State Autism Insurance Mandates: The 50-State Landscape

The headline

All fifty states have passed laws requiring some level of autism coverage in state-regulated health plans. Autism Speaks confirms this: "All fifty states have taken action to require meaningful coverage for the treatment of autism in state-regulated health plans." Most of these laws name Applied Behavior Analysis (ABA) as a covered treatment.

So the good news is real. The catch is that "all 50 states have a mandate" does not mean "every family is covered." Two things break that promise:

1. The mandate only reaches state-regulated plans (fully insured plans and,

in some states, state employee plans). It does not reach self-funded employer plans. See erisa-self-funded-exemption. This is the single biggest gap and it affects a large share of families.

1. Even inside state-regulated plans, the mandates vary a lot in how much

they actually cover.

What varies state to state

The green-on-the-map states all require ABA, but the fine print differs on at least four levers. Always check your own state's statute for current numbers, because legislatures change these.

1. Age caps

Many states only require coverage up to a certain age.

• Alaska: coverage required for individuals under 21 (Alaska Stat.

21.42.397).

• Nevada: under 18, or until age 22 if still enrolled in high school (Nev.

Rev. Stat. 287.0276 and related).

• Nebraska: under 21 (Neb. Rev. Stat. 44-7,106).

Some states have no age cap. The pattern is inconsistent, so read your statute.

2. Dollar caps (annual benefit limits)

Some states cap the dollar amount of ABA per year, often stepping down as the child ages. Examples, as written in the cited state statutes (these are the statute figures, not guaranteed current, and were compiled by NCSL as of 2021):

• Arizona: up to $50,000 per year for a child through age 9, and up to

$25,000 per year ages 9 through 16 (Ariz. Rev. Stat. 20-826.04 and related).

• Arkansas: ABA limited to $50,000 annually, children under 18 (Ark. Stat.

23-99-418).

• New Hampshire: ABA may be limited to $36,000 per year ages 0 to 12 and

$27,000 per year ages 13 to 21 (N.H. Rev. Stat. 417-E:2).

Note: some of these dollar caps may conflict with the federal Mental Health Parity and Addiction Equity Act (MHPAEA), which bars separate dollar limits on mental health benefits that do not apply to medical benefits. See mhpaea-parity-lever-self-funded. A hard annual dollar cap on ABA alone is worth challenging on parity grounds.

3. Plan types covered (and carved out)

State laws differ on which plan types they reach. Common carve-outs:

• Group size: some laws exempt small employers (for example Alaska exempts

small-group employers with 20 or fewer employees, with a partial waiver up to 25).

• State employee health benefit (SEHB) plans: some legislatures left their

own state employee plans out of the mandate to avoid the budget cost.

• Plan issue date: some laws only apply to plans issued or renewed after a

certain date.

So a state can be "green" on the coverage map and still have real gaps in its fully insured market.

4. Treatment scope

Most laws cover ABA plus diagnosis, but many also list speech therapy, occupational therapy, physical therapy, psychiatric and psychological care, and pharmacy care. The exact list is statute-specific.

The "issued, not resides" rule (important and often missed)

A fully insured plan is governed by the law of the state where the policy was issued, not where you live. The issuing state is usually where the employer is headquartered.

Example from Autism Speaks: you could live in Wyoming but be covered by a plan issued in Colorado, in which case Colorado law controls your coverage, not Wyoming law.

How to find the issuing state: look on the insurance card for a name like "XYZ Health Insurance Company of Colorado," or ask the primary insured's HR department. This matters when you are checking which mandate applies to you.

What to do with this note

1. Confirm whether your plan is fully insured or self-funded first

(erisa-self-funded-exemption). That determines whether any state mandate applies at all.

1. If fully insured, find the issuing state and read that state's autism

insurance statute for age caps, dollar caps, and carve-outs.

1. NCSL keeps a state-by-state summary with statute citations (linked above);

note the NCSL page was last updated in 2021, so verify current numbers against the actual state statute or your state department of insurance.