note: Such plans can usually be purchased only during an open enrollment period.
Is MassHealth free for all people with disabilities?
No. Until the person turns 19, the premium is determined by family income. For those 19 and older, the premium is based on the applicant’s income.
Does MassHealth cover ABA the same way ARICA does?
Yes, except that MassHealth only covers ABA until age 21, whereas ARICA has no age limit.
Is a person required to have MassHealth to get ABA co-pays covered under ARICA?
Does MassHealth coverage expire?
No, but MassHealth periodically reviews the eligibility of covered persons. When MassHealth contacts you asking for updated information, it is critical that you respond in order to avoid the termination of MassHealth coverage.